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THE 



GLASGOW MEDICAL JOURNAL. 



THE 



GLASGOW MEDICAL JOURNAL 



EDITED BY 

JOSEPH COATS, M.D., and 
ALEXANDER NAPIER, M. D., 

FOR THE 

dlasgolD anb Mcst of Scothmb ittebical Jljssorktion. 



JANUARY TO JUNE 1885. 



VOL. XXIII. 



GLASGOW: 

ALEX. MACDOUGALL, 81 BUCHANAN STREET. 

LONDON : H. K. LEWIS, 136 GO WEE STEEET. 

1885. 



6(00^ 



THK 



GLASGOW MEDICAL JOURNAL. 



No. I. January, ISS.^). 



ORIGINAL ARTICLES. 



ON THE ADMINISTRATION OF CHLOROFORM. 

By GEORGE T. BEATSON, B.A. (Cantab.); M.D. (Edin.) 
Dispensary Surgeon, Glasgow Western Infirmary. 

I v the present communication I have no intention of entering 
nn the question of the relative safety of cliloroform as compared 
w itli other anajsthetics. I desire merely to bring under the notice 
of those who, like myself, still hold to chloroform as the most 
suitable and practical anaesthetic for everyday use, a mode of 
aduiinistering it that I have found to work very satisfactorily, 





Fig. 1. 



Fk;. 2. 



and that I believe contains in it several elements of safety. ] 
ivW-v to its administration by menus of what is known ns 
Allis' Ether Inhaler, an instrument which was first exhibited 
Ix'fore the Philadelphia County Medical Society, in October, 
Xo. ]. B Vol. XXIII. 



fy- 1 /^ <i 



2 Dk. Beatson — On tlw Ad)iilnidyatio)i of Chloroform. 

IST-i. and is descril)e<l in the PJiUadelpli'm Medical Tiines, No. 
162. The accompanyinLC figures show its construction. 

As will be seen from Fig. 1, it consists of a metallic frame- 
work, which is about four inches long by three broad, and is 
sufficiently large to cover the lower part of the face. This 
framework is made up of a number of bars placed parallel to 
one another about a (juarter of an inch apart, and soldered on 
to metal rims above and below, or cut from a solid sheet of 
metal, as shown in the drawing. To prt^pare the apparatus foi- 
use a strip of bandage is passed between the wires from si<lc 
to side, thus dividing the instrument into parallel sections eaeii 
of which is separate from the adjoining one, and allows the aii- 
to pass freely on both sides of it. Fig. 2 shows this arrange- 
ment of the bandage, as well as the hood or cover of thick 
rubber which is passed over the framework, and projects 
beyond one end of it to the extent of two or tliree inches, so as 
to make a soft and pliable mask, which will lit accuratclj^ to 
the nose and mouth. When the inhaler is complete, as in 
Fig. 2, with its threaded bandage and its hood, it is quite pos- 
sible to look through it from end to end, as tho'e is a space of 
quite a quarter of an inch Ijetween the several sections of the 
bandage. From this description of the instrument it will b«- 
seen that it is of very simple construction, and cannot get out 
of order. Its cost is but a few shillings. 

The mode of using the apparatus involves no difficulty. 
The administrator provides himself with a drop bottle of 
chloroform, and sprinkling a fevj droiis of the drug on tht- 
inner side of the inhaler, places the instrument over the 
patient's face covering only the nose and chin. In a little, 
a few more drops of chloroform are added, either on the outer 
end, as it is in sifn, or, as before, on the inner side of the inhaler. 
when, of course, it must be removed from the face. Tliis 
latter is the course I myself prefer. Fresh chloroform is from 
time to time added in drops until tlie patient is fully anassthe- 
tised, and the conjmictiva tells of complete. insensi1)ility. The 
apparatus is then removed, and the administration resumed 
only when the patient "shows signs of coming out of the 
influence of the drug. 

Employed in this way, I have been always pleased with the 
.•iction of this inhale)-, and I speak from an experience with it 
of some yeai-s and many hundred administrations. One great 
feature fdiout it is tlie rapidity with wliicli patients can be 
anaesthetised, and the; hhkiJI amount of chloroform that is ]'e- 
quired. They go under literally with the vapour from a few 
drops, repeated two or three times, and tliat in three or 



Dr. Beatsox— 0/> th> AdinhN'sfi-idlon of Chloroform. 3 

four minutes, very few taking as long as five. So much 
is this the ease that I have now a higher opinion of the 
potency of chloroform as an ana3sthetic, and that even 
in a few drops, tlian I previously had. What exactly is i\\v 
explanation of this I am not prepared to say, but I am inclined 
to think that the series of thin surfaces furnished by the strips 
of bandage, with air on each side of them, favours the instan- 
taneous evaporation of the chloroform ; and the construction 
of the inhaler furnishing no impediment to respiration, thr 
patient breathes comfortably an atmosphere thoroughly, but 
not excessively, impregnated with chloroform, and comes under 
its influence gradually, safely, and rapidly. 

And here I may say that my practice in administering 
chloroform is to ask the patient to count, in an audible tone 
and at a steady rate, from one upwards, so as to ensure that 
necessary regular breathing which is essential for a rapid and 
satisfactory anesthesia. We all know how quickly children 
go under chloroform, partly because they invariably cry when 
the drug is brought near them, a state of. matters necessi- 
tating deep inspirations ; and we also know that nothing delays 
ana?sthesia more than the obstinacy with which many patients 
hold their breath, or at any rate respire as feebly as they can. 
It is to obviate this that I follow the plan of counting, and it 
has also, what seems to me of great importance, the further 
recommendation that hj it some indication is given as to the 
exact moment when the patient is coming under the influence 
of the drug, and is entering on that dangerous period, requir- 
ing the greatest care and caution, when the nerve centres arc 
being affected, and by artificial means we are separating those 
closely allied and mutually dependent factors, sensibility and 
life. It is interesting to notice how high the counting 
reaches. Very few get above seventy, many not above 
fifty, and often the first sign noticed of approaching un- 
consciousness is a repetition of one or two of the numbers 
uttered. Then follows silence, broken only in a very short 
time by the deeper and heavier inspirations which tell that 
the drug is doing its work, and that soon sensibility will be 
removed, to be followed by a period requiring the greatest 
care and vigilance on the part of the administrator. 

It was with some reluctance that I abandoned the use of the. 
towel in the administration of chloroform, as I was educated 
in the belief that it was the best plan to follow. I now think 
that the employment of Allis' inhaler is better, and even safer. 
In the first place, I am sure that there must be less risk when 
only a few drops of chloroform are used at a time than when 



4 Dr. Beatson— 0)i the Administration of C%loroform,. 

an indefinite quantity is poured out from a bottle, as is done 
with the towel. Again, the rapidity with which the patient 
goes under does not allow of any large amount of the drug 
being absorbed into the blood, and this is an advantage as it is 
an element of safety. I admit that persons anaesthetised by 
the inhaler come out very rapidly from the influence of the 
anaesthetic, but I prefer that to seeing them remaining deeply 
under long after the towel has been withdrawn, and when at 
the end of the time, some violent measures have to be resorted 
to to obtain some indication of returning consciousness. 
The deepei' the narcosis the greater the risk, for sensibility 
and life are so intimately allied that one cannot be removed 
without endangering the other. But the chief recommenda- 
tion of the inhaler, in my opinion, is the ready access 
of atmospheric air that it gives. In this respect the towel 
has always seemed to me deficient, and that, looking to the 
different ways in which one sees it used, some placing at a 
distance from the patient's face, others quite close to it, it 
is mere haphazard as to the proportion in which the air gets 
mingled with the chloroform inhaled. Now, if there is one 
thing above ;dl others that has been shown in reference to 
chloroform, it is this, that its fatal effects do not so much 
depend on the absolute quantity of the drug as on the propor- 
tion in which, when breathed, it is mixed with atmospheric 
air, more than 4 per cent being regarded as fraught with 
danger. The construction of the inhaler gives most free 
admission of air, and with only a few drops at a time 
sprinkled, there is no risk of the vapour being dangerous from 
its concentration. Lastly, the inhaler has, I think, one other 
advantage over the towel, and that is that it enables the 
administrator to see the patient's face and eyes without 
removing the apparatus, and as it requires only one hand to 
hold it in position, it leaves the other free to feel, if neces- 
sary, the pulse — a precaution that experience has taught us is 
now necessary in addition to watching the respiration. 

In thus briefly recording my experience with Allis' inhaler, 
I do not desire to bring it forward as perfectly safe, or to 
maintain that with it no accidents can happen. My own feel- 
ing about cliloroform is that, while it is our most suitable 
anaesthetic it is in itself a dangerous drug, and that, from 
causes we cannot foresee, such as, perhaps, some idiosyncrasy 
on the part of the patient, there will always be a certain 
amount of mortality attaching to it, even in the hands of those 
who arc most experienced in its use. This being so, it behoves 
every one using it to satisfy himself that he administers it 



Dk. Beatson — On the Administration of Chloroform. 5 

with every known pi-ecaution, and under those conditions 
which experience has shown ensure the best chances of safety. 
On weighing the matter carefully, I have convinced myself 
that these are obtained by the inhaler, and that, by using it, 1 
am studjnng the interests of my patients. Hence the reason 
for my adopting it, and for my putting on record my experi- 
ence of it, which, I may add, has been that of others who 
employ it. Thus, Dr. Woodburn, who was the tirst in Glasgow 
to use it in his dental practice, is pleased with it ; so also is 
Professor Chiene, of Edinburgh, who has tried it on my 
suggestion ; and in the Glasgoiu Medical Journal for Septem- 
ber, 1883, Dr. Renton speaks in high praise of it. I do not 
think that with it the after effects of the chloroform are in 
any way different from those observed after using the towel. 
With some the sickness has been trivial, with others more 
severe. This, however, is a matter I believe that depends very 
much on personal predisposition. One objection to the inhaler 
is that the hood that covers it may get soiled somewhat with 
blood or saliva in operations about the mouth, but it can be 
very readily sponged with some carbolic lotion and dried, when 
it is ready for use immediately. It is also advisable to change 
the bandage if the instrument has been used for any case of 
an infectious nature. Thus, I deemed it advisable to do so 
after employing it recently in a case of diphtheritic croup, w^here 
I had to perform tracheotomy. Apart from these little dis- 
advantages, I am sure that any one using this inhaler will lie 
pleased with it, and will find what I have said above, that 
under it patients are anjesthetised rapidly, quietly, and with a 
very small amount of tlie anaesthetic. In fact, with it there is 
a great economy of time in operations, and also of chloroform, 
provided a drop bottle is used. Of course this latter is not a 
special desideratum, but it is still worthy of consideration. I 
know that I use drachms now where I would have employed 
ounces with the towel, and though I have not kept special 
records of the amount in individual cases, I know that on 
one occasion, while on duty in the Western Infirmary, my 
four-ounce drop bottle served me for an amputation of the 
fore-arm, another of the thigh, removal of a tumour from the 
face, and excision of a large epithelioma of the vulva. 



Dr. Kelly — C(is<c^ of Stralloiving Foreign Substances. 

NOTES OF GASES OF SWALLOWING FOREIGN 
SUBSTANCES* 

By a. l. ki<:lly, m.d. 

Gases of foreign substances being swallowed are not uncommon, 
often giving rise to considerable anxiety, and are by no means 
free from danger. As might be expected, they happen most fre- 
quently amongst children from simple carelessness. Yet how 
often do we observe grown-up people guilty of the injudicious 
and reprehensible practice of putting pins, needles, nails, and 
manj' other sharp pointed substances in their mouths, which a 
rapid inspiration, an attack of coughing, or a sudden start or 
alarm may cause to be swallowed before the person is really 
aware of their disappearance. 

I. Miss W— — ; aged 2'1 years — several years ago, shortly 
after midnight, I was hurriedly summoned to visit. She was 
said to be choking from her artificial teeth, wdiich having become 
loose in her mouth during her sleep, and slipping backwards, 
were now firm and fast in her throat. Upon reaching her bed- 
side I found her greatly agitated and alarmed, complaining of 
ticute pain in her breast, pointing to about the middle of the 
sternum, and stating that she felt the teeth there pricking her. 
Upon examining the throat, I could discern in the roof of the 
mouth, and upon the edges of the pharynx, several bleeding 
scratches, but no appearance of teeth or gold plate, although 
the alveolus disclosed a considerable vacancy by the absence of 
one of the left upper incisors, and two tricuspids. Calming her 
fears as best I could, I urged her to endeavour to obtain sleep, 
assisting her thereto by means of 40 drops of solution of 
morphia, which failing, an additional dose of lo to 20 drops 
was to be administered in about an hour and a-half afterwards. 
Upon my visit in the forenoon, I found her calm, drowsy, and 
complaining of pain and soreness in the throat and chest, but 
she had taken and sw^allowed easily a small quantity of porridge. 
Inquiry elicited the fact of her bowels being habitually con- 
stipated, relief once a week was her accustomed habit, and that 
the last evacuation was three days ago. Urging her to be 
patient and to be of good cheer, her anxiety and mental 
distress being soothed, and having upon this occasion some 
respect for her constipated disposition, I simply desired her to 
continue her usual regimen, which, consisted chiefly of porridge, 
tea sparinglj^ with toast bread, mutton chop or beef steak 
* From a pajjev read at CJlasgow Soutliern Medical Society. 



Dr. Kelly — Gases of Swalloiving Foreign Substances. 



7 



ilaily, with sago or rice puddino-. Liquids of every kind she 
was to avoid. To take a little exercise, or employ herself 
with household duties, and to have no medicine. Day after 
day passed by unchanged until the morning of the sixth d&j 
after the accident, when she complained of. pain in the 
abdomen, and inability to relieve her bowels, although the 
desu'e to do so compelled frequent attempts. Knowing her 
imrvous diathesis, I at tirst tliought this might be some spas- 
modic contraction of the sphincter ani and rectum causing the 
retention, and requested her to take a tablespoonful of castor 
oil. But in the evening, finding she was much worse, pain 
more severe and of a remittent character, and desire to 
defecate more constant, I ventured to express the opinion that 
the teeth might be causing the discomfort and the obstruction. 
With some difficulty the rectal speculum was introduced, when 
just beyond the spliincter, a hooked portion of the gold plate 
was seen adhering to the mucous membrane. It was easily 
iletached and extracted, defecation was soon after accomplished, 
and no untoward symptoms of any kind followed. 

II. On Friday afternoon, about three o'clock, Maggie B , 

aged 2i years, was amusing herself on the nursery fioor with 
a string of beads. The string broke, and in a few minutes 
afterwards she was seen with two or three beads in her mouth. 
A momentary struffsrle with the nurse ensued, who, in her 
agitated condition, only extracted one, at the same time felt 
ctirtain that one or more were swallowed. After pacifying the 
I'xcitement, and endeavouring to assure the mother that there 
was not any cause for great anxiety, I advised a continuance 
of the child's ordinary food — viz., arrowi'oot, rusks, Savory & 
-Moore's food, well boiled porridge, but to be given in a more 
solid condition than usual. Next day I found that although 
there had been one alvine evacuation, no Ijeads had appeared. 
Advised a continuance of food as formerly prescribed. On 
Sabbath afternoon no change, the child well. I now caused 
to be administered a teaspoonful of castor oil, which acted in 
al)out three hours afterwards, brinfjino- with it, in some rather 
firm faecal matter, one bead, and next morning the other, now 
sliown, was evacuated. During the past night the child had 
been restless, with frequent crying as if pained, probably the 
result of the bead causing some irritation l)y 1 )eing retained in 
some convolution, or possibly from slight griping of the oiL 

III. A. G., 8 years of age, was amusing himself with several 
toys on the fioor, amongst which were a few screw nails — of 
this (one inch in length) size — one of which he picked up, put 
in his mouth, and swallowed. I saw him shortly afterwards, 



8 Dr. Kelly — Case.H of Sivalloiviwj Foreign Substances. 

lively and well, and uncomplaining, advised him to have food, 
consisting only of porridge, bread, arrowroot, with small 
quantities of milk. No untoward symptoms of any kind 
appeared during the four succeeding days. The child con- 
tinued active, cheerful, and happy, had daily stools, which were 
carefully examined, but disclosed no nail. A teaspoonful of 
castor oil was now administered, which had the desired effect 
early next morning of expelling the nail without injury oi- 
pain. 

IV. A. L., aged 15 months, when sitting beside her mother. 
who was engaged sewing hooks and eyes upon a dress, picked 
up two of the eyes, and conveyed them to her mouth. Before 
the mother, who was considerably alarmed, could attempt to 
remove them, they had disappeared, the baby having 
swallowed them. A dessert spoonful of castor oil was at once 
administered, which purged very freeh* within two hours, and 
upon my visit about three hours after the occurrence, the two 
eyes were shown me, having- been expelled in one of the 
watery stools, without apparent pain or uneasiness. A few 
minutes before the accident, the child had been given a 
quantity of arrowroot. 

V. J. C, aged live years, was about to seize the sides of his 
bath to step into it, when, having this farthing in one hand, he 
suddenly placed it in his mouth so as to secure a better hold 
with both hands. Having got into the bath, his foot slipped 
and falling backwards, the farthing disappeared. He at once 
C) ied, " It's gone, it's away down." It had passed down without 
causing any inconvenience. Having satisfied myself that it 
was neither in tlie pharynx nor larynx, I desired the mother 
to give him his accustomed plain food, with as little beyond as 
possible, and no medicine. Next day he had no complaint — 
bowels moved freely. No change occurred till the evening of 
the fourth day, when he repeatedly complained of pain in his 
stomach, but when desired to place his hand upon the site of 
the pain he at once carried it to his anus. A dessertspoonful 
ol. ricini was now prescribed, which acted freely several hours 
afterwards, and upon my morning visit the little fellow was 
busily engaged polishing the farthing to present it to me, it 
having been expelled in one of the evacuations during the 
night. 

VI. W. K., age«l 1 4 years, was about to tie this half of a 
sleeve link to a fishing line when, having occasion to use his 
knife, he placed this in his mouth to free his hand to obtaui 
the knife in his trousers pocket. At this instant his com- 
panion spoke to him. Not hearing distinctly what was said. 



Dr. Kelly — Cases of SwaUowing Foreign Substances. !) 

he lifted his liead, saying, " Well V The link rolled l)ack wards 
in his mouth, merely tickled his throat, and %vas swallowed, 
and, cis he expressed himself, " Before he could say a 
word he felt it cold in his stomach." At the suggestion 
of friends on the beach he drank a quantity of salt water, and 
vomited freely, but not the link. Three hours afterwards took 
castor oil, without any further effect than free purgation. 
Next day he came to Glasgow, where he was desired to con- 
tinue his usual food : porridge, bread freely, sago, rice, &c., 
but to have very little tluid, no medicine in the meantime. 
He continued well, and nothing of moment transpired till the 
eighth day afterwards, when he complained of slight dull pain 
with flatulence in his bowels. He was now prescribed a dose 
of castor oil. Upon the following morning it produced a 
copious ffecal evacuation, and also tlie link now shown. 

VII. H. C, aged 7 }"ears, when amusing himself on Monday 
evening, 20th October, 1879, with bobbing this shawl pin 
(2 1 inches long, including black beaded head) in and out of 
his mouth, with a sudden inspiration it went backwards, and 
though it caused him to cough slightly he failed to expec- 
torate it, and it disappeared downwards. Shortly afterwards 
I found him crying and excited, but suffering no pain. I 
caused him to eat a biscuit, and to continue eating as many 
as he wished, to have food plain and dry, and to omit all 
liquids. Nothing unfavourable occurred till Wednesday night, 
about eight o'clock, when he suddenly screamed with pain in 
right hypochondrium, and continued writhing and twisting 
himself, almost frantic with acute suffering, for about ten 
minutes. Again on Thursday evening, in the same situation, 
a similar attack of intense pain set in, with constant screaming 
and writhing agony for about an hour, but as suddenly as 
on the preceding evening it subsided, and afterwards he 
was well and lively as if in perfect health. During Friday 
he suffered from several slight attacks of pain in his bowels, 
when in the evening he was prescribed a small tablespoonful 
of castor oil, which relieved the bowels, and in the motion, 
completely concealed from view, the pin must have been 
expelled, because until the firm faecal mass was broken up 
with water it was not perceived. 

It may be remarked that all the cases here recorded have 
had happy and successful terminations. It may be asked, are 
there no failures then ? No cases with unfavourable complica- 
tions or unfortunate results ? Because we are well aware that 
a candid report and confession of failures and faults would be 
frequently useful and important, and convey valuable instruc- 



10 Dr. Kelly — Cases of SivaUoiving Foreign Substances. 

tion. In reply, I might cite an instance I know of, and with a 
report of wliich I have been favoured by my brother, Dr. 
James Kelly, as follows : — " On New Year's day, 1876, I was 
called to M., aged 18 months, and found her suffering from 
vomiting and feverishness, with a peculiar pointed naturally 
coloured prominence over the centre of the stomach, two inches 
to left of mesial line. I took this swelling to be an incipient 
cutaneous boil, and a mere accident in the case, which seemed 
one of purely gastric catarrh. At the end of ten days the boil, 
after passing through the usual stages, came to a head, and 
when I opened it I found to my astonishment the point of 
what proved to be this large needle (nearly 3f inches in length) 
protruding from the wound. I extracted it cautiously, with 
tlie dread of peritonitis vividly before my mind, but almost 
immediately the child began to improve, all the symptoms of 
gastric irritation disappeared, and the child has never since 
been troubled with any bad effects from the passage of the 
needle. It had, no doubt, been picked up and swallowed, had 
stuck in the mucous membrane of the stomach, pierced its 
walls, and passed through the peritoneum before finding exit 
from the integument." 

Another case is that of a lady engaged in dressmaking, who 
swallowed a needle in April of this year (1884). It has not yet 
appeared nor given any trouble or inconvenience. Another, that 
of a boy aged 6i years, who three months ago swallowed a small 
china doll (1| inches in length) which has repeatedly produced 
spasmodic pains in stomach, but has not yet been expelled. 
What the issue of these two latter cases may be I may be able 
to report at some future time. It will have been noticed tliat in 
all the cases the treatment, so far as medicines are concerned, 
has been almost nil, or at least of the most simple character. 
Xot that I can or do undervalue therapeutics. We are expected 
to afford some service and assistance to those who confide 
to us the care of their diseases, but neither wisdom nor duty 
convinced us that medicinal treatment would assure the com- 
fort or the safety of the patients, and every one here must have 
seen many recoveries from serious sickness without artificial 
intervention. All here are cognisant of the fact that judicious 
and careful nursing, with attention to diet, is ample in many 
cases to secure thorough convalescence, when to have inter- 
fered with drug treatment would have been unwise and most 
prolmbly prejudicial. In the foregoing cases liquids were 
avoided, and the food prescribed was of a drying and slightly 
astringent character, and in considerable quantity, so that the 
noxious and offending substance might not be hurriedly carried 






Dr. Napier — Case of Purulent Pneumonia. 1 1 

into and throuo-h the bowels, but become surrounded, and, as it 
were, incorporated with the solid and slowly dig-estinj^' mass as 
it moved onward, so that the feces graduall}- enclosing it 
might thoroughly protect the coats of the intestines. In tlie 
case of any body with sharp points or edges, such as the plate 
of false teeth and the pins and needles, the danger of exciting 
violent peristaltic action lies in the impaction of the foreign 
body in the mucous membrane causing ulceration and penetra- 
tion of the bowel, with subse(|uent peritonitis. I have not in 
lay practice met with any such case. In Case VII, the pin 
that is before you had evidently pricked the mucous membrane 
!is it passed along the duodenum, very probably just where the 
iirst bend takes place under the liver, but it is peculiar that in 
Case I the plate of teeth should traverse the whole intestinal 
canal to the sphincter ani without causing any pain or uneasi- 
ness. I understand that it is not an uncommon thing for 
small bodies to get impacted in the vermiform process and give 
rise to abscess in the iliac fossa, but I have not seen any case 
of this kind. Perhaps the success which has attended the 
treatment of these cases has been merely accidental, but for 
my own part I regard it as in great measure due to the avoid- 
ance of purgation in the early stages, and the administration 
of dry food yielding a considerable proportion of faecal matter. 



CASE OF PURULENT PNEUMONIA DUE TO THE 
PRESENCE OF A FOREIGN BODY (A PIECE OF 
THE PITH OF THE ELDER) IN A BRONCHUS. 

By ALEX. NAPIER, M.D., 

Assistant to the Professor of Materia Medica and Therapeutics, Glasgow 

University; President of the Southern Medical Society. 

{Read before the Olasgoio SoutJtem Medical Society, 13th November, 188.'}.) 

The case here narrated was one of suppurative pneumonia, 
the cause of which was not ascertained till pod-mortem, exami- 
nation was made. 

G. T., a healthy and vigorous boy of 4 years of age, was 
first seen by me in his last illness on the evening of Sunda}'', 
1 2th October. His mother stated that he had been noticed to 



12 Dk. Napier — Case of Purulent Pneumonia 

be ill only from the Wednesday previous, that is, about four 
days before ; he had been dull, feverish, listless, suffered from 
entire loss of appetite, headache, and had a ver}^ furred tongue. 
This was thought to be a " stomach attack," and was treated 
domesticalh', but ineffectuallj^ by grey powder. From the 
Wednesday evening he had had a short and peculiar cough, 
accompanied by what is described as a suppressed sneeze ; this 
spiiptom, of much importance when considered in connection 
with the cause of the disorder, had quite disappeared on 
Smiday, and was never afterwards noticed. It was mentioned 
to me on Sunday, but little importance was ascribed to it as 
there was no history of a foreign body having passed into the 
air-passages, and from the symptoms presented no such event 
suggested itself to my mind. 

On the evening of Sunday, 12th October, the little patient 
was found to be in a high fever: temperature, 103^ F.; pulse 
very fast, at least 140 ; respirations 70, accompanied by a 
painful catch at the end of inspiration and an obvious working 
of the alse nasi. There was a frequent short cough, l)ut no 
expectoration. Tongue moist, and coated with white fur. 
Severe pain was complained of, and referred to the pit of the 
stomach ; this pain persisted throughout the whole course of 
the case, and was the symptom most often mentioned by the 
patient himself. At no time Avas the pain referred to the lung, 
or near the part at which the foreign body was afterwards 
found. On physical examination there was discovered com- 
parative (not absolute) dulness to percussion on the right 
side, posteriorly, from the base of the lung up as high as the 
middle of the scapula; there were no rales, but a comparatively 
feeble respiratory murmur. The interior of the throat was 
slightly congested and swollen. At this, my first visit, the 
idea formed of the case was that we had to deal with an 
impending pneumonic attack, and such was the announcement 
made to the parents. Poultices were ordered, and a diet of 
milk and beef tea ; a mixture was also prescribed, the principal 
ingredients of which were chlorate of potash and tincture of 
aconite. 

Next day, Monday, 13th October, the temperature had risen 
to 104° F., the pulse to 156, while the respiratory rate and the 
general symptoms were unchanged. The physical signs were 
now found to indicate the presence of fluid ; the percussion 
dulness was absolute (juite up to the middle of the scapula, the 
respiratory murmur was inaudible, and so was the vocal 
resonance ; no distinct alteration of the vocal fremitus was 
observed, and no rale was heard. The cough remained much 



I 



Due to the Presence of a Foi'e'njn Bodi/ in a Broiicltiis. 13 

the same, with little or no expectoration. Patient was noticed 
to rest most comfortably on right side. 

From this date till Friday, 17th October, there Avas no per- 
ceptible change in this boy's condition. The cough remained 
unaltered, and accompanied by a scanty whitish expectoration. 
The fever persisted, but was invariably, throughout the whole 
case, higher in the morning (11 a.m.) than in the evening 
(about 8 P.M.), the temperature ranging from lOo'o to 104'o' 
in the morning to 102'2 to 103^ in the evening. The pulse 
rose and fell with the temperature. 

On Friday there seemed to be a crisis, and wIk n Dr. Finlay- 
son saw the patient with me for tlie tirst time on that 
afternoon the temperature was luider 100 F., the pulse had 
much fallen, the respiration was slower and easier, while the 
percussion dulness was found to have receded about 1 i inches ; 
in other respects the physical signs were unchanged. The boy 
was more cheerful, and his appetite had revived. I should 
state that on Thursday, IGth October, I had put a small fiy- 
blister (2"x2") over the base of the lung, and that on 
Wednesday, loth October, his mediqme had been changed to 
iodide of potassium wnth ammonia. Dr. Finlayson agreed 
with me in the view that we had to do with a case of pleurisy 
with effusion, and gave a good prognosis, an opinion which I 
also shared. He suggested the propriety of giving quinine in 
a few days. 

During that day ( Friday) and on Saturday and Sunday, the 
little patient seemed to progress favourably ; but on Monday, 
20th October, he was found to be not quite so well. The 
temperature and pulse began to rise, and soon became as 
febrile as ever, while the respiration became quick and painful 
as before. The morning rise and evening fall in fever 
were again noticed. The patient began to perspire freely, 
especially about the head. The cough became frequent and 
teasing, and on this day distinct!}^ purulent matter began to 
come up with the expectoration. The pus was thin and fluid, 
soon became very abundant, often appeared with little or no 
mucus, and from the first had a f(ptid odour, which, however, 
became more marked in the course of a few days. Neverthe- 
less, many sputa, which contained almost no pus, had scarcely 
any trace of odour : with the appearance of pus in the sputa, 
the odour invariabl}' returned. The odour was that of decom- 
posing pus, and not the sickening foetor characteristic of 
ordinarj' pulmonary gangrene. 

During the week which followed Monday, 20th October, the 
boy went steadily down hill, fever being maintained and 



14 Dr. Napier — ('(/si' of P undent Pneumonia 

streng-th deeliiiino-. Pain in head on coughing was luuch com- 
plained of, and the pain in the " stomach " persisted. 
Perspiration became more profuse, and a vivid hectic flu.sh 
made its appearance on the cheeks. The patient nipidly 
emaciated. With all this there was no perceptible change in 
the physical signs. Suspecting the development of pyo- 
pneumothorax, the Hippocratic succussion sound was often 
sought for, but never discovered. 

On Saturday, 2oth October, the patient was again seen witli 
me by Dr. Finlayson, who agreed with me in thinking tliat 
the pleuritic fluid had become purulent, and was plainly 
decomposing, and that the best course to adopt was to procure 
tlie evacuation of the fluid externally. This view of the case 
was strengthened by the absence of fibres of lung tissue in the 
sputum. Accordingly, on Sunday, 26th October, Dr. Macewen 
inserted an aspirator needle at three difierent points on the 
chest- wall, one in front, just under the nipple, and two behind, 
]iear the angles of the ribs ; no pus was obtained, but only a 
little reddish serous fluid from one of the punctures. As the 
needle was felt to move freely in a cavity, it was thought it 
had become blocked. Dr. Macewen tlien performed resection 
of part of one of the ribs, the seventh, removing about an incli 
of its length, and thus making a free opening into the pleura. 
No pus escaped, but a small ([uantity of reddish serum. This 
was disappointing, as we had evidently not hit on the part from 
v.hich the foetid material was being coughed up. On intro- 
ducing his finger, Dr. Macewen found it in a large but shallow 
eavit}', l)Ound in on all sides by adhesions ; the lung, which he 
touched, was consolidated. It was then suggested that 
tlie lung itself should be explored, in the hope of finding the 
suppurating part, but this suggestion was negatived, as Dr. 
Macewen could feel no part at which there was any bulging or 
fluctuation to show in what direction to explore. A drainage- 
tube was left in, and the part dressed. 

For two days after the operation the boy improved a little, 
and some of the foetid matter got away through the wound 
into the dressings. After this, however, his symptoms 
returned with greater violence, cough became more frequent 
and distressing, more of the fcetid material was brought up : 
the patient sank gradually, and died on Saturdaj^, 1st Novem- 
ber, apparently from exhaustion. Death was preceded for 
ali()ut 12 hours by diarrhoea, though throughout the illness 
the bow(ds had been constipated rather than otherwise. 
During tlm last 24 hours of life, cough and expectoration had 
ceased. During the last two days of life also, the lips of the 



Due to the Presence of a Forei;/n Hudu in a Bnjavhas. lo 

wound assumed a greenish, gangrenous appearance, and there 
was a deep red erysipelatous-looking blush round it for a con- 
siderable distance. 

The other treatment adopted during the last stage of the 
illness consisted in the administration of (juinine, stimulants. 
milk, beef -tea, beef-juice, &c., and the use of antiseptic inhal- 
ations to remove the fcetor as far as this was possible. 

Post-mortem examination, 48 hours after death. Only the 
chest and the upper part of the abdomen were examined. The 
body was already much decomposed ; the wound had gan- 
grenous edges and was surrounded by a deep red blush which 
extended for several inches down the right side. 

The liver was noticed to be pushed down at least an incli oi- 
an inch and a half. 

The left lung and the heart were normal. 

The right lung was solidified throughout. The upper lobe 
was perfectly non-adherent and smooth, and in it the hepatisa- 
tion was red and apparently recent : it contained no abscesses. 
The lower lobes, with the exception of a portion corresponding 
to the cavity opened into at the operation, were adherent; the 
adhesions to the diaphragm were particularly firm. These 
lower lobes had a dirty greyish-green appearance and a very 
foetid odour. There was a shallow wound on the posterior 
surface of the lung, opposite the operation-wound in the chest 
wall. On making a deep vertical incision into the lower lobes 
from the front, numerous abscesses, some as large as a walnut, 
and all having foetid contents, were opened. On removing 
the lung, and slitting up the bronchus, a foreign bod}- was 
found firmly lodged beyond its first svibdivision, blocking \\\) 
the bronchus communicating with the two lower lobes. The 
foreign Vjody was imbedded in a deep groove in the side of 
the bronchus, and the mucous membrane round this groove 
was deeply injected. The air passages below this point were 
full of stinking pus. 

The foreign body removed was cylindrical in shape, and 
broken ofi" irregularly at each end; it was 7-16ths of an inch 
in extreme length, 5-16ths of an inch in diameter, and weighed 
4 grains, being light, therefore, considering its size. Being in 
doubt as to the nature of this body, I submitted it to Dr. 
Thomas Reid, who at once pronounced it to be the pith of 
some plant, probably the elder bush, a variety of Sambucus. 
He made sections of the foreign body, while I made sections of 
the real pith of the elder, obtained from the Queen's Park : 
these, on being compared, were found to be identical in 



16 Dr. Napier — Case of ParaJeut Pncamonia. 

structiiiv. You may convince yourselves of their identity \\j 
comparing the two microscopic sections exhibited. 

Rehi'irl-^. — 1. This foreign body passed into the right 
bronchus, as is most common!}' the case when such bodies pass 
the larynx. This is due to the greatei- diameter of the right 
bronchus, and the more powerful current of air passing to it ; 
but most of all to the fact that the rostrum at the bifurcation 
of the trachea lies more to the left than the right, so that 
bodies dropping downwards pass more readily to the right. 

2. Such cases have usually a definite history of sudden 
onset ; there is usually an initial paroxysm of coughing when 
the body enters the air passages. Not uncommonly there is 
haemorrhage in greater or less amount ; and also loca.lised 
pain. But not one of these symptoms was present in this case, 
and there was absolutely no history of tlie boy having 
swallowed anything of the sort found : in fact, the case was a 
mystery to the parents as well as to us till the post-mortem 
examination wris made. I now learn, however, that the elder 
bush grows abundantly in Queen's Park, in a house facing 
which the boy lived ; that the boy was in the park every day, 
and that he seldom returned without a handful of sticks and 
branches of various kinds. I know also that children are in 
the habit of chewing tlie elder branches, as they are sweetish 
in taste. 

The peculiar cough which the boy had for some days before 
I saw him, but which had disappeared before my first visit, has 
now an important significance in the light of the post-Tiiorterti 
discoveries. It seems not to have been of the paroxysmal 
choking kind that we associate with the entrance of foreign 
bodies into the air-passages, and was ascril)ed to a cold the 
patient was supposed to have caught in the wet weather which 
prevailed at the time he took ill. 

3. It is not easy to say how long the foreign body may have 
been in the lung. Dense non-porous substances may remain a 
very long time in the lung without giving rise to any symptoms, 
such is the toleration occasionally shown by the part. But I 
can scarcely imagine a porous substance such as this pith, in 
the interstices of which the fluids of the part would be so 
ready to decompose, remaining long localised without giving 
evidence of its presence. The probability therefore is, that it 
was not long in the lung before the occurrence of actual 
.symptoms of illness. 

4. Physical examination is said to be of great value in deter- 
mining the presence or absence, or site, of a foreign body in 



Mr. Macintyre — Us^e of the Electric LigJit 'ui Medicine. 17 

tlie lungs, though Sir Benjamin Brodie held the contrary 
opinion. It is said that if a bronchus is blocked up entirely, 
the percussion sound over tlie part of the lung with which it 
is connectetl is clear, while the respiratory murmur is 
abolished ; tlie latter is only weakened if the bronchus be not 
entirely closed. Such signs are of value only early in the case, 
and not after morlnd changes have been set up in the part. 
In the present instance the boy had been ill four days before I 
saw him, and then the indications were simply those of a 
commencing pneumonia, to which were soon added those of a 
pleurisy ; hence the error, especially in the absence of any 
characteristic history, into which I fell. 

5. The indication for treatment of sucli a case, when its 
cause is early enough recognised, is clearly to remove the 
foi'eign body as soon as possible, even when it seems to be 
giving rise to but little distui-bance, as the results are apt to 
be bad once mischief has beoun. 



SOME NOTES ON THE USE OF THE ELECTRIC 
LIGHT IN MEDICINE. 

By JOHN MACINTYRE, M.B., 

Hurgeon for Diseases of the Throat, Anderson College Dispensai'^ ; JDemonstratoi- 

of Anatomy, (Glasgow Royal Intinnary School of Medicme. 

Having made experiments lately on the illumination of 
cavities by the Electric Light, it may interest the readers of 
this Journal to hear something of methods of examination 
which ai'e daily coming more within the reach of the profession. 
Some observers, who have become accustomed to the usual 
gas or oil flame and reflectors, may be inclined to content 
themselves with these, which, for ordinary purposes, are 
doubtless very satisfactory. On the other hand, many whose 
work necessitates the frequent examination of mucous mem- 
branes would prefer to use a clearer and whiter light than can 
be got from oil or gas. One can easily understand this, for 
although one may have an efficient apparatus in the Consulting 
room, the practitioner is often compelled in the patient's home 
to use a badly placed gas bracket, lamp, or candle giving a 
very inferior light, unless he be in possession of a more or less 
complicated and often not very portable apparatus. Another 
No. 1. C Vol. XXIII. 



18 Mr. Macintyre — IV of tJic Electric Light in Medicine. 

serious objection may [>e mentioned to our present methods of 
illumination, that is, the necessity in laryngeal cases' for 
])lacing the patient in the upright position in order to obtain 
a satisfactory view of the parts. It would obviously be a 
great benefit could the cavity be examined with the patient 
lying in bed and tlie head resting comfortably on the pillow. 
All things considered it is not surprising to find that attempts 
sliould be made to furnish an apparatiis which would combine 
efficient illumination with simple and portable arrangements. 
That electricity has given us a better light most men will 
admit who have seen Trouve's photophore. This fails in por- 
tabilit}^ however, not to speak of its cost. It will be noted 
nevertheless, that the appliance simplifies our arrangements by 
dispensing with the mirror on the forehead. 

Being convinced that a less powerful light, if more directly 

and thereby more economically applied, would illuminate the 

cavities sufficiently, Mr. White, optician, was instructed to 

make some apparatus with a view to this. The first thing to 

ft be obtained was the lamp, and it was 

selected with regard to its size ; secondly, 

sufficient power of illumination ; and, lastly, 

so easily driven that for portability a small 

battery could work it. This was soon 

placed at my disposal, and instructions 

were given to fit it up as described in 

Fig. 1. The lamp is drawn natural size. 

p, , , A is a small platinum cup, serving the 

double purpose of a reflector anteriorly, and 

posteriorly a shade to protect the eye of the observer from the 

glare ; b, b, are the wires to the battery ; C, the stem ; D, the 

lamp itself. 

For the battery required it may be stated that after many 
experiments I determined to adopt the common Bichromate cell 
as being the most suitable. For the Consulting room three 
No. 3 Leclanche cells do very well, and they can be used for 
charging secondary batteries. However, it may be said that 
.so little power is required to work such a lamp that a suitable 
battery might be arranged in mwaj portable forms. The one 
made for me consists of two cells placed in a box measuring 
7x7x4 inches, which also holds a small resistance coil to 
regulate the force of the current and leaves room for various 
specula. 

The first instrument to which the lamp was fitted was 
Schnitzler's nasal speculum. See Fig. 2. A represents the 
lamp in position ; v, the non-conducting receiver for it; B, wire 




Mr. Macintyre — [he of the Electric L'njht in Medicine. 19 

to battery ; the circuit beino- completed by touching- any part 
of the metal speculum. 

Having succeeded with this, the lamp was next attached to 
the ear speculum, as seen in Fig. 3. A, the lamp ; B, b, the 
wires ; v, the terminal. The lamp was also fitted to the 
vaginal speculum, as seen in Fig. 4. A, the lamp ; B, B, wires 
to battery : w, means of placing it on the speculum. This can 
readily applied to any set. 




Fk;. .5, 



Fig. 5 represents a clip which can be applied to any tongue 
depressor, and to either side of the instrument. A, the cover 
of lamp; B, wire; D, lamp; F, the clip. It will be seen that the 



20 Mr. Macintyre — Use of the Electric Light in Medicine. 

lamp can be turned in any direction, and is very convenient 
for lighting up the mouth and posterior wall of the pharynx. 
Having had a number of cases where an illumination of 
the nasal cavity from behind was thought desirable, instruc- 
tions were given to make an apparatus which could be passed 




^ 




to the posterior nares. Here a difficulty was experienced in the 
heating of the lamp, and consequently it could not be retained 
any length of time in this position. This was overcome by 
sending a stream of water over the surface of the lamp, as 
shown in Fig. 6. D is the lamp ; G, a glass cover ; w,w, are 



Mr. Macintyre — Us^c of the Electric Light in Medicine. 21 




Fig. 



two tubes leading to the inside of G ; B,B, the wires to the 
battery. By attaching small elastic tubing to w,w, a current 
of Walter can be passed over D, the lamp. 

In all the above instruments the light falls directly on the 
object itself, but to see the larynx, of course, necessitates 
the introduction of a reflecting surface to the back of the 
mouth ere the organ can be lit up, and an image seen. This 
throws a difficulty in the way, but it can be overcome. The 
first attempt to illuminate the larynx by the electric light 
w^hich was brought under my notice was one figured in Leiter's 
Catalogue for 1883. 
The apparatus de- 
scribed in Fio;. 7 is crot 
up on this principle. 
A is the cup and lamp ; 
G, a cover to protect 
the soft parts as the ^ 
lamp warms. The lamp 
can be placed on the 
back or a lower border 
— anywhere in fact. 
Several objections can 
be urged against this 
arrangement, however. Firstly, the lamp becomes warm, and 
the metal rim heats very rapidly. Doubtless this could be 
overcome by a similar arrangement to that described in Fig. 6 ; 
in fact, Mr. White was instructed to do so, but the idea was 
abandoned, as it complicated the apparatus very much. 
Secondly, to bore a hole, or in any way to allow the light to 
pass through the mirror interferes wdth the image of the larynx. 
Thirdly, the antero-posterior diameter is increased considerably, 
an awkw^ard thing in many morbid conditions. Fourthly, it 
necessitates the filling up of each mirror ; and, lastly, it is not 
easily kept clean. For these and other reasons the above 
was rejected, and after many experiments a totally difierent 
principle was tried.* The lamp was placed in the front of 
the mirror as seen in Fig. 8. v is a non-conducting bracket 
which slides on the stem of the laryngeal mirror, so that the 
lamp can be placed anywhere between it and the handle. By 
doing so, we get a good view of the larynx, heating is greatly 
done aw^ay with, and it can be attached to any set of laryngeal 

* The above instruments were sho^\^l at the Glasgow Medico-Chirurgical 
Society on 7th Nov., 1884, and since, then Messrs. Hilliard & Son, who 
kindly placed the whole of their electric apparatus at my disposal, tell me 
that a M. Laverne of Paris is exhibiting a lamp similar to this. 



22 Mr. Macintyre — Use of the Electric Light in Medicine. 

mirrors ; and these, of course, can be kept as clean as those in 
daily use. This method has its objections ; amongst others, it 
may be mentioned that, to a small extent, the lamp is in the 
way of instruments when operating. 




Fig. 8. 



It will be noted that, could we place the lamp entirely 
outside the mouth, on the handle of the mirror, the incon- 
venience of heating would be at once overcome, and would no 
longer be in the way of instruments. By doing this, however, 
a loss of light is experienced, and so it is better to use a more 
powerful lamp, which, of course, means a larger battery ; and 
this last method may, therefore, be better suited for the 
consulting room. When this is done we require to twist the 
mirror slightly on the stem, because, as at present placed, 
it is necessary to depress the handle to get the proper angle . 
o'f 45° to the horizon, and without this the teeth would 
interfere with the light. Fig. 9 shows this instrument. 
D, the lamp; A, the cover; b,b, wires to battery; K, band for 
binding it at the handle ; J, joint for altering the position of 



Mr. Macintyre — Use of the Electric Light in Medicine. 2'^ 



the lamp, D. This arrangement, when the mirror is removed, 
is an excellent one for illuminating the pharynx or mouth. 

What, then, are the advantages to be derived from such 
apparatus ? That a light well suited for the examination of 
mucous membrane can be got 
is evident. Secondly, the re- 
flectors can be dispensed with. 
Tliirdly, the patient can be more 
comfortably examined, and this 
at his own house. On the other 
hand, thei'e are, of course, dis- 
advantages. At present most 
electric lights are somewhat 
expensive, but the above battery 
and lamp can be got for little 
more than the price of our com- 
mon laryngoscope. Again, the 
light must be used for a time 
before one becomes accustomed 
to the appearance of morbid 
conditions as seen by it. The 
greatest difficulty lies in the 
battery itself, which is always 
troublesome. Of late, so many 
improvements have been made 
in secondary batteries, that 
strong hopes may be entertained 
that this will speedily be over- 
come. If it be the case, as the 
inventors, Messrs. Woodhouse & 
Rawson, London, and M. Laverne, 
Paris, state, that thoroughly 
reliable accumulators are in the 
market, the whole difficulty will 
disappear. They have yet to 
be tested, but from what I have 
seen of them they bid fair to 
become an invaluable aid, and 
■are a striking proof of the 
advancements which are daily 
being made in this department 
of science. 

At a future time something about the results of clinical 
examination with these instruments may be placed before the 
readers of this Journal. The above apparatus must necessarily 




24 Mr. Marshall — Aphasia and Cerebral Hmmorrhage 

be deficient in many details, which will be added as may 
be found advisable. Meantime, let it be said that although 
we are as yet in the region of experiment, as we become more 
familiar with the electric light, it is certain to be extensively 
employed in medicine. 



APHASIA AND CEREBRAL HEMORRHAGE COMPLI- 
CATING WHOOPING-COUGH. 

By J. N. MARSHALL, M.B., 
Assistant Physician, Belvidere Fever Hospital, Glasgow. 

Case I. Jane P., aged 5, admitted into the Glasgow Fever 
Hospital on 8th June, 1884, with the history of having had 
whooping-cough for four weeks. 

The child had always been healthy. She is now fairlj^ well 
nourished, and very precocious in manner. There is distinct 
internal strabismus on left side, which her mother says fol- 
lowed a suppurative inflammation of the eye in infancy. 

She coughed with the characteristic whoop, but nothing 
remarkable occurred till loth June, when the paroxysms of 
cougfh became more severe, and she was noticed to be feverish. 
Temperature was 102'8 . 

On examination of the chest the breath sound at the back 
was found deficient, and accompanied by some rale. Blood 
was often spat up with the cough, and the paroxysm was 
occasionally followed by vomiting. 

17th Jane. — The temperature is still slightly elevated, but 
the paroxysms of cough are less severe. The child has become 
very drowsy, and lies in a state of semi-stupor. She never 
speaks, and she has ceased to take notice of anything going 
on about her. This is all the more remarkable, as up till this 
time she was extremely playful. 

18th June.— Yesterday it was observed that she did not use 
her right arm ; and to-day, so far as can be made out in her 
present unconscious state, there seems to be paralysis. When 
pinched, the right arm remains motionless, although when this 
is done to the left, or to either leo-, the limb is at once with- 
drawn. Patient swallows well enough, but cannot be roused 
to speak, or to take notice of anything. Urine is passed in 
bed. Pupils are equal, and widely dilated. Since this stupor 
came on the coughs have been less severe. Vomitino- occurs 
after the paroxysm, but this was present from the first. 



Gompllcating Whooping-Gough. 25 

19th June. — The temperature this morning is 101'2°, 
Patient is much livelier, and now takes notice of what is 
going on. She evidently understands what is said to her, 
and she puts out her tongue when told to do so, but is unahle 
to speak. She was playing in bed with a kitten at the visit 
to-day, laughing, and stroking it in an intelligent manner. 
When askeil what it was, she evidently' tried to name it, but 
failed. This aphasic condition has probably been present for 
one or two days, but owing to her semi-unconscious state it 
was not recognised. The right arm can be moved slightly 
from the shoulder, but the paralysis seems to be nearly 
complete from the elbow downwards. When the right arm 
is pinched, the left hand is used to interrupt the process. The 
face is slightly drawn to the left side. The pupils are natural, 
and there is no ptosis. 

To-day she made signs for the bed-pan. The cough is still 
accompanied by expectoration of blood. During the last few 
days blood seems to have come from the mouth, and is spat 
out in the interval between the coughs. The temperature 
to-night is 100-2 '. 

'20th Jane. — Patient took a convulsion this mornino- lasting 
for about three minutes, and affecting the right side of face 
and right arm and leg. It occurred in the middle of a 
paroxysm of coughing. Otherwise, the child is better; she 
moves her arm more freely, and in answer to some question, 
pronounced the word " here " distinctly. 

In the evening she recognised and named her father and 
mother. There is now no perceptible difference between the 
two sides of the face. 

21st June. — To-day patient speaks pretty distinctly, though 
with a limited vocabular}', using disconnected words and 
phrases. She uses her arm pretty freely, and can grasp with 
the fingers, though not so strongly as with the left hand. 
Temp, is !)9"2'. The cough is still severe. 

27th J II nc. — The paralysis has now quite disappeared, and 
the child is chatting as volubly as she did before her seizure. 
The temperature was 102'6° on the evening of the 23rd, but 
since then it has been about 99". There has been no expec- 
toration of blood with the cough for the last few days. 

26th Jul I/. — Patient still takes very severe coughs, occasion- 
ally accompanied by expectoration of blood. To-day there is 
a large subconjunctival ecchymosis on the right side. There 
have been no nervous symptoms. 

14th August. — Child takes the coughs less frequently, but 
they are still violent and often leave her in a state of stupor. 



26 Mr. Marshall — Aphasia and Cerebral Hoiinorrhage 

with rigidity of the arms and legs. This, however, does not 
last more than a few minutes. 

11th Noveinher. — Since last note the coughs have graduallj- 
become less frequent, and now they have all but disappeared. 
There have been no more nervous symptoms. 

At the present date the child seems to be in robust health, 
but her mental condition is somewhat peculiar. She is pre- 
cocious and replies readily and often intelligently when spoken 
to, but an entire absence of restraint in her speech gives one 
the impression that she is not quite right. This, however, 
seems to have been her condition before she took this illness. 

The treatment adopted in this case was the administration 
of chloral hydrate in small and frequent doses, to allay the 
violence of the paroxysms. This was afterwards changed to 
nitro-hydrochloric acid. 

Case II. Thomas C, aged 2. Admitted 18th June, 1884, 
having been ill with a cough for six weeks, and having 
coughed with a whoop for four weeks. . 

On admission the tempei'ature was 100'2°. Breathing was 
hurried, and the child had the appearance of being very ill. 
There were moist rales all over the chest, but no evidence of 
consolidation of the lung. 

For the next few days the morning temperature ranged 
between 99° and 100° and the evening between 101° and 102". 
The paroxysms of cough were not particularly severe, and they 
were never accompanied with expectoration of blood. The 
condition of the lungs did not improve, and the lips and finger 
nails became livid. 

On 24th June patient developed distinct cerebral symp- 
toms. The stupor which was present more or less from the 
first, became more profound. There was distinct twitching of 
the left side of the face. Breathing was irregular, the respira- 
tions being rapid and slow by turns, and at times ceasing 
altogether for a second or two (Cheyne-Stokes' respiration). 
There was apparently paralysis of the right arm, although this 
was difficult to make out in the child's semi-comatose condition. 
The limb, however, always lay helplessly by the side, while 
the left hand was occasionally used to grasp the drinking cup. 
The temp, did not rise above 102°. Pupils were equal and 
rather dilated. The child remained in the same condition till 
the following day, when death took place. 

The treatment in this case consisted of poultices to the 
chest, an expectorant mixture containing hydrocyanic acid, 
and a small quantity of stimulant. 



Compllcdti iKj \\'/n>o/>iiig-Cough. 27 

Fosf-mortnn exaininafkm of head, 26th June, I.88J4.. — 
There is considerable serous effusion on the surface of tlie 
brain, a little at the base, but no excess of fluid in the 
ventricles. About the middle of the hemispheres on the sur- 
face of the brain, and close to the lonoitudinal fissure on each 
side, is a considerable hjemorrhage. Tliere is no clot, but the 
brain substance, to the depth of about \ of an inch, is soft and 
easily broken down, and of a dark red mottled colour. The 
vessels in the neighbourhood are much distended, and one of 
the veins contains a pale clot. 

In the substance of the left optic thalamus is another 
hsemorrhage, about the size of a horse bean, having the same 
characters as the others, and from its mottled appearance 
evidently of about the same date. 

ifevv/K /'/>•.— There seems to be no doubt that the symptoms 
in the first case were due to an actual haimorrhage into the 
substance of the brain. Coincident with the onset of the 
cerebral symptoms, there was a grave exacerbation of the 
cough, and it seems probable that the violence of the latter led 
to a rupture of some of the minute arteries in the brain. 
That there may have been some abnormal condition of the 
walls of the vessels is quite possible, seeing that the patient 
was peculiarly liable to hsemorrhage from the respiratory tract, 
and also that at a later date there was a subconjunctival 
haemorrhage. The markedly one-sided character of the 
symptoms, along with the aphasia, distinguish it from an 
ordinary case of hooping-cough with cerebral symptoms. 

The 2^osf-inortem appearances in the second case, to some 
extent, confirm the view' that was taken with regard to the 
pathology of the symptoms in the first. In this case the con- 
vulsions were probably due to the haemorrhage on the surface 
of the brain, while the paralysis was the result of the haemor- 
rhage into the optic thalamus. 

From the very small nundjer of cases recorded, this com- 
plication seems to be of considerable rarity. 

In the Obstetrical Journal, for Sept., 1876, Dr. Finlayson 
reports the case of a girl seven years old, who suffered from 
right hemiplegia and aphasia in the course of an attack of 
whooping-cough. The nervous symptoms in this case persisted 
for several weeks. Dr. Jules Simon {Revue des Maladies de 
VEnfance, Dec, 1883,) reports a case of right-sided paralysis in 
a girl five and a-half years old, suffering from severe whooping- 
cough. He attributes the symptoms to cerebral irritation, and 
possibly sclerosis. Gerhardt and Ziemssen merely mention 
such a complication as being of rare occurrence. 



28 Dr. Renton — Cocaine in Opldhahnic Surgery. 



COCAINE IN OPHTHALMIC SURGERY. 

By J. CRAWFORD RENTON, M.D.Ed., 

Surgeon to the Eye Infirmary, and Surgeon to the Dispensary of the Western 
Infirmary, Glasgow. 

Cocaine, the alkaloid first obtained by Niemann from the 
leaves of erythroxylon coca in 1859, was stated, in 1862, by- 
Professor SchrotF to possess the property of anajsthetising the 
mucous membrane of the tongue. Dr. A. Hughes Bennett was 
the first in this country to prepare and use cocaine, and in an 
elaborate series of experiments performed in 1872, he investi- 
gated its properties, and drew attention to the fact that the 
peripheral nerves of the skin and mucous membranes were 
paralysed by its application in small doses, v»'hile in larger 
(juantity the deeper nerve centres were affected. In Bolivia 
and Peru, where the coca plant grows, the native Indians 
chew the leaves to appease hunger and support strength. In 
1876, Sir Robert Christison found by experience that eat- 
ing the coca leaves prevented fatigue, giving as an instance 
that he had twice ascended Ben Yoirlich under the inlluence 
of 60 and 90 grains without experiencing the least fatigue, and 
Avithout having partaken of any food, or having felt the need 
of it. Since then it has been greatly used by athletes, bicy- 
clists, and others undertaking a great amount of mental or 
bodily fatigue. 

Dr. Von Anress, in 1880, confirmed the facts pointed out by 
others as to its controlling power over the nervous system, and 
hinted that it might be useful as a local anaesthetic, after 
which it was frequently employed in operations on the throat. 
In September, 1884, Dr. Carl Roller, of Vienna, announced the 
results of his experiments, stating that when a few drops of a 
two per cent to five per cent solution of cocaine were put into 
the eye, in from three to six minutes, complete corneal and 
superficial conjunctival anaesthesia took place, lasting from 
fifteen to twenty minutes. During the last two months I have 
repeated the experiments made by Dr. Roller in a considerable 
number of cases, and I have much pleasure in stating that I 
can confirm his observations with regard to the valuable 
efiects produced. In these experiments I have been most 
kindly assisted by Dr. Mackintosh, our present house surgeon, 
and Mr. Macmillan, who placed at my disposal a variety of 
solutions of various strengths. Cocaine is not so soluble as its 



Dr. Rentox — Cocaine in Ophtludmic Surgery. 29 

salt, the hydrochlonite, and the preparations of it vaiy ; it is 
not so (piic]<ly alisorbed on that account, and the anaesthetic 
results obtained by it were longer delayed, although 
undoulited. The hydrochlorate is very soluble and solutions 
of it, when carefully prepared are durable, although a fungus 
(juickly forms in them ; glycerine effectually prevents this, but 
its addition delays the an;esthetic action. Mixed with vaseline 
the application is (piite satisfactory, but in tatooing the cornea, 
which is often very painful, the glycerine solution and the 
vaseline mixture should be avoided as preventing the cornea 
from absorbing the ink used. Gelatine discs, of the strength 
of 1-200 of a grain prepared by Savory & Moore, on the sug- 
gestion of Mr. Nettleship, are by far the best and most 
economical mode of using the hydrochlorate, two discs being- 
sufficient to produce anpesthesia in three minutes, and may be 
repeated when it is necessary to maintain it. The discs are 
easily dissolved in a little warm water, and may then be used 
in removing polypi from the ear, and in incising the meni- 
branum tympani. 

When, therefore, anaesthesia is desired, two discs or a few 
drops of the solution are placed on the cornea, and if it cannot 
be touched with a needle, unknown to the patient, in three 
minutes, the cocaine should be repeated ; but, as a rule, one 
application has been found sufficient. Dilatation of the pupil 
occurs to a greater or less degree when the eye is free from 
irritation, but cocaine has not by any means the mydriatic 
power of atropine. In one or two instances the pupil remained 
dilated for several days. 

As regards the value of cocaine in operations on the eye, we 
found generally that in all those involving the cornea, the 
patient stated that there was complete absence of pain. The 
following are the principal operations in which it has been 
tried : — 

1. In removal of foreign bodies from the cornea. Everv 
surgeon knows how troublesome it often is to do so, owing to 
the sensitiveness of the eye, and although atropine to a 
certain extent relieves this, still, with cocaine the patient does 
not know when the cornea is being touched, and the foreign 
1 lody can be easily removed. 

2. The thermo-cautery has been applied to the cornea on 
several occasions for sloughy ulcers without any pain. 

3. In iridectomy the incision in the cornea is painless, but 
the iris, when dragged on and cut, causes pain in some patients, 
in others no pain is complained of. One patient felt no pain 
in the one eye, with two instillations of the two per cent solu- 



30 Current Topics. 

tion, but in the other eye in which the glycerine sohition had 
been used he felt pain when the iris was cut. 

4. It is in cataract extractions that the greatest benefit 
seems to be derived from the drug. No pain is complained of, 
and patients state that they hardly know that anything is 
being done. In one case where the remains of an old trau- 
matic cataract were removed, and necessitated a pair of forceps 
being put into the eye, the patient stated that he felt no pain 
whatever. 

5. In all needle operations on the cornea the results were 
quite satisfactory, absence of pain being the general statement. 

6. In enucleation I have not found the anajsthesia complete, 
and patients complain of pain when the conjunctiva is seized, 
and greater pain when the muscles and nerVes are divided. 

As a controller of ciliary pain I have not found the cocaine 
of any value. 

Altliough pain is a very relative term, and varies very much 
in different patients, and on that account it is necessary to be 
careful in our observations, still, there seems no doubt that 
in cocaine we possess a drug of great value in preventing pain 
during the operation, and keeping the eye soothed for some 
time after, which cannot fail to conduce to good results in 
ophthalmic surgery. The expense of the drug prevents many 
from using it, but, acting on the suggestion of Dr. Hughes 
Bennett, I have asked Mr. Macmillan, of this city, to have 
prepared the muriate of caffeine and theine, and if they are 
equally successful as cocaine it will enable the anaesthesia to 
be produced at much less expense. 



CURRENT TOPICS. 



We learn that Prof. G. H. B. Macleod, of this city, has been 
chosen a Foreign Corresponding Member of the Academic de 
M^decine of Paris, as an expression of the estimation in which 
his works and person are held by the members of the 
Academy. We believe that Dr. Macleod has also been asked 
to accept the ofhce of President of the Section of Surgery at 
the next meeting of the British Medical Association at Cardiff, 
but he has not been able to accede to this request. 



Mevlews. 



REVIEWS. 



Handbook of the /)^sv'f^sr.^• of f/tc Eye. By Henry R. Swanzy, 
A.M., F.R.C.S.L, Surgeon to the National Elye and Ear 
Infinnaiy, Dublin. Pp. 437. 122 Illustrations. London: 
H. K. Lew is. 

This is the age for condensed manuals. Nor could we expect 
an}- other result from the rapid strides made in the various 
departments of surgery during the past decade. These 
advances have enlarged the literature enormously in the 
different specialities into which surgery has been of late years 
subdivided. The bewildered student turns from his ever- 
increasing text-books, wdth their inadequate information on such 
suV)jects as those of ophthalmology and otology to special 
treatises, for more exact and definite, as w^ell as more recent 
information. But the time required to read these, when added 
to that already absorbed in attention to general medicine and 
surgerj-, and the time necessarily devoted to clinical instruction 
and study, render it impossible for him to attempt their per- 
usal, unless at the risk of neglecting his general work, so he 
lays them down in despair. Hence the demand for manuals 
which, wdiile not too diffuse or abstruse, still furnish the 
student or junior practitioner with sufficient information to 
enable him intelligently to follow his teacher in the special 
department of the hospital, or to serve as an introduction to 
more extended studies, and also as safe guides in general 
practice. In no branch is such an assistance more required 
than in the science of ophthalmology. And in no department 
of medicine is there, perhaps, still prevailing such lamentable 
ignorance amongst those in general practice. Nor is this any 
matter for surprise, whilst the licensing bodies, wdth tw^o 
exceptions, forbear from enforcing an attendance on an 
ophthalmic hospital or department during the undergraduate's 
course in medicine or surgery. The work before us, the 
author says, "is chiefly intended for students attending an 
ophthalmic hospital." He hopes also that it may prove more 
than this, and be of use after the nominal studentship has 
ceased, as a book of reference. 

We need not remind our readers how- rapidly has this — the 
most exact of all our medical sciences — advanced during the past 
twenty-five years. During that period modern ophthalmology 
may be said almost to have sprung into existence. Helmholtz 
gave it a new birth with the ophthalmoscope. Bonders was 



32 Rt'viev)H. 

the parent of our improved sj'stem of treatment of aber- 
rations of refraction. Graefe was the sponsor to whose 
genius and fostering care we owe the conception, growth, and 
development of such operative measures . as iridectomy and 
linear cataract. We can hardly realise how this science has 
grown unless we recall what the past few years have effected 
in bringing it to its present state of comparative perfection. 
Taking up, for example, such an excellent epitome of its progress 
as the plainly written and lucid handbook of Dr. Swanzy, and 
passing over the heading of its pages, let us note a few of 
the most important additions of recent years. In his chapters 
on refraction, which follow a summary of useful hints on 
" elementary optics," there are the perimetric charts of Landolt 
for recording the dimensions of the field of vision, and the 
relative acuteness of vision for various colours in the periphery 
of the field, and the tables of the same distinguished oculist, 
which give the proportionate lengths of the eye in different 
degrees of ametropia, both in myopia and hypermetropia. Even 
with a small work like this of Mr. Swanzy's, the student has no 
longer any excuse for ignorance in estimating the degree of 
astigmatism, both simple and compound. A few years since, 
even some ophthalmic surgeons smiled when the existence of 
astigmatism was spoken of as a connnon source of trouble, and 
the necessity for its correction was enforced by those who took 
more pains to discover its presence. In chapter iii the principle 
of retinoscopy and the " shadow test " is explained, and the 
determination of myopia, hypermetropia or astigmatism bj" this 
method is clearly taught. The adoption of this plan, which 
saves an immensity of time and trouble in testing the eyes for 
various degrees of myopia or hypermetropia, has only, A^•ithin a 
few years, become general; in fact, the use of the metrical system 
of numbering lenses is comparatively of recent date. In the 
treatment of diseases of the conjunctiva, chap, iv, the treatment 
of gran Illations by electrolysis (Walpole), by jequirity (Wecker), 
and the cure of pannus by the operation of peritomy, remind 
us of these new and important means of cure. The transplan- 
tation operations of Teale and Knapp for symblepharon, 
and the transplantation of a piece of rabbit's conjunctiva 
(Wolfe), are all now practised with success for this most serious 
complication. Chapter vi, on diseases of the eyelids, reminds 
us of the vast improvement in operations on the eyelids for the 
common troubles and deformities arising out of inverted lashes. 
Dianoux's, and the complete operations of Snellen and Berlin 
for entropium, especially the latter ; and the ingenious operation 
of Argyle Robertson for ectropium, are described in addition to 



other better known and more anti(j[nated operations, and the 
operative steps are illustrated by excellent engravings. Of 
late the galvano-cautery is rightly coming into more general 
nse in the treatment of small najvi and various tumours of the 
eyelids. Bowman's admirable suggestion for the treatment of 
stricture of the nasal duct and lachrymal obstruction, made 
as far back as 1857, has hardh' been improved on, but hi.s 
subsequent employment of larger probes completed one of the 
most important suggestions of the many made by the veteran 
Eno'lish ophthalmologist. 

The whole management of corneal ulcers has undergone a 
re\olution since the relative advantages of atropine and eserine 
in the treatment of corneal ulceration have come to be under- 
stood (chap. viii). In this particular atl'ection, the operative ste]) 
of Sj^misch has become a recognised step, and we cannot point 
to a more telling example of the consequences of ignorance in 
ophthalmic practice than the daily loss of eyes, which is the 
result of neglect, in not carrying out this simple step in certain 
ulcerations of the cornea. The relation of hereditary s^'philis 
to corneal affections, and the evidences of this taint in the 
structure of the cornea and the eye generally, as also the other 
concomitant evidences of its presence, have been clearly dwelt 
on by Mr. Hutchinson. In the improvements in surgical 
procedures on the cornea, we are reminded of the various 
operations of ablation in staphylomatous states (Wecker and 
Critchett), and the now familiar but ingenious device of 
Wecker, of tatooing in cases of leucoma. 

Our author treats us to but two and. a-half pages on affec- 
tions of the sclerotic, and we cannot help remarking that, even 
at the risk of a little enlarging his handbook, he might 
have been a little more generous of his thoughts and pen in 
parts. There is such a thing as too concentrated nutriment. 
However, in this pithy chapter we are reminded of the intro- 
duction of massage by Pagenstecher for painful affections of 
the eye, more especially rheumatic and neuralgic ; and in a foot- 
note, Mr. Swan2y describes the method of practising this 
therapeutical measure. In the chapter on diseases of the iris, we 
have the reasons assigned for the more intelligent use of atropine 
in iritic complications ; importance rightly attached to iridec- 
tomy, performed at the right time in cases of iritic adhesions 
threatening closure of the pupil : the value of the salicylates in 
rheumatic iritis pointed out, while the indications for mercury in 
affections of the iris, as well as the employment of pilocarpine to 
lower tension in cases of serous iritis and other hyper-exudative 
states are here alluded to. But we must again express regret 

No. 1. D Vol XXIII. 



34 Reviews. 

that this chapter of the work does not more fully enter into 
some of the aifections of the iris which certainly deserve, even 
for a student, more notice than the scant one of a few lines, 
while the onl}- operation on the iris described at length is that 
of iridectomy, though in this section of the work, as well as in 
that devoted to aiiections of the crystalline lens, we might 
have anticipated detailed allusion to the operations of Critchett 
and Wecker, more especially that of the latter (iritomy) in 
cases of closed pupil. Perhaps it is in the pathology and 
therapeutics of abnormal changes in the deeper tissues of 
the eye that we most realise the substantial progress of 
ophthalmology (chap, xi-xx), and we may thus sununarise 
these : — 

(«.) The connection between the pathological changes in the 
ciliary region, the result of traumata or disease, and sympathetic 
ophthalmia. 

(h.) The evidences of the syphilitic taint, inherited and 
acquired, in choroidal or choroido-retinal morljid changes. 

{(■.) The importance of the early recognition of sclero-choroiditis 
anterior and its treatment ; the early diagnosis of sarcomatous 
growths of the choroid. 

(d.) The pathology and treatment of sympathetic ophthal- 
mitis, and the accepted rules for the operation of enucleation 
in cases of injury or disease, which threaten the implication of 
a sound eye. 

(e.) The etiology and pathology of glaucoma ; the researches 
of Graefe, Weber, Knies, Donders, Leber, and others on the 
continent, and of Priestly Smith in England, throwing light on 
the part taken relatively by the lymphatics and blood-vessels 
in the process of hyper-distention, as also the pathological 
changes in the filtrating media of Fontana and Schlemm ; 
the rationale of the operations iridectomy and sclerotomy, and 
the contra-indication for the use of atropine, and the explana- 
tion of the therapeutical action of eserine (Wecker) in the 
treatment of this disease. 

(/.) The diagnosis of hyalitis, and the differentiation of 
vitreous opacities, and the introduction of the use of the 
magnet (a substantial gain), which M'Keown, of Belfast, was 
the first in this country to advocate, for the removal of 
foreign bodies in the vitreous humour. 

(^.) The relations of retinal haemorrhages and apoplexies to 
cardiac and renal diseases, and the bearings of retinal infarc- 
tions on the prophylaxis of puerperal eclampsia; the diagnosis 
of retinitis albuminurica ; the relation of nyctalopia to retinitis 
pigmentosa ; the treatment of detached retina by replacement 



Reviews. 85 

and puncture (Sicliel and Wecker) ; the occurrence of retinal 
euibolisni from aneurism of the aorta, mitral disease, and 
albuminuria ; the early recognition of glioma. 

(Jl.) The connection between optic neuritis and intracranial 
disease, various disorders of menstruation, syphilis, blood 
poisoning, sclerosis of the spinal cord, locomotor ataxia ; those 
curious cases recorded by Nettleship, Priestly Smith, and Leber, 
of persistent dropping of the nostril, attended by atrophy of 
the papilla; the results of the abuse of tobacco and alcohol, 
seen in atrophic papilla ; the various methods for estimating 
the degree of colour blindness. 

A useful chapter for the student, added by Mr. Swanzy, is 
that on "The Motions of the Pupil in Health and Disease," ex- 
plaining the physiology of myosis and mydriasis and the action 
of myotics and mydriatics on tlie iris. In the clearer under- 
standing of the action of the alkaloids atropia, duboisine, 
hyosciamine, gelsemine, eserine, and pilocarpine, and the indica- 
tions for the use of these <litierent agents in ulcers of the 
cornea, glaucomatous states, after cataract and other operations, 
in suppurative conditions of the cornea, and in the diagnosis 
and treatment of myopia, important advances have been made, 
thanks more especially to the work of Wecker. 

The author does not mention the muriate of cocaine, which 
promises to be an important addition to the ophthalmologist's 
pharmacy, through its unquestionable power of producing local 
anaesthesia in certain operations on the eye. The relation of 
the state of the pupil to both cerebral and spinal lesions has 
assumed of late years a special signilicance. The contracted 
pupil of tabes dorsalis (Argyle Robertson), of general paralysis, 
sclerosis, aneurism, paralysis of the cervical sympathetic ; the 
mydriatic condition which attends on growths in the cervical 
region of the cord, as an early symptom of tabes dorsalis, in 
mental deranginent, in glaucomatous conditions, in diseased 
processes affecting the third nerve, have all been carefully 
differentiated, whether they are due to an irritation or a 
paralysis. 

Dr. Swanzy's short, but concise and well written, chapter on 
"Aff"ections of tlie Crystalline Lens," is prettily illustrated, and 
sufficiently indicates the favourite modern methods for removal 
Vioth of hard and soft cataract. He gives the preference to 
Wecker's peripheral ffap method, the "three millimetre flap." 
The author does not refer to Bowman's suction operation for 
soft cataract. Perhaps he considers it risky to recommend to 
those whose experience in the diagnosis of the consistency of a 



■Hi Reviewf<. 

cataractous lens is limited. But it certainly deserves a place 
in a student's manual. Performed with a steady hand, in a 
suitable case, there are few prettier or more effective operations 
in eye surgery. 

In the concluding chapters, on " The Orbital Muscles and 
Diseases of the Orbit," the operation for the advancement 
of the recti (Wecker) is described, and the treatment both by 
lenses and prisms, as also the ordinary operative measures 
for strabismus, are sufficiently detailed. Tumours of the 
orbit, malignant growths, and exophthalmic goitre, the latter 
affection particularly, with an account of some recent views 
(Fitzgerald) of its pathology, form the subject matter of the 
last chapter. Taking at random, as we have done from the 
Avork. before us, these descriptions of some modern advances 
in this important science, we have instanced sufficiently the 
ground it covers, at the same time that readers will under- 
stand how difficult a task is that undertaken by any one who 
would endeavour to condense so large a subject as that of 
ophthalmology into a small handbook of a few hundred pages. 
Indeed, to us, the literary feat seems an impossible one. 
Readino; through this excellent book one cannot but feel, here 
and there, that but scant justice is done to modern ophthalmo- 
logical science in the brief allusions to many important matters 
in the necessarj^ "boiling down" process to which such impor- 
tant matters as affections of the conjunctiva and cornea, 
glaucoma, retinal diseases, and amblyopia have been subjected. 
Xor would it be fair to analyse hypercritically this first effort 
of Mr. Swanzy's to place a reliable and "up to date" book in 
the hand of the student. Perhaps in a second edition, in some 
of the chapters referred to, he will see good reason for enter- 
ing more fully into several topics of etiological and pathological 
interest which can hardly be omitted in an exact description. 
So, also, in point of treatment and tlierapeutics generally, we 
should like to see additions and greater detail, to make the 
work more valuable to the junior practitioner in his daily 
work. But we can say, conscientiously, of this book that, for 
its size, in the information it contains, in the lucidity of its 
style, and the practical directions found throughout its pages, 
there is no work we should prefer to place in the hand of the 
student. 

We have omitted to mention that the book is well 
illustrated throughout, and that, both in the general get up 
and printing, nothing has been left vuidone by Mr. Swanzy's 
publishers. 



Reviews. :37 

A Treatise on the Continued Fevers of Great Britain. By 
Charles Murchisox, M.D. Third Edition, Edited by W. 
Cayley, M.D. London : Lono-mans, Green, & Co. 1884. 

In no country has any Avork on the continued fevers appeared 
comparable in t'uhiess of detail, or in originality, to that of Dr, 
Murchison. Eleven years have elapsed since the issue of his 
second edition, and in the interval good work has been done m 
regard to both the aetiology and the treatment of fevers. The 
time had, therefore, come for a re-issue of the work, but the 
lamented death of the author has rendered it necessary that 
the revision of the book should l)e put into other hands. To 
incorporate the results of modern researches with the well 
known views of Dr. Murchison, without materially altering the 
teaching of the author, at least in some important points, has 
been both a difficult and a delicate duty, but the editor has 
performed his task with great judiciousness. He has been 
guided, as he says in his preface, by the belief " that he would 
best meet the wishes of the medical profession, as well as of 
Dr. Murchison's representatives, by making as few alterations 
in it as possible. He has not, therefore, considered himself 
justified in materially modifying any views expressed b}^ the 
author, and wherever he has thought it necessary to add to or 
dissent from any statements of importance, he has indicated 
this by enclosing the passage in brackets or in some other 
manner." In order to make room for additions, it has been 
necessary- to make some omissions, so as not to increase the size 
of the woi'k. Among these latter we find chapter VII of the 
second edition, that devoted to " Circumstances Influencing the 
Mortality of Continued Fevers at Difl^^erent Places," and a 
large portion of chapter V, dealing with the " Specific Distinc- 
tions of Typhus and Enteric Fever." The latter has been 
curtailed, as the distinction between these fevers is now gener- 
ally admitted ; but we confess to a feeling of regret at this, 
for the discussion of this question was extremely interesting, 
and it was a valuable illustration of the methods of investi- 
gation necessary in the differentiation of diseases somewhat 
similar. Some of the cases adduced by Mui'chison have also 
been omitted, but fresh ones have been substituted or added, 
and new tables from the Reports of the Registrar-General have 
been inserted to show the prevalence of fever is the United 
Kingdom since the date of the previous edition. It may not 
be amiss to point out that these changes have landed the 
editor in several clerical inaccuracies, a considerable number 
of the references in the tt.'xt to cases and tables being incorrect. 



38 Revieivs. 

It would be a •work of supererogation to offer any criticism 
of Dr. Murcliison's book, but we may be permitted to offer 
some remarks on the additions which appear in this re- 
issue. 

Within recent years little has been added to our knowledge 
of typhus, and consequently we find that few additions have 
been made to the chapter dealing with that disease. With 
regard to its aetiology, the editor has contented himself with 
the safe statement, that analogy points to the probability 
"that typhus is due to a specific microbe which requires 
conditions of overcrowding and imperfect ventilation to 
de\;^lop its virulent and contagious properties" (p. 119). To 
thfe general section on the Causes of the Continued Fevers he 
,iias added a note, seeking to bring Dr. Murcliison's de novo 
theor}^ into harmony with the belief in the existence of 
specific micro-organisms, and we cannot do better than quote 
his Avords : — " But this view (that contagious fevers are due 
to parasitic organisms) by no means disproves the possibility 
of their arising de novo, apart from the theory of spontaneous 
generation which few would be inclined to accept. For the 
researches of Pasteur and others have shown that the 
properties of these organisms may be modified in an extra- 
ordinary degree by placing them under different conditions ; 
hence it is quite conceivable that the germs of a disease like 
typhoid or typhus fever might, under ordinary circumstances, 
be harmless, and only acquire virulent properties when under 
the influence of pent up stagnating sewage, or overcrowding 
and imperfect ventilation, in the same manner as the bacillus 
of anthrax may be rendered more or less virulent by being- 
cultivated with the access of more or less oxygen" (p. 12). 
Since Pasteur's well known experiments on the taming of the 
virus of anthrax were published, the principle underlying his 
observations — namely, that a virus may exist of various 
degrees of virulence, has been employed, and with good 
reason, to explain the great difference we find in the mortality 
of various epidemics of scarlet fever, &c. It is no longer custom- 
ary to account for these by referring to that intangible abstrac- 
tion, the "epidemic atmosphere." It seems more reasonable 
to suppose that the microbes of the various fevers (presuming 
that such exist) become modified by circumstances as yet 
unknown, so that at one time the}' are more virulent than at 
another ; and it may even be the case that a virus may become 
so attenuated as to be innocuous, though still capable of having 
its virulence re-developed under proper conditions. If that is 
what Dr. Cayley means, then we are quite at one with him, 



I 



McL'icics. 29 

only that we would entirely discard the term de novo as mis- 
leading. From the use, however, whicli he makes of that 
term, and from his remarks on the ;etiology of enteric fever 
(" some facts Avould indicate that tlie contagion may be de- 
veloped under certain conditions out of other organisms present 
in decomposing matters, which, until they have undergone 
this moditication or transformation are innocuous, or, at any 
rate, incapable of communicating the disease," p. 499) it would 
appear as if he believed tliat a specific organism could l)e 
developed out of a non-specific one. In the present state of 
our knowledge we are not entitled to deny that this may be 
the case, but, so far as our understanding of Pasteur's obser- 
vations goes, we can see no support for it there. Pasteur's 
tamed virus of anthrax still remains the virus of anthrax, 
though quite innocuous ; and anthrax virus has not been 
developed from other microbes, however similar in appearance 
to the bacillus of that disease. 

The only addition to the clinical history' of typhus is a note 
indicating the frequency of inequality of the pupils, a fact of 
no prognostic significance. The succeeding paragraph deals 
with the deafness which so frequently accompanies the specific 
fevers, and we are disappointed to find that Dr. Cayley has 
added notliing to the original statement on that suljject, which 
is distinctly defective. The various fevers are responsible for 
a large proportion of the incurable cases of deafness in our 
midst, and it would have been well, now that aural diseases 
are better understood, to have given a more accurate descrip- 
tion of the causes of deafness in fevers, with some information 
as to the proper treatment to be adopted. 

Obermeier published his discovery of the spirillum of re- 
lapsing fever when Dr. Murchison's second edition was passing- 
through the press, and a note was appended briefly chronicling 
this fact. In the present volume the section on relapsing 
fever contains a concise account of the present state of our 
knowledge on that subject. It is incorporated in the text, with- 
out anything (except dates of references) to indicate that it is 
new. This is a small matter, but we find a similar omission 
in the general section on the theory of fever (pp. 19-21), where 
Liebermeister's views are much more fully detailed than 
in the previous edition, and evidently with a leaning to 
them, thereby tending to convey a somewhat different idea 
from that entertained by Dr. Murchison. Perhaps Dr. 
Cayley's well known favour for the antipj'retic treat- 
ment may have obscured his vision somewhat in i-egard 
to this. 



40 Reviews. 

To the chapter on Enteric Fever we turn with greater 
interest, and here, as miglit have been expected, we find many 
more additions than in any other part of the volume. 

The subject of the infectiousness of enteric fever has always 
been one round which both interest and discussion have 
centred. While all are agreed that the disease is not readily 
communicable from the sick to the healthy, some deny the 
possibility of this contagion, while others affirm it. Dr, 
Murchison's experience was opposed to its being- contagious in 
the strict sense of the term ; he held that the alvine evacua- 
tions were the chief, if not the sole, medium of communication, 
the poison being developed in them after decomposition. But 
it is well known that in his view the poison might be generated 
independently of any previous case by fermentation of faecal, 
and perhaps other forms of organic matter. According to 
him the fresh stools from an enteric case are not infectious ; 
putrefaction must take place to render them so. The position 
taken up by Dr, Cayley has been already adverted to. He 
admits that the poison is most probably a specific contagium 
ricurn; that it is contained in the alvine dischai'ges of persons 
affected, and that it is propagated out of the body in decom- 
posing fffical and other organic matters. At the same time 
he does not discard the de novo theory, as some facts seem to 
him to support the idea that the contagion may be developed 
out of other organisms under certain imperfectly known con- 
ditions, among which must probably be reckoned transmission 
th.rough the human organism. While we cannot deny that 
tliis may be the case, we have already indicated that it seems 
to us more than doubtful. Dr. Cayley is on more secure 
ground when he points out that, while enteric stools become 
infectious only after decomposition, decomposition may occur 
in a very short time, certainly in many cases within twelve 
hours after evacuation. Dr. Collie, of the Homerton Fever 
Hospital, has gone further, asserting that the contagion may 
be conveyed by the fresh stools. As it is extremely difficult 
to be certain of the mode of communication of the enteric 
poison, we consider that this should still be looked upon as an 
open question. We have known of a few cases which seemed 
to corroborate Dr. Collie's view, and, therefore, we would not 
deny that in some instances the disease niay be com}nunicated 
directly. At the same time it is probable that the majority of 
cases arise from infection after decomposition of the evacua- 
tions has taken place, and we are glad to see that Dr. Cayley 
so clearly states that decomposition may take place so soon 
after evacuation. It is to be regretted that he does not give 



Revleivs. 41 

(.letailed int'onnation as to liow the stools should be treated. 
We believe that in a large number of instances the infective 
material is not properly disposed of from first to last, partly 
because the medical man in attendance does not fully 
explain to the nurse or othei" attendant what ought to be done, 
and partly because the carrying out of his instructions has to 
be left to some person not fully alive to the necessity of 
attention to the minutest details as to cleanliness, &c. When 
a nurse has to attend to only one case, or to nothing but enteric 
cases, there is every probability that disinfection and disposal 
of the excreta will be sutKcieiitly carried out. But when a 
nurse has to attend to a large number of other cases, there is 
great risk of slackness in regard to the treatment of the 
excreta ; and hence there is a risk of enteric being contracted 
by the nurse herself, or bj* other patients under her charge, as 
happens now and again, though fortunately but rarely. Hence 
it is that we think no case of enteric fever, if recooiiised, should 
be admitted into our general hospitals, and if, from any cause, 
an outbreak of enteric should occur in a general hospital, the 
cases ought to be removed to a special fever hospital at once. 
When a solitary case of enteric does crop up in a general ward, 
the safest thing, no doubt, is to remove it to the fever hospital 
if the disease is not too far advanced before the diagnosis has 
been reached ; but if the case be required for teaching pur- 
poses, and if dependence can be put upon the necessary 
precautions being carried out, we would leave the removal of 
the case at the discretion of the physician in charge. 

As to the avenue by which the poison enters the system, there 
is a general consensus of opinion in this- countr}^ that it is by 
the alimentary canal in food, and especially in drink, mainly 
through pollution of water or milk. Dr. Cayley says that 
only one case of direct infection of milk, apart from infection 
by contaminated water, has been proved. But it seems to us 
to be probable that milk may frequently become contaminated 
apart from the direct addition of polluted water. For in 
many instances, in the absence of proper care and cleanliness, 
the air of a house containing enteric cases must contain float- 
ing infective particles, given off from the stools, from dried 
discharoes on soiled linen, 6lc. If we ffrant that, then we can 
readily see how infection of milk might occur from the settling 
on it, and multiplication in it, of such infective particles. 
Indeed, in this country w^e are too apt to lose sight of the fact 
that the air may become polluted in this way, and infection 
possibly take place through the respiratory tract, while in 
Germany they are too pi'one to ignore our vie^^'s, and to accept 



42 Revievjs. 

this tract as the chief mode of entrance of the enteric poison 
into the system.* 

A sliort account of tlie so-called microbe of enteric, as 
described by Klebs, Eberth, &c., is given from the pen of Dr. 
Heneage Gibbes. From observ^ations made by himself he is, 
for various reasons, unable to admit that the microbe described 
is pathognomonic of enteric fever. 

To the list of complications and sequehe of enteric fever 
Dr. Cayley has added pericarditis, hemiplegia, and periostitis. 
These are all rare, and it is remarkable that the recent outbreak 
in the Glasgow Western Infirmary furnished one case of hemi- 
plegia with aphasia, and one case of periostitis of the bones of 
the legs. The hemiplegia occurred in a woman, 72 years of 
age, towards the end of the fever, and proved fatal ; unfor- 
tunately no 'post-niorfeni examination was allowed. 

On the subject of the treatment of enteric fever Dr. Cayley 
gives forth no uncertain sound. He is a firm supporter of the 
treatment by cold baths. The objections at various times 
urged against them he discusses concisely. He denies that the 
cold bath, when begun early in the disease, before the heart 
has begun to fail, causes any risk of fatal collapse, of intestinal 
haemorrhage, or of congestion of the lungs. The patients are 
said to come to like the bath, and the mechanical difficulty 
may be overcome by an apparatus for lifting the patient, 
figured in the book. The bath, he says, clears up the typhoid 
state, prevents serious complications, and greatly diminishes 
the rate of mortality. Our own experience of this mode of 
treatment has been extremely limited; we found the mechanical 
difficulty a great obstacle. We cannot, therefore, speak of the 
immediate effects of the bath. But the statistics brought for- 
ward in support of it do not strike us as remarkably good: In 
the only instances in which Dr. Cayley gives the numbers 
treated we find : — (1) That at the Bethanien Hospital of Berlin 
2,228 cases, treated between 1848 and 1867 without the l)ath, 
gave a mortality of 18-1 per cent; while 2,068 cases between 
1868 and 1876, after the introduction of the cold bath, gave a 
mortality of 13"2 per cent. (2) That at the London Fever 
Hospital from 1872 to 1878, there were treated without the 
bath 550 cases, with a mortality of 17 per cent ; from 1879 
to 1882, during which time, at all events, the more severe 
cases had the cold bath treatment, 458 cases were treated 
with a mortality of 13"9 per cent. (3) That at the Middle- 

* Die Acuten Infectionskrankheiten. Bearbeitet voii Dr. Beniliard 
Kiiessner und Dr. Richard Pott. Braunschweig : Friedrich Wreden. 1882. 
This book, by the way, is not mentioned in the BibUography by Dr. Cayley. 



Reviews. 43 

.sex Hospital, from lbG7 to 1877, wht-n bathing was only 
occasional, 423 cases gave a mortality of 16'8 per cent ; 
and that from 1878 to 1888, when bathing had become more 
general, 400 cases gave a mortality of lo'2 per cent, the 
average rate of mortality in iho London hospitals being about 
17 per cent. 

It is well known that there are many sources of fallacy in 
comparing statistics of mortality in fever cases, and notal)ly 
the fallacies arising from the varying severity of different 
epidemics, and from the ages of the patients not being stated 
who make up the different totals. In the absence of details as 
to age and sex, kc, in the figures above quoted, it is fair to 
assume that those would be much about the average, when 
taken over a large number of cases, and we may therefore 
compare with them the statistics at our hand in reference to 
the results obtained in Glasgow over somewhat similar periods, 
and without recourse to the cold bath treatment. The Belvi- 
dere results are as follows : between the 3'ears 1865 and 1870 
Dr. Russell treated 304 cases with a mortalitv of 11 "51 per 
cent. From 1871 to 1878 Dr. Macphail reports* that 2,334 
cases of enteric were treated with a mortality of 11 '3 per cent. 
At the Joint Hospital for the Burghs of Partick, Hillhead, and 
Maryhill the number of cases treated between 1877 and 1883 
was 241, with a mortality of 13"2 per cent. We may set aside 
the figures from the latter source as being too insignificant, 
and confine our attention to the later statistics of Belvidere. 
We find that the death-rate varied from 7'01 per cent out of 
342 ca,ses in 1874-75, to 14'1 per cent out of 283 cases in 
1877-78. Now, even the maximum mortality does not come 
up to the average London one, and the general average is dis- 
tinctly below that obtained by the cold liath treatment. And 
yet it was recently stated that in Glasgow we were behind the 
age in our knowledge of this disease ! So far as statistics are 
concerned, therefore, we cannot see any reason for adopting a 
system of treatment admittedly difficult of application, and for 
which it is not claimed that it cuts short the disease. Of 
course we are not blind to the fact that this might be met with 
the statement that by adopting the cold bath treatment our 
mortality might be still fui-ther reduced. 

Dr. Cayley does not regard drugs as of the same anti- 
pyretic value as cold water, but he has found them useful 
as adjuncts to the cold bath, and in cases in which the bath 
cannot be had recourse to for various reasons. He prefers 
quinine to salicin and its compounds, rightly remarking 
*aias. Med. Journal, Oct., 1879. 



44 Reviews. 

that the hitter may cause depression of the heart's action, 
delirium, and albuminuria. No doubt it is only in exceptional 
cases that these results follow, and they may be due to 
impurities in the drugs ; but we have seen both collapse 
and delirium result from pushing salicin or the salicylates 
to such an extent as to have a marked effect in keeping 
down the temperature. 

Although we have written thus fully on some of the 
questions raised by Dr. Cayley's additions to Dr. Murchison's 
original work, it must not be supposed that these additions 
are voluminous. The book remains essentially that left 
to us by its author, and, though we have had occasion to 
differ in some points from the editor's observations, we 
camiot close this notice of his work without expressing 
our appreciation of the manner in which he has discharged 
his editorial functions. Thouoh he must at times have 
been tempted to modify Dr. Murchision s views, and to 
enlarge upon many of the questions on which he has touched, 
he has held his hand, and his additions are concise. We can, 
therefore, cordially commend this edition to the favourable 
consideration of the profession. 



A Manual of Physiology for the use of Junior Students of 
Medicine/ By Gerald" F. Yeo, M.D., F.K.C.S. London: 
J. &. A. Churchill. lcS84. 

As the title indicates, this manual is written for Junior 
Students of Medicine, and it is of the type of textbooks which 
junior students love. The functions of an organ or sj'stem of 
organs are discussed after a brief description of its structure, 
so that a student does not need to refer to his histological 
textbook when reading up his physiology, for here he finds 
them closely associated. It is, without doubt, the adoption of 
this general method that has made Kirke's Handbook so great 
a favourite among students. Much may be said in its favour. 
For while the space required for histology necessarily 
diminishes what can be devoted to discussions of physiological 
problems, if the book is to be of a handy size, and thus prob- 
ably tends to encourage a method of too detinite and dogmatic 
statement on subjects still not well understood, it yet presents 
to the learner's mind a more general and complete view than 
is otherwise obtainable. After all, it is when the student has 
ol>tained such a general view that he can afford to go on to 
such textbooks as Foster's, for example, for wider discussions 



on the problems ot" pui\' pliysiology. We, tlieret'ore, think 
that Professor Yeo acted wisely in the interests of those for 
whom he was writing-, wlu'ii he determined on this type of 
book. 

After some introductor}' chapters on the objects of 
physiology, the structure and vital character of organisms, 
and the chemical basis of the body, Professor Yeo begins his 
systematic stmly of physiology with the alimentary system. 
After a careful perusal of tlie book, we think the chapters on 
this subject may well be taken as an example of the style of 
the whole work. The systematic wa}^ in which the student 
is led, step by .step, through the consideration of food stuffs, 
the mechanism of digestion, mouth digestion, stomach digestion, 
pancreatic juice, bile, and the functions of the intestinal 
mucous membrane, is worth}- of remark. For though these 
subjects are discussed in separate chapters, the author has 
contrived to link them as closel}- together in his description 
as they are in fact. One gains a sense of ordered thought, as 
the result, very different from the impression derived from 
many textbooks, fitted only to convey the idea that physiology 
consists of a collection of facts and theories, without pervading 
and connecting principles. There is evidence also that the 
author has continiied to keep before him the needs of the 
cla.ss of men for whom he was writing. Thus, now and again, 
he sums up the conclusions that have been arrived at, putting 
in a few sentences the meaning of several previous pages. 
For example, in half a page, he recapitulates the chief facts 
of gastric digestion, the subject of the previous ten pages. 
Another good illustration of this is afforded in the suunnary 
of the facts of salivary secretion. In connection with salivar}' 
secretion, we notice the satisfactory results of introducing here, 
since it is the first time that secretion has been mentioned, a 
description of the method of secretion, and of the changes the 
gland cells undergo during the periods of activity and rest. 
\Ye think Professor Yeo would have extended this method 
with l)enefit, had he described the action of ferments in 
general, just before proceeding to consider the action of 
ptyalin in particular, since ptyalin is the first ferment alluded 
to. For what students need is a means of classifying their 
knowledge. They require to have pointed out to them the 
thread on which many facts hang. Such a general description 
would have served for connecting and comparing the action 
of all the digestive ferments. For the same reason, in the 
admirable and useful review of the action of the digestive 
fluids, given towards the end of the chapters on the digestive 



4() Be r lews. 

system, we should have liked to see what might be called the 
principle of action of all the digestive fluids more insisted on. 
For students, as a rule, have considerable difficulty in 
reniemberino- how each fluid acts. We have found this 
difficulty greatly overcome when they appreciate the idea that 
the purpose of digestion is to render dialisable substances that 
cannot naturall}' pass through animal membranes. They have 
then the key to the whole process. For, since starch albumen 
and fat cai>dot so pass, they must be converted into modifica- 
tions that can. On this thread they can string the facts 
connected with each digestive juice in a way not difficult to 
remember. 

Another feature worthy of remark in these chapters is the 
introduction of practical points that do not necessarily come 
within the scope of a systematic textbook of physiology. 
Thus, methods of testing milk are given, tests for bile, &c. 
In this part of the book the onlj' deficiency that strikes us is 
the absence of any detailed statement regarding the economy 
of a mixed diet. Only a passing remark is made as to the 
practical unsuitability of an exclusive diet. After digestion, 
chapters on absorption Ijlood and circulation, respiration, &c., 
succeed in natural order. They all exhibit the same systematic 
method, and the same care in the manner of arranging and 
cl.issifying that have been already commented on. The only 
criticism one might make is that the physics of the various 
processes has been rather scantily treated. Under absorption 
too little importance is attached to the part played Ijy the 
mere physical process of osmosis ; and under respiration the 
significance of gaseous diffusion, not only in the interchange 
between the blood and the air in the air cells, but also in the 
interchange between the air in the alveoli, and the air inspired, 
is not sufficiently enforced. 

The chapter on the urinary excretion is conspicuously clear ; 
and in the space of three pages the author contrives to give an 
admirable account of the older and the newer views concern- 
ing the mode of formation of the urinary secretion. 

It is unnecessary to comment on succeeding chapters which 
deal with nutrition, the contractile tissues, the nervous system, 
&c. They, equally with preceding chapters, afford evidence of 
being written, by a skilful teacher and master of his subject, 
for men whose special need he is keeping in view. 

The work is copiously illustrated throughout with woodcuts, 
illustrative of structure and of various physiological apparatus 
and methods. The concluding chapters on Reproduction are 
particularly rich in illustration, chaptei's and illustrations 



Rf'viewfi. 47 

wliich will not 1)0 the least appreciated in the book by the 
student. 

We hope the Munxuil will become popular among- junior 
students, for we know ot" none better fitted to convey the 
information thev seek, or to encouratro anionic them a hii;h 
standard of physiological knowledge. 



Clinical and Paflioloij'n-al Oht^er vat ions on Tumoiirs of the 
Ovary, Falloj^ian Tube, and Broad Ligament By Alban 
H. G. DoRAN, F.R.C.S. With 32 Illustrations. London: 
Smith, Elder & Co. 1884. 

This w^ork is the legitimate outcome of a large amount of 
experience and observation, and has the immense advantage of 
being based both on pathological and clinical experience. The 
author states that "since I first joined the staff of the Samaritan 
Free Hospital in the spring of 1877 I have assisted at nearly 
seven hundred abdominal sections." An experience like this, 
carefully followed out. more especially in its pathological 
aspects, was sure to lead to a valuable contribution to medical 
literature. 

There are several points of special interest in connection 
with the ovaries and broad ligaments to which we may 
specially direct our readers. We are here concerned chiefly 
with cystic growths, the solid tumours of these structures being 
relatively rare. It is not long ago since all cysts of these parts 
were called indisci'iminately " ovarian." Recently, however, 
surgeons have become alive to the fact that many of these 
tumours are not really ovai'ian, but that the ovary is often to be 
found adhering to the cyst and no moi'e altered than by the 
pressure and dragging to which it may have been subjected. 
It soon became the habit to call such cysts "parovarian," in the 
view that they take origin in the parovarium. It is now well 
known that such cysts have not only special relations to the 
peritoneum. Fallopian tubes, and ovary, but that they have 
very different characters to the majority of the ovarian 
tumours, their contents generally consisting of a clear fluid, 
while those of the ovarian cysts are usually colloid. The 
important practical point as to the mode of operating in these 
different forms of cystic tumour is intimately related to these 
characters. The " parovarian " cyst, when once emptied, does 
not readily refill, and so the view came to be entertained that 
the proper operation for this kind of cyst is simple tapping, 
which is the more efficacious that these cysts are mostly unilo- 



•i8 Rcrieii's. 

cular. This view is still held l)y no less an authority than 
Thomas Keith, although our author is opposed to it, chielly 
on the ground that some of these cysts contain papillary 
ingrowths which may grow and produce serious results, but 
also l)ecause a loose collapsed cyst may do some damage lying 
ahout the pelvic organs. 

The author rather ohjects to applying the name "parovarian" 
to cysts ai'ising apart from the ovaries. Many of these cysts 
have undoubtedly a parovarian origin, but many of them have 
not, and in a given case of fully developed cyst, the origin is n( > 
longer ascertainable. He prefers therefore to speak of cysts of 
the broad ligaments rather than parovarian cysts. 

Of the true ovarian cysts he distinguishes two foiiiis and 
differentiates them both as to their origin and structure. The 
essential structures of the ovary are the Graafian vesicles which 
are distributed at the peripheral parts of the gland. Besides 
these structures there are at the hilum the remains of the 
Wolffian body. The most obvious relic of the Wolffian body in 
the adult is the parovarium, but the tuljes of this l)ody also 
pass to the hilum of the ovary and are to be found there dur- 
ing ftetal life. Now cysts originate from the Graafian follicles 
on the one hand and from the remains of the Wolffian body on 
the other. The former constitute the great class of colloid 
ovarian cysts, and, originating at the periphery of the ovar}', 
they as it were destroy the organ or replace it. The latter 
give rise to cysts which have serous rather than colloid con- 
tents, and show papillomatous ingrowths in their interior. As 
these originate at the hilum of the ovary they do not destroy 
the organ, at least in the earlier periods, and the ovar}^ can 
often be seen as an appendage to the cyst. These cysts, like 
those of the broad ligament, are frequently sessile, as from their 
situation they tend to luirrow into the folds of the broad 
ligament. 

In regard to dermoid c}^sts, the author believes that the}- 
originate from the Graafian vesicles, but has not much to say 
as to their genesis. He gives a very good description of these 
cysts. 

Besides the subjects referred to above there are chapters 
on solid tumours of the ovar}^, rupture oi ovarian cysts, twist- 
ing of the pedicle, the abdominal wound, notes on adhesions, 
complete intraperitoneal ligature of the pedicle, morbid con- 
ditions of the kidney associated with ovarian tumours, and 
tumours of the Fallopian tube. The chapter on kidney 
disease is important but not perfectly clear. That on the 
Fallopian tubes has some interesting remarks on their normal 



Reviews. 49 

position. The prevalent idea is that the tubes run directly 
outwards from the uterus and so lie in their whole course above 
the ovary. But the author holds that they really form a loop 
around the ovary, the timbriated extremity being really below 
the level of the gland. He says, " I have repeatedly verihod 
this discovery made by Professor His, finding- that the healthy 
ovary hangs from its ovarian ligament obliquely downwards, 
embraced above by the tube, the fimbriai of which lie on its 
surface externally, and, to a certain extent, inferiorly." . . . 
"It is evident that the ripe ova can, by this arrangement, drop 
into the tube, and may fall at once among spermatozoa." This 
position of the tubes is of importance when they come to be 
dilated by obstruction of the fimbriated extremity. In that 
case the dilated tubes " instead of rising high above the ovary, 
as would be the case were the conventional ideas concerning 
the relative position of these structures true, half the dilated 
tul^e coils round the outer side and lower part of the ovary." 
. . . " In cases of foetation within the outer third of the 
tube, the ovary lies above the iVietal sac, between it and the 
inner third of the iuhe." 

We welcome this monograph as giving the carefully tested 
results of modern pathological research as well as practical 
observation in the surgical operating room and ward. 



Brain Exhaustion, with soine Preliininary Considerations 
on Cerebral Dynamics. By J. Leonard Corning, M.D., 
Physician to the New York Neurological Infirmary, &c. 
New York : D. Appleton & Co. 1884. ^ 

The condition to which Dr. Corning has given the name of 
brain exhaustion is one, " the chief feature of which is a 
morbid limitation of the ratiocinative capacity of the indi- 
vidual, consequent upon functional brain disease." In a some- 
what loose and discursive fashion he treats of the various 
symptoms to which this gives rise — and their name is legion — 
presenting a few typical pictures from his case books. There 
is nothing, however, new in these : we are all more or less 
familiar with similar cases due to inattention to the elemen- 
tary laws of health, especially in their bearing on the neces- 
sity of giving a sufficient amount of rest to the nervous 
centres. We are inclined to believe that the author rather 
overshoots the mark in his desire to throw the whole respon- 
sibility for the many ills he talks of upon the nervous system, 
malnutrition of the brain being in his view the first and most 

No. 1. E Vol. xxm. 



50 Revieius. 

important link in the chain of events. It seems to be the 
case, however, that in America physicians see more of such 
cases than we do in this country. This is to be gathered from 
the fact that the literature of the subject is more American 
than European ; and it is admitted by Dr. Corning, who attri- 
butes it " to the institutions of America, v/hich are well 
calculated to promote mental exhaustion," and to the American 
climate, many foreigners domiciled in America declaring that 
" mental exertion is very much more difficult in America 
than abroad." 

Among the chief causes of brain exhaustion he reckons 
the worries caused by the struggle for existence, increasing 
with the increase of civilisation ; false educational methods ; 
abuse of alcohol and tobacco, &c. His views on educational 
over-pressure in our schools are quite in harmony with those 
recently enunciated by Dr. Crichton Browne ; but they lack 
weight from being unsupported by evidence, and there are so 
many loose general statements in the book that we cannot 
attach to them the importance they would have had, had they 
come from an author with whose work we were more favour- 
ably impressed. 

The chapters dealing with general considerations on Cerebral 
Dynamics are, we confess, somewhat beyond our comprehen- 
sion. The only clear idea w^e have of them is that they are 
an attempt to show that the great law of conservation of 
energy applies with as much truth to psychical as to physical 
forces. But the argument is so wanting in lucidity that we 
cannot commend it to our readers. In these preliminary 
chapters the author finds opportunities for explaining the 
phenomena of the emotions, sleep, memory, dreams, &c. With 
regard to the latter, he makes the somewhat alarming 
statement, that " a dream is a phenomenon which detracts 
from the physiological ideal of sleep ; it is therefore essentially 
a morbid production. And, furthermore, inasmuch as it is a 
psj'chical manifestation of morbid brain-function, it consti- 
tutes a species of temporary mental derangement in itself." 

With regard to treatment, he in the main believes that rest 
and over-nutrition, as recommended by Weir Mitchell in his 
little book on Fat and Blood, are the most important indica- 
tions. It is worth noting that for sleeplessness and irritability 
he prefers coca to the bromides, holding that coca produces 
its good effect without depressing the patient as the latter do. 
He gives it in the form of a wine-glassful of Mariani's coca 
wine thrice daily. It may also be mentioned that one of the 
remedies he employs is a rather formidable one, an instrument 



Revieivs. .j1 

(devised by himself) " for electrisation of the sympathetic 
nerve, with simultaneous bilateral compression of the caro- 
tids." Should any one desire further information as to its 
eti'ects, we must refer him to the book itself, the last chapter 
of which is devoted to tliis subject ; but we cannot admit the 
author's " modest assumption " that this " constitutes a valuable 
<leparture in therapeutics," ' and that "it is entirely without 
danger " if proper care be taken. 



Hie Science and Art of Surgerij : a Treatise on Surgical 
Injuries, Disease and Operations. By John Eric Erichsex, 
F.R.S., LL.D., &c. Revised and Edited by Marcus Beck, 
M.S. and M.B. Lond. Vols. I and II. London : Longman 
& Co. 1884. 

It is with pleasure we welcome the excellent work now before 
us. A book of large dimensions and exhaustive charactei-, 
essentially one of reference, rather than a te.xt-book for the 
student of surgery, it is now more than thirty years since 
the first edition was published; since that time the work ha,s 
increased very considerably in bulk and completeness, and in its 
extended and amended form occupies over 2,400 pages, so that 
it may now be said to be beyond the wants of a considerable 
number of students. The large amount of favour which the 
earlier editions received at the hands of students was due to 
the circumstance that the author, while representing faithfully 
the teaching and practice of surgery of the time, managed to 
do so by a book of moderate size and cost. A student is quite 
unable, if attending three or four classes daily, and working 
them conscientiously, to study text-books of more than 1,000 
or 1,-500 pages. We do not wish it to be inferred that the 
work now in our hands contains superfluous matter ; quite the 
contrary, we cannot speak too highly of it. Much care has 
been bestowed on it throughout, and the descriptions of the 
symptoms, pathology, diagnosis, and treatment of surgical 
diseases, are particularly clear and full. 

The portions of the book which treat of pathology have 
V^een entrusted to Mr. Marcus Beck, who, from his practical 
knowledge of the subject, can speak with authority, and not 
as most writers on and teachers of surgery, merel}^ from what 
they have gathered from others. Amongst the writers on 
surgery, even the best, how few show a thorough grasp of the 
.science upon which their art is founded ; not many of them 
have a thorough knowledge of ])ractical pathology, and only a 



52 Revieivs. 

few keep abreast of the advances and changes of the time, so 
as to be enabled to test the doctrines of others by their own 
observation. 

The more we look into the book— it is too large to read 
throughout — the more Ave are satisfied with the way the work 
has been done ; but if there is a fault, it is that too much 
attention has been given to the work and opinions of the 
London School. 

In the first division the first principles of surgery are con- 
sidered, such as the objects of surgical operations, preparation 
for operation, the prevention of haemorrhage during, and the 
constitutional effects produced by, operations, &c. A considerable 
portion of the first chapter is devoted to the consideration of 
anaesthetics, including chloroform, ether, nitrous oxide gas, 
and bichloride of methylene ; but although sixteen pages are 
occupied by this subject, we cannot but admit that it is the 
least satisfactory portion of the book. 

The second and third chapters are devoted to amputations, 
while the fourth, fifth, and sixth are occupied by the discussion 
of local disturbances of the circulation, and inflammation and 
its consequences. These latter chapters are very well written, 
and considering the great diflficulty of the subject, and the 
fact that the process of inflammation is only considered in 
outline, and not as it would be discussed in a book on pathology, 
we must regard the efibrt as highly satisfactory. The chapter 
(xxxiv) on tumours is also good, and those on hernia, diseases 
of the bladder, and diseases of blood-vessels are specially 
worthy of attention. The book is well printed, and the bind- 
ing is good. The illustrations, nearly 1,000 in number, are 
mostly clear and correct, but some of them might be improved. 



On Tumours of the Bladder; their Nature, Symptoms, and 
Surgical Treatment; Preceded by a Consideration of the 
Best Methods of Diagnosing all the Forms of Vesical 
Disease, including Digital Exploration and its Results. 
By Sir Henry Thompson, F.KC.S., M.B.Lond. London: 
J. & A. Churchill. 1884. 

The little book now before us is the work of an observer whose 
opportunities of studying the subject under consideration are 
greater than those of any other living surgeon. It is made up to 
a considerable extent of two lectures delivered by the author in 
June last, at the Royal College of Surgeons. The book is 



Re clews. o3 

divided into four chapters, in the first, the author urges the 
necessity of making a systematic inquiry into, and observa- 
tion of, the symptoms, and he gives a clear outUne of the chief 
points to be observed in examining patients suffering from 
vesical disease. The chief point of interest in the volume is 
contained in the second chapter, which treats of the method 
of performing and the value of digital exploration of the 
bladder in obscure cases of disease. The operation consists 
in opening the membranous portion of the urethra in the 
middle line, so as to admit the linger into the bladder without 
the prostate being incised. The account of the operation is 
given very fully, and is clearly described, and, although not 
in itself a new" one, its application as a means of diagnosis 
is most important, and cannot but be regarded as a great 
advance in vesical surgery. 

Digital exploration of the bladder is of practical value (1) 
in the diagnosis and treatment of every case in which 
symptoms of tumour are present ; also (2) in cases in which 
all the symptoms of chronic cystitis have existed for a long 
period, and in a severe degree, and which persist, in spite of 
long continued and appropriate treatment, and without any 
traceable cause, such as stone, stricture, &c. ; (8) in chronic 
cystitis with prostatic hypertrophy, and of atony of the 
bladder, with aggravation of the cystitis from frequent 
catheterisation; (4) in cases in which the existence of impacted 
calculous or of adhering calculous matter may be suspected ; 
(5) in painful or frequent micturition or bleeding without 
obvious cause, even after opening the bladder ; (6) in adhesions 
between the mucous lining of the bladder ; or (7) in cases of 
haematuria in which the surface of the mucous membrane is 
studded with minute villous papillae. 

The third chapter is devoted to the consideration of the 
history of operations for vesical tumour in the male, and to 
the ph3^sical character and intimate structure of tumours of 
the bladder, together with the symptoms to which they give 
rise, and the physical signs associated with them. 

In the last chapter the author considers the treatment of 
tumours by means of styptics, injections, &c. These he regards 
as of little value, and urges rather operative interfei-ence, 
which he thinks should be practised more frequently than it 
has been in the ])ast. He also describes the method of 
removing new growths from the bladder by the incision of 
the perinseum and urethra, and warndy supports it as being 
superior to the supra-pubic operation, even though the tumour 
may be large and vascular, on account of former operation 



54 Revieivs. 

beino- more advantaoreous for drainao-e, and because of its 
allowing more thorough exploration of the bladder. 

The book is one which every surgeon should possess. We 
have little doubt that the further employment of the simple 
operation of digital exploration of the bladder will prove of 
great value in the relief of suffering, and if carefully carried 
out on the lines indicated by the author, it may be the means 
of bringing hitherto not easily recognisable diseases within 
the range of accurate diagnosis and appropriate treatment. 



Manual of Pathological Histology/. By Cornil and Ranyier. 
Second edition. Re-edited and enlarged. Translated by 
A. M. Hart. Vol. II, part I. London : Smith, Elder & Co. 
1884. 

About two years ago, in our somewhat lengthy notice of the 
first volume of this work, we remai'ked that there was at that 
time a distinct necessity in the English language for a good 
and recent text-book on Pathology. Such a want has now 
in large measure been met by the appearance of several 
excellent works on the subject — works, too, which may be 
looked upon as representative of all the different and conflict- 
ing phases of the present state of pathological science and 
teaching; e.g., the translation of Ziegler, Coats • 3[anual, the 
work we are again bringing under the notice of our readers, 
and, in the domain of practical pathology, Woodhead's Text- 
book. The result is that the student can now no longer conj- 
plain that he has not, in his own language, a sufficient 
selection to chose from ; and we trust that before very long 
he will have at his disposal the present work in its entirety. 

As our previous notice was largely a critical review of 
the general opinions of the authors as expressed in the 
first, it is unnecessary for us now to do more than to give 
a brief outline of the contents of the second volume. It is 
devoted to the discussion of special pathological histology, 
and contains a description of the morbid anatomy of various 
organs. The book consists of two sections — Section I dealing 
with the Respiratory, and Section II with the Digestive System, 
Each chapter begins with an account of the normal histology, 
which greatly aids in the appreciation of the succeeding very 
careful and accurate descriptions of their morbid changes ; 
and the perusal of the text is greatly simplified by the inter- 
position of numerous excellent engravings on wood — 125 in all. 
The descriptions and woodcuts illustrative of the pathology of 



Revlew)<. 55 

acute bronchitis remind us very strongly of the account 
given by Hamilton of Aberdeen in his recently published 
volume on the Pathology of Bronchitis, &c. ; and the fact that 
independent observers have arrived at the same results is 
strong corroborative proof of the correctness of their observa- 
tions. This volume bears out the opinion we have already 
expressed — that the work, as a whole, is certain to rank as 
one of our great standard treatises on pathological histology, 
and as such, we have great pleasure in again recommending it. 



A Treatise on the Theory and Practice of Medicine. By 
John Syer Bristowe, M.D. Lond. Fifth edition. Lon- 
don : Smith, Elder & Co. 1884. 

In our issue for May 1883, we briefly noticed the appearance 
of the fourth edition of this valuable work, and the fact that 
during the present year the publishers have found it necessary 
to issue a fifth seems to indicate that its popularity amongst 
students and others is still undiminished. We have already 
indicated the very high opinion which, as the result of a 
careful perusal of one of the earlier editions, we formed of 
the plan and scope of the work ; and so, while still adhering 
to this opinion, it is only necessary for us now shortly to state 
in what respects the present volume differs from its prede- 
cessors. Although no very great changes have been made in 
the work, its size is considerably increased, and the remarks 
on the Theory of Inflammation, &c., contained in an appendix to 
the former edition have now been incorporated in the text 
under their proper chapters and headings. The introductory 
chapter to the section on Diseases of the Heart has been almost 
entirely re-written, and we think that the result of the 
revision has been a very distinct gain in simplicity and clear- 
ness. Descriptions of the so-called " acute rickets," and of a 
few of the rarer affections of the skin, have been added to the 
present volume, and three new woodcuts have been introduced 
illustrating Koch's bacillus of tubercle, that of the septicaemia 
of mice, and a cardiographic tracing. On the last page of the 
book we notice a shoi't paragraph, introduced while the pages 
were passing through the press, giving a brief notice of 
' Koch's researches on cholera and his discovery of the comma- 
shaped bacillus. 

It will thus be seen that the work is kept thoroughly up to 
date, and it gives us much pleasure again to bring a new 
edition of it under the notice of the profession. 



•56 Mevietvs. 

Regional Surgery, including Surgical Diagnosis : a Manual 
for the use of Students. Part II. The Upper Extremity 
and Thorax. By F. A. Southam, M.A., M.B., Oxon, 
F.RC.S.Eng. London : J. & A. Churchill. 1884. 

In our notice of the first part of this work, we described it as 
treating almost solely of surgical diagnosis, and suggested 
that it would gain by greater detail as to the pathology 
of the diseases named. We are glad, therefore, to observe that 
the second part is much less faulty in this respect than the 
first, the descriptions being much fuller, and the references to 
patliological states more numerous. So anxious has Mr. 
Southam been to include every diseased condition that could 
possibly occur in a given region of the body, that he prefaces 
each chapter with a list of such length as must frighten the 
earnest student, and not a little confuse the enquiring prac- 
titioner; and describes many affections which have little 
surgical significance — such as infantile paralysis, lead palsy, 
paralysis agitans, hemiplegia, pneumonia, &c. Nor does he 
omit the latest fashions in surgery, such as lawn-tennis arm, 
Charcot's joint disease, athetosis, and myxoedema. The book 
throughout gives evidence of great care and painstaking, and 
is remarkably accurate on the whole ; we might join issue with 
him as to the mechanism of the displacement in fracture of the 
clavicle, and we are sure he is in error in describing the 
synovial sheath of the long flexor of the thumb as communi- 
cating with the great synovial sheath of the wrist ; but these 
are small blemishes, and do not seriously impair the general 
accuracy of the work. 



Elements of Practical Medicine. By Alfred H. Carter, 
M.D.Lond. Third edition. London : H. K. Lewis. 1884. 

It is only a few months since we reviewed the second edition 
of this book, not in very favourable terms. From the short 
time taken to dispose of that edition, it is evident that the 
book is popular with medical students. That, however, does 
not lead us to change our mind as to its merits. We all know 
that many students seek to pass their examinations with the 
minimum amount of knowledge, to obtain which they eschew 
the standard text-books, as being too large, and have recourse 
to vade mecums, essentials, &c. These latter might find a 
legitimate place in the student's book-shelf, if they were 
looked upon as subsidiary to the more complete works. But, 
as a rule, the student who invests in the smaller book neglects 



Prira/r i'ractlce. 57 

the better one entirely ; and that is the reason why we object 
to the niultipUcation ot" grind-books. This new edition does 
not dirter in any material point from its predecessor, and 
demands therefore no more comment at our hands. 



Observations de Pneiimonies traitecs prt?* leg Bains froids. 
Par le Dr. L. Gignoux, Mddecin des Hopitaux de Lyon. 
Lyon: Association Typographique. 1883. 

This is a reprint of a paper read at the Societe des Sciences 
Medicales of Lyons, and consists of a careful, brief resume of 
the leading German views on the cold bath treatment, with 
records of a few cases treated by the author. These cases are 
well recorded, and lead one to view this method of treatment 
as one deserving of a fair trial in suitable cases. Dr. Gio-noux 
admits that it does not hasten the crisis or cut short the dis- 
ease ; and he also admits the difficulty of determining the 
cases in which it is to be used, especially as the duration of 
pneumonia is so definitely limited. If the temperature do 
not rise above lO-i' F., and the general condition be good, then 
he hesitates to commence the baths ; but if the temperature 
rise to 105'8° F., baths must be ffiven at once, even thouuh 
there are no complications. Again, all cases of pneumonia 
which present typhoid symptoms, whatever height the tem- 
perature reaches, in his view demand cold baths, with careful 
attention to feeding and stimulation. The degree of cold 
applied and the daily number of baths must vary with each 
case. 



REPORTS OF HOSPITAL AND PRIVATE 
PRACTICE. 



PRIVATE PRACTICE. 

CASE OF GOUTY KIDNEY RESULTING IN A SUDDEN OUTBURST 
OF UR.EMIC POISONING WITHOUT ANY MANIFEST PREMONITORY 

SYMPTOMS. [Reported by R. S. Thomson, M.B., CM., B.Sc, 
Glasgow.]— Friday, 14.th November, 1S84-.—W. A., set. 67 
years, was suddenly seized with an apoplectiform attack this 
morning. 

On enquiry, the following story was given : — He had retired 
to rest the previous night in his usual health, and had risen 



58 Private Practice. 

early this morning to get a drink of water, had returned to 
bed, and was at once seized with the fit. 

He had never any serious illness in his life, which has been 
a very active arid busy one, until the present seizure ; and 
when first se^i he was unconscious and breathing stertor- 
ously ; his pLt'pils, however, responded to light, though slug- 
gishly ; hi.syreraperature was slightly subnormal — viz., 97'8° F. 

Efibrts/were at once made to restore consciousness. An 
enema "was administered, and sinapisms and warmth were 
applied to his body, with the result of producing symptoms of 
r^t'iirning consciousness. Dr. M'Call Anderson's assistance 
'W'as sought in view of the gravity of the symptoms, and we 
were able to diagnose a condition of ursemic poisoning, which 
was fully borne out by subsequent observation. 

As our patient regained consciousness he manifested symp- 
toms of great restlessness and distress. These we were able 
to keep in check by cold applications to the head, and he then 
fell into a somnolent condition, from which he was easily roused. 

His temperature was taken about 1"30 p.m., and indicated 
100° F. ; his pulse was hard and incompressible. The tem- 
perature rose gradually to 101*4° F. at 10 p.m., and had fallen 
again at 1 A.M., on the loth, to 100"6° and gradually receded 
till the normal was reached on the moi'ning of the 17th. 

The urine was drawn off after a lapse of 24 hours, and 
measured about 30 oz. ; sp. gr., 1025 ; high coloured, strongly 
acid, giving no reaction with heat or nitric acid, but yielding 
with the picric acid contact test an opaque area at the point of 
contact, after the lapse of a short period. 

On microscopical examination granular and hyaline tube 
casts were found in abundance with urates and oxalates. 

He was much more conscious, though still dro•v\^sy on this 
morning (the loth), and could move himself when asked to do 
so, but was perfectly oblivious of the day he had lost. With 
the aid of an active purgative voluntary excretion was 
restored, and in the urine, which was voluntarily passed, 
tube casts were found, though not so abundantly as in that 
which was drawn off, and the urine was similar in other 
respects except that the precipitate by picric acid was much 
longer in appearing. 

17th. — His temperature and pulse returned to the normal 
this morning — the fourth day after the attack ; he takes his 
food "well and frequently. 

19th. — Yesterday patient was out of bed for a short time, 
had a good night's rest, took his breakfast well this morning, 
and feels quite ready to resume his duties. He perspired 



Privdtc Pvactice. 51) 

very freely during the niglit, passed about 30 oz. of pale urine 
in 2-i hours; sp.gr., 1020, Avith little or no deposit, and no 
tube easts to be seen. 

24ih- — Patient gets up daily, takes a good deal of exercise, 
enjoys his meals, and is being treated by Trousseau's diuretic 
wine. 

On percussing the cardiac region there is considerable dis- 
placement to the left side, and a systolic bruit could be 
detected ; a sphygmographic tracing indicates a pulse of high 
tension. 

There was no indication of the approaching attack except 
weariness at the end of the day's work, and no manifest signs 
of failing health previous to it. 

lat Dec. — At this date our patient has resumed his duties 
and seems to enjoy his usual health. 

DIABETES MELLITUS IX A CHILD OF 5 YEARS. [Under the 

care of Robert S. Thomson, M.B., CM., B.Sc, Glasgow.]— The 
followinof notes of a case of diabetes are of interest on account 
of the age of the patient and the large quantity of urine 
passed daily : — * 

A. H., aged 5 years, was brought to my house on the 9th 
of August, when the mother gave the history as follows : — 
The patient enjoyed excellent health till three weeks ago, 
when he was noticed to drink from the water tap every few 
minutes. His appetite also was extraordinary. At first these 
were attributed to a childish freak, and he was forbidden 
to take so much water. When water \vas withheld he satis- 
fied his craving for fluid by drinking castor oil, which he 
stole for the purpose. The quantity of urine passed daily 
was large. Bowels had been all along confined. Since his 
illness was first noticed, he seemed to be getting daily more 
and more easily tired, paler, and thinner. 

When seen by me, patient was pale and thin, the muscles 
wasted, soft, and flabby, and he weighed, with his clothes, 32 
lb. 14 oz. Thirst was severe, and while being examined he 
had to be supplied with water, which he drank greedily. 
Immediately after he passed a quantity of pale acid urine, 
having a sweet taste and a sp. gr. of 1035, but free from 
albumen. Fehling's solution and fermentation demonstrated 
the presence of a large quantity of grape sugar. 

*0n account of its great rarity in children, diabetes is not considered by 
Steiner of Prague, nor by Meigs and Pepper. West quotes 18 cases only 
between two and five yeare of age from Prouts, Klitz, Eedon, and his own 
experience. 



GO Meetings of Societies. 

The thoracic organs seemed normal. 

The abdomen was tense and rather hard, but neither pain 
nor tenderness on pressure was complained of. Liver seemed 
natural, and there was no evidence of abdominal fluid. Temp. 
99' F. 

The urine was measured and examined daily till 15th 
Aucjust, as follows : — 



9th Aug. 


Sp. gr. 


, 103.5. 


Sugar, abundant. 


Quantity, 8 pints. 


10th „ 


?) 


1034. 


n 5' 


)> 8 5> 


11th „ 


5) 


1035. 


5) 5) 


". 1^ ." 


12th Aug. 


Sp. gr.^ 


, 1034. 


Sugar, abundant. 


Quantity, 6 pints. 


13th „ 


?5 


1034. 


5? J» 


)) 5 j> 


14th „ 


'> 


1036. 


)? 5) 


7-1- 

5) ' 2 J' 


15th „ 


5) 


103.5. 


)? )? 


5 

5 5 " 5 5 



The urine was free from albumen throughout. 

Treatment. — The usual dietetic treatment was tried, and the 
(quantity of fluid allowed limited, hence no doubt the sudden 
fall in the quantity of urine passed on the 12th. 

On 16th August patient became very ill, and complained of 
pain and tenderness in the abdomen, which was greatly swol- 
len and tympanitic. There was no appreciable quantity of 
fluid present. The symptoms became worse towards evening, 
and during the night he became unconscious, continuing 
so till death, which took place about noon on the 17th. 



MEETINGS OF SOCIETIES. 



GLASGOW PATHOLOGICAL AND CLINICAL SOCIETY. 



Session 1884-85. 
Meeting III. — 8fh December, 1884- 



The President, Professor George Buchanan, in the Chair. 

Professor George Buchanan presented a boy aged two 
years and four months, on whom the OPERATION for the 
RADICAL CURE OF HERNIA had been performed, and said that 



Patlioloijiail ((ltd Clinical faciei ij. 61 

there was nothing very remarkable in the case except its 
rarity. The chihl was hroiiglit into the Infirmary with a 
stranguhited liernia of the left side. The tumour was the size 
of an orang-e, and was hard and resistant. Twenty-four hours 
before admission taxis had been attempted by a medical man, 
but had failed. The hernia had been down before, but on 
that occasion had been reduced. When Dr. Buchanan saw 
him he found that the child had been vomiting, which was 
somewhat rare, and, although not collapsed, was ver}- cold and 
much exhausted. Chloroform was then administered and firm 
taxis applied. This not proving effectual he cut down and 
relieved the stricture, which was \gy\ tight. The bowel was 
of a purple colour, evidently showing that any further attempt 
at taxis might have been attended with evil results. Having 
returned the bowel, he then performed the radical cure by bring- 
ing together the pillars of the external ring with silver wire. 
He had never before seen a case in which the cutting operation 
was required in a child. Mr. Thomas Smith, of the Great 
Ormond Street Hospital for Children, to whom he had written, 
had never seen a case. Three months ago a similar case had been 
dealt with in the Western Infirmary, but as the operation was 
too long delayed the result was fatal. In conclusion, Dr. 
Buchanan remarked that the occurrence of such a condition 
would be a good opportunity, not to say excuse, for performing 
the radical cure, and he would like to know if any of the 
other surgeons present had seen a similar case. 

Dr. Win. Maceiveii remarked that he had once seen a similar 
condition in a child under 9 months of age. When called to the 
case he had inferred that it might be a hydrocele, but found 
that it was not so. Taxis had been tried before he saw the 
child, but ineffectually. When he arrived the child was very ill, 
was vomiting, and the pulse was very weak. He tried taxis, but 
failed. He then cut down, and relieved a very tight constric- 
tion. The bowel was of a dark colour, and had a grey spot 
upon it. The child recovered. In this case he also introduced 
chromic stitches, and brought the pillars of the ring together. 
He had since had a case in the Children's Hospital which he 
reduced hj taxis. 

Dr. David Knox had seen this condition once in a child 
aged 22 months. The symptoms of strangulation were well 
nharked. He performed the ordinary operation, but did not 
stitch the pillars. The child recovered. 

Dr. James Dv/alop said that he had not seen any such cases. 

De. JA:NrES DuNLOP presented a leg which had been ami'L- 



()2 Meetings of i^ocicfies. 

TAXED FOR A VERY EXTENSIVE CIRCULAR ULCER, and asketl 

his house surgeon, Dr. Peacock, to read the following report 
of the case : — 

John Y- , get. 86, a clerk, was admitted on 28th October, 

1884, to the Royal Infirmary. The affection began six years 
ago with a pain at the point of both great toes. Immediately 
afterwards the skin broke at the base of the metatarsal bone 
of the great toe of the left foot, and this opening extended 
superficially, and also in depth. There was very little discharge 
from it. A tumour appeared at the lower third of the tibia, 
and in front of the leg. This burst, and remained open for six 
nionths. In the same way all up the leg superficial ulcers 
appeared. These extended as far up as the middle third of the 
thigh. About 1^ years ago his great toe came off apparently 
Ijy ulceration, and not by gangrene. There was also some dis- 
charge from an opening inthe lower surface of thegreat toe of the 
other foot, but this has healed up. At present the affected leg 
and foot are greatly deformed. Four of the toes are present, but 
are greatly thickened, and are deep brown in colour, and point 
in different directions. What was formerly the second toe now 
appears in the position of the first, and is almost directly at 
right angles to the axis of the foot. There is much thickening 
of the sole of the foot. Along the dorsum is a long ulcer, con- 
tinuous with a large ulcer on the outer side of the leg, about 
9" or 10" long, and 4" broad. This is covered with tolerably 
healthy granulations. On the inner side of the leg there is 
great hardening of the tissues, and at places are hardened 
tubercular masses, brown on the surface. There are some on 
the inner side of the sole of the foot also, and some ulceration 
on inner side of the foot passing round to the back. As high 
as the middle of the thigh the skin is shining, and composed 
largely of cicatricial tissue. It is at places redder, and at 
others whiter than normal, and here and there is all dotted 
over with brown spots, the upper margin of the cicatricial 
tissue being edged with a brown zone. There is some brown 
staining on the buttocks, and on the front of the thigh. The 
other leg is rather healthy looking, with the exception of some 
skin on the dorsum of the foot, which is of the same cicatricial 
appearance as above described. As to the cause of all this it 
appears to be syphilitic. He had venereal disease the year 
before it began. He says he had a " runner." He nevei- 
noticed any spots on his body. He had iio so)-e throat, but 
he was troubled with numerous ulcers on the roof of the 
mouth. The hair of the beard came and is still coming out, but 
not that of the head. His teeth are very much deformed, that 



Piithuloglcal and Clinical Sucidi/. ()."> 

is, the few he has remaining. They are very brown in colour, 
are very much decayed, and are also very irregular. There 
are no signs of old ulceration of the throat. He states that his 
teeth were destroyed by medicine given him by iinqualified 
medical men. He has hev.n much abroad ; he was 17 years in 
Malta, and 3 years in Tripoli. He left Tripoli *i years before 
his leg troubled him. He always enjoyed good health in these 
places. It should have been mentioned that the arteries were 
distinctly atheromatous, and the radial could be easily seen 
pulsating in its tortuous course. 

Dr. Daidup stated that he was under the impression that 
the disease in this instance was syphilis, and of the kind which 
is described as originating in foreign countries — the patient 
had contracted it in Tripoli. Dr. Dunlop referred to a variet}' 
of sypliilis he had seen in Lisbon in 1854, which was called the 
" Black Death," and which was contracted b}^ English sailors. 
He proposed that Dr. Newman and Dr. Steven should examine 
and report upon the case. 

Dr. David Newman showed a brain which was the seat 

of IDIOPATHIC SUPPURATIVE MENINGITIS, and Dr. ALEXANDER 

Robertson read the following report of the case, but a dis- 
cussion of it was postponed till the next meeting of the 
Society : — 

Douglas J., set. about 40, music teacher. Lodging House, 
51 Portugal Street. Admitted about 10 o'clock on the morn- 
ing of 5th December, 1884, in a comatose condition. Attend- 
ant states that he had turned sick, and had vomited about 
12 o'clock of the previous day. He soon after this had 
become unconscious, and h.id continued so till admission. 
Dr. Chalmers saw him, and ordered blisters to be applied 
behind the neck. He afterwards ordered his removal in the 
ambulance to the Infirmary. Previous to this warder states 
that he had enjoyed good health, and had not complained of 
any illness until the present. Patient has resided in the 
lodging house for the last four months. He is said to be 
a quiet, steady man, and has not been in the habit of drinking, 
for some months back at least. 

On examination the pupils were found to be normal ; they 
responded quite well to light. Urine was found slightly 
albuminous, no ursemic smell in breath, and no dropsy pres- 
ent. The fingers and forearm of left side were found to be 
occasionally slightly rigid, anl the left side of face was seen to 
twitch a little momentarily on two occasions. Pulse about 
148 per minute, and temperature on admission 97^. As far as 



t)4< Meetings of SocU'tics. 

can be made out, the heart seems normal, as are also the lungs. 
On examining ears a slight amount of pus is found in left 
meatus. 

Dr. Macfie, aurist, reports as follows : — " Saw patient about 
r80, and on drying out left ear with a camel's hair brush a 
little blood came away. The side of speculum was also noticed 
to be covered with blood. Previous to this, however, he had 
had his ears syringed. The ear is a deep one, but the mem- 
brane can be made out fairly well — from the layer of what is 
now chiefly watery discharge lying on the membrane, and the 
reflection from it. The membrane is perforated behind and 
above the level of the umbo. There is certainly no bulging or 
excessive pressure outwards. The right ear was examined, 
and the greater part of it found obscured with a plug of ceru- 
men ; the portion of the membrane seen was dull." 

Cold afl'usions to head were tried, but symptoms increased, 
and temperature soon rose to 103'4°. 

Dr. Robertson saw patient about 5 p.m., and having sent for 
and consvdted with Dr. Knox, trephining was proceeded with. 
No pus or signs of it discovered, but there was a large exit of 
dark coloured fluid, more especially after the membranes 
were punctured. Patient died about 9"30 P.M. There was no 
paralysis of arms, neither did their seem to be any of legs, 
though a doubt was felt on the latter point. On touching 
conjunctivae the eyes did not close. 

RemarlxS by Dr. Roherison. — On the admission of this 
patient several important questions required immediate con- 
sideration. Was his state the result of injury ? There was 
no mark on head or body, and no bleeding' from ears, nose, or 
mouth, or under conjunctiva to support this supposition. The 
symptoms did not correspond with opium or other poisoning, 
nor with uraemia. The state of the left ear a/qjeared to 
supply a clue, yet the post-moi^tem examination showed the 
instructive fact — viz., a purulent discharge from ear, with per- 
forated membrana tympani and a purulent meningitis without 
any apparent or probable connection between the two morbid 
conditions. A point of interest was the active reflex action 
of the pupils when that of the conjunctiva and orbicularis 
palpebrarum was in abeyance. That is to say, the conjoint 
action of the second and third nerves was preserved at a time 
when the corresponding action of the fifth and seventh nerves 
was paralysed. 

General conclusion. — This is a case of simple primary 
meningitis of the convexity of the brain. 

Dr. Perry stated that the patient whose brain was exhibited 



Pathological and Clinical Society. 65 

was his son's music teacher. He was said to be in the hahit 
of taking opium, and had disappeared for some time. Tliis 
was the first information that he had got of him since. 

Dr. J. Lindsay Steven, in the absence of Professor M'Call 
Anderson, read for him the notes of an obscure case of 
HEPATIC DISEASE, in which there was extensive and generalised 
drop.sy, without apparent cause. 

On the 2nd May, ISS-i, a message boy, Thomas E., set. 18, 
was admitted into Wai'd II of the Western Infirmary, on 
account of a swelling of the whole body, of ten days' duration. 

His family history was doubtful, but as far as could be 
made out not satisfactory, his father, mother, and some of his 
brothers and sisters being dead. 

The illness for which he was admitted was one of a series of 
similar attacks extending over a period of fully seven years, 
the first being attributed by him to getting his feet wet. He 
had six or seven of these in all, generally at intervals of about 
a year, and each was characterised by almost identical symp- 
toms — viz., very pronounced swelling of the whole body, 
scanty urination, pains in the right loin and occipital region, 
and some cough and expectoration, the duration of the attacks 
varying from six weeks to two months. 

When he entered the Infirmary, his illness was of ten days' 
duration, and set in after he had " taken a cold." We found 
very marked dropsy of the whole of the subcutaneous cellular 
tissue, including that of the face, as well as a considerable 
amount of fluid in the peritoneum, and iri both pleural cavities. 

He was pallid, and, had it not been for a suspicion of lividity 
of the lips, presented the typical appearance of a patient 
labouring under tubular nephritis. We were surprised, there- 
fore, to find that . there was no accentuation of the second 
aortic sound (although the first sound was distinctly and 
permanently reduplicated) : that the pulse was soft and 
natural : and that the urine, though scanty and high coloured, 
and of high specific gravity (1028), contained neither albumen 
nor casts. 

There was nothing in the state of the lungs to account for 
the widespread dropsy, though slight bronchitic rales were 
pre.sent. The liver, however, was very deci<ledly enlarged, 
the enlargement being pretty uniform, and measuring about 
.5 inches in the nipple line. 

His tongue was somewhat furred, and he was very thirsty, 
but his appetite was good and his bowels regular. Dr. Steven 
examined the blood microscopically, and found no abnormality 

No. 1. F Vol. XXIII. 



66 Meethigs of Societies. 

except that the red corpuscles were slightly deficient, as 
might have been expected under the circumstances, numbering 
4,640,000 instead of 5,000,000 in a cubic millimetre. 

It is unnecessarj' to dwell vipon the treatment, except to say 
that when we succeeded in increasing the flow of urine there 
was a proportionate diminution in the dropsy. This was 
especially the case during the month of Ma}^ when he was fed 
exclusively upon skimmed milk, and freely purged with 
compound powder of jalap, the urine being then increased 
from ;30 to over 100 ounces per day. 

On the 4th of November, without apparent cause, he became 
feverish, complained of pains in the back of his head and 
neck ; in his extremities ; and in the abdomen, which was 
excessively tender, and soon became tympanitic ; symptoms 
which were accompanied by vomiting and diarrhoea. 

This attack of peritonitis carried h'nn oii' on the 7th of 
November, three days from the commencement of the symptoms. 

Dr. Joseph Coats will describe the results of the jjust-mortem 
examination. I have only, therefore, to add that the case is 
in some respects quite unique, as far as my experience goes ; 
and while the ascites might have been explained by the con- 
dition of the liver, I fail, even in the light of the jjost-mortem 
examination, to make out any satisfactory explanation of the 
extensive and well marked dropsy of the subcutaneous cellular 
tissue, and of the fluid in the pleural cavities ; nor can I 
account for the frequently recurring attacks, all of which, with 
the exception of the last, apparently terminated in complete 
recovery. 

Dr. Josejih Coats described the pathological appearances in 
this case. 

Dr. Joseph Coats said that on making the post-viortevi in 
this case the organ that bore evidence of disease of some 
duration was the liver, but this organ did not present to him 
the appearances which he was accustomed to find in disease of 
the liver. At first sight it looked as if it was a case of 
cirrhosis of the liver, the surface being markedly irregular, 
but there were distinct divergences from the ordinary appear- 
ances of cirrhosis. The orsran was larger than normal, weiohing 
4 lbs. The general colour was paler and the consistence less 
firm than in ordinary cirrhosis. On cutting into the organ it 
appeared that thei'e was much less new formed connective 
tissue than the condition of the surface suggested, and this 
was confirmed by the microscope, which showed much more 
considerable intersection of connective tissue bands at the 
surface than more deeply. It was also seen under the micros- 



Pathological and Clinical Society. 67 

cope that the hepatic cells generally were in a state of cloudy 
swelling rather than of the atrophy and degeneration found 
in cirrhosis. On these grounds ])r. Coats was inclined to 
regard the case as possibly one of subacute parenchymatous 
hepatitis, followed by shrinking, and comparable with the 
subacute parenchymatous intlaunnation of the kidneys. He 
suggested the speculation that this, which is a rare condition 
of the liver, may have given rise to the oedema and dropsy. 
The (Tedema of acute Bright's disease is immediately due to the 
condition of the blood, Ijrought about doubtless by the lesion 
in the kidneys, and, possibly, a somewhat similar condition of 
the blood may be brought about by a diseased condition of the 
liver. 

The other noteworthy condition in the case was acute peri- 
tonitis. No cause of this was found except the condition of 
the liver. Considering the close relationship of the liver to 
the peritoneum, the latter forming a thin capsule applied 
immediately to the surface of the organ, it was not unlikely 
that the inflammation had spread from the liver to the perito- 
neum. The liver is very much more closely related to the 
peritoneum than the kidney, which has first its proper capsule, 
then its fatty capsule, and then the subperitoneal tissue 
sepai-ating it from the peritoneum. 

Dr. M'Vail said that this was the most extraordinary case 
clinically he had ever seen. He had carefully examined the 
urine — the urea was normal in amount, and there was not a 
trace of albumen to be discovered. He had lately seen 
another case of acute general dropsy where there was not a 
trace of albumen. 

Dr. Xeivriuin said that if the dropsy were due to an altered 
condition of the blood induced by the liver, would such an 
alteration not also cause albuminuria ? 

Dr. Flnlay.son said that the case was an interesting one, 
but he thought that the peculiarity of it was perhaps slightly 
exaggerated. The presence of general dropsy without 
albuminuria was by no means rare. Scarlatinal dropsy is 
occasionally seen without alltuminuria. He had at present 
under his care a child with symptoms indicating serious 
mischief in the kidneys, and with no albumen in the urine. 
He was aware that chronic disease of the liver occasionally 
caused general oedema, which was generally supposed to be 
due to an altered state of the blood. 

Dr. Donald Mdcpliail had quite recently seen a case of 
generalised dropsy without albumen in the urine. The liver 
was not enlarged and was not tender. In addition, the patient 



68 Meetings of Societies. 

suffered from breathlessness and palpitation. The state of 
the stomach and bowels pointed to probable derangement of 
the liver, and treatment was directed to this. At present his 
dyspepsia was gone, and the dropsy nearly gone. 

Dr. Perry read the following notes of a case of aneurism 

OF THE aorta RUPTURING INTO THE TRACHEA, and Dr. DaVID 

Newman described and exhibited the specimens. 

Dr. Perry said — J. B., labourer, aged 47, was admitted on 10th 
October, 18S3, into the Glasgow Royal Infirmary, complaining 
of hoarseness of voice, and of pain in the left side of the 
chest, the former symptom having been present for about ten 
weeks, and the latter for a fortnight. He had previously 
enjoyed good health. On admission, he had a slight dry 
harsh cough ; the chest was generally hyper-resonant, and no 
rales were heard on auscultation. The heart's apex beat was 
found displaced downwards towards point of sternum. Sounds 
normal. The right (?) vocal cord was inflamed. He had a 
very peculiar and irascible temperament, and having quarrelled 
with some one in the ward, he left the Hospital irregularly on 
20th October. 

Re-admitted to the Glasgow Royal Infirmary, 2oth October, 
1884. Patient states that he has been for some time under 
treatment in the Western Infirmary, but had not experienced 
any relief from it. He is now complaining of hoarseness and 
weakness of voice, and of pains in the chest very similar to 
what he suffered from when in the Royal Infirmary last year. 
He has pretty frequent harsh cough without any expectora- 
tion, considerable shortness of breath on exertion, and had some 
slight wheezing. The respiratory murmur is equal on both 
sides of chest, and no difference is detected by the finger 
between the right and left radial pulse. The pupils are 
unequal. Examination by the laryngoscope reveals paralysis 
of the left vocal cord. There is dulness on percussion in 
front of chest over manubrium sterni, and extending more 
to the left than to the right side. No dulness posteriorly. 
No bruit nor pulsation can be detected over the dull part, nor 
in the inter-clavicular space. On applying the stethoscope 
about the juncture of the third costal cartilage with the 
sternum, on the right side, the second sound of the heart is 
heard to be appreciably more distinctly accentuated than it is 
heard to be over the situation of the aortic valves. The 
heart's sounds appear to be pure. A mixture of potassium 
iodide and potassium bromide in infusion of gentian was 
prescribed, and the patient was told to keep in bed. 



Pathological and Clinical Society. (>9 

On 5th November he commenced to expectorate small 
(juantities of mucus tinged with blood. The amount of 
blood varied slightly from day to day, being, however, very 
little till the afternoon of the 17th November, when he was 
seized with sudden and very copious haemoptysis, and expired 
within half-an-hour. 

Dr. Newman said that this case had been first brought 
under his notice on account of the condition of the larynx, 
which he had been asked to examine by Dr. Perry. On 
laryngoscopic examination the left vocal cord was found to 
be completely paralysed, and the right cord only responded 
slightly during phonation. Both cords were slightly thick- 
ened, but there w^as no evidence of recent inflammatory 
change. The larynx was unusually large in size, and the 
epiglottis was somewhat rigid. The chink of the glottis, at 
its posterior part, was never seen to exceed an eighth of an 
inch, even during a deep inspiration. Dr. Newman expressed 
his opinion at that time that the paralysis of the vocal cords 
was due to pressure upon the left recurrent laryngeal nerve 
by intra-thoracic tumour. 

At the 'post-inorteni examination the following conditions 
were found : — The cardiac area was found to be almost 
completely covered by the lungs, so that only a small portion 
of the pericardium was visible on opening the chest. There 
was a slight pericardial thickening over the tricuspid area, 
and the pericardium contained about two ounces of clear 
serous fluid. The heart was strictly normal, but there was 
marked atheroma and calcification of the aorta. The only 
fact worthy of note in respect to the condition of the lungs 
was the great injection of the air passages and lung alveoli by 
blood, so that the lower lobe of the left lung was completely 
solidified, and presented very much the appearance of pul- 
monary tissue in a state of red hepatisation, only that on the 
cut surface a large number of small dark red projections 
appeared, and, when these w^ere pressed by the knife, a 
quantity of pure blood escaped. The upper lobe of the right 
lung was much in the same condition as the lower lobe of the 
left lung. On the lower aspect of transverse part of the arch 
of aorta, there is an aneurism, about the size of a small 
orange. The opening into the aneurism is situated about 1 1 
inch above aortic segments, but the aneurism itself occupies 
the whole concavity of the arch, and rests against the left 
bronchus, into which it opens by a small aperture, about size 
sufficient to admit No. 1 catheter. The opening is im- 
mediately below the bifurcation of the trachea. The parts 



70 Meetings of Societies. 

surrounding the aneurism were found to be greatly in- 
durated, so that it was with great difficulty that a dissection 
was made of them. The left vagus nerve was found to 
have become so incorporated in the wall of the aneurism, that 
it was impossible to dissect the nerve strands from the 
connective tissue surrounding them. This adhesion of the 
vagus involved the trunk of the nerve above the point where 
the recurrent laryngeal nerve is given off, so that the latter 
nerve has also become obliterated. The nerves on the right 
side were described as normal. 

The abdominal organs were strictly normal. Dr. Newman 
remarked that the rupture of aneurisms into the bronchial 
tubes was of very frequent occurrence, and that he had now 
collected a considerable number of cases which are preserved 
in the Museum of the Royal Infirmary. The point where 
rupture is most apt to take place is, undoubtedly, at the 
bifurcation of the trachea, and probably this occurrence is 
due to the fact that, during respiration, the trachea and 
bronchial tubes move to some extent, and so cause friction 
against the trunk of the aorta as it passes in front of the 
left bronchus. 

In this case the rupture in the mucous membrane of the 
bronchus was very small and situated upon a slight projection 
caused by the mucous membrane having been dissected from 
the sub-mucous tissue, pi'evious to the final rupture taking- 
place. This mode of rupture is frequently seen in aneurisms 
rupturing into the bronchi, and was first described by Professor 
Gairdner. 

The condition of the lower lobe of the left lung and the 
upper lobe of the right was demonstrated microscopically. 

The air vesicles and bronchioles were completely filled by red 
blood corpuscles, so that it presented the same microscopical 
characters as a hsemorrhagic infarction. The blood appears 
to have been poured out of the aneurism in comparatively 
small quantities at a time, and as it escaped into the bronchus 
instead of being expectorated was carried into the air vesicles 
of the lung by the current of the inspired air. 

Dr. Finlayson read the notes of the case taken while it was 
under his charge. The complaint was chiefiy of hoarseness and 
pain in the region of the sternum. There was accentuation 
and deepening of the second sound. It was thought that the 
symptoms and signs were probably due to aneurism. 

Dr. Joseph Coats showed the brain of a sheep contain- 
ing A PARASITIC CYST. The animal had been affected with 



Glasgow Southern Medical Society. 71 

" sturdy," and after death a cyst was found occupying the 
greater part of the right temporo-sphenoidal lobe. This cyst 
was composed of connective tissue but inside it was the 
chitinous cyst of the parasite. This also was shown, and it 
could be seen that though there was only one thin-walled cyst 
there were many small heads projecting from its internal 
surface. These heads were seen under the microscope to 
possess four sucking discs and a circle of booklets, resembling 
the head of the taenia solium. The condition presented is the 
scolcx form of a tapeworm which is common in the dog, the 
taenia coenurus. Dr. Coats pointed out that this is a totally 
different creature to that which causes hydatids of the liver, 
the taenia echinococcus, the heads in the present case being 
very much larger. 



GLASGOW SOUTHERN MEDICAL SOCIETY. 



Session 1884-85. 
Meeting III — 13th November, 188Jf.. 



The President, Dr. A. Napier, in the Chair. 

Mr. Peter Maclean, M.B., CM., and- Mr. Matthew Martin, 
M.B., CM., were balloted for, and unanimously elected mem- 
bers of the Society. 

The President showed specimens from, and read notes of, a 

CASE OF multiple FCETID ABSCESS OF THE RIGHT LUNG FROM 
IMPACTION OF A FOREIGN BODY (ELDER PITH) IN A BRONCHUS. 
This will be found at p. 11. 

Dr. Finlayson, after referring to various points in Dr. 
Napier's case, to the difficulties of the diagnosis, mentioned 
a somewhat similar case which had come under his notice 
in 1876. It was that of a young man who had suffered 
for a year and a half or two years from well marked 
symptoms of phthisis. He had been examined by several 
physicians, who agreed in pronouncing it to be a case of 
phthisis. The patient was sent abroad, and spent one 
winter in the south of France. When seen by Dr. i'inlayson 
the patient was evidently in a hopeless condition ; he was far 



72 Meetings of Societies. 

advanced in phthisis, and the signs of cavity could easily be 
made out. The only element of doubt in the case was that 
the family history was exceedingly good, with no phthisical 
taint. The patient then began to expectorate very foetid 
pus — quite a new feature in his case. Then it came out 
that about 18 months before, at the beginning of his illness, 
the patient had swallowed a mutton bone ; he had all along 
maintained that the bone had not gone down properly, that he 
could still feel it, but the statement was not really believed in 
by his friends. When the patient died there was found firmly 
hxed in the left bronchus a mutton bone liinch long and | 
inch broad. The cavities referred to existed only in the left 
lung. 

Another case somewhat of this nature had come under Dr. 
Finlayson's notice, and was recorded in the Glasgow Medical 
Journal for April, 1883, p. 313. [Patient was a young man, 
aet. 22 ; suffered from vomiting, cough, and emaciation ; expec- 
toration and breath had a gangrenous odour; cavity in left 
lung ; on taking food vomiting at once began, and was accom- 
panied by coughing. At post-r)iorter)i examination there was 
found a perforating ulcer of oesophagus, opening into left 
bronchus. The foreign body in this case was the food 
.swallowed]. 

A third case of a slightly similar character was narrated by 
Dr. Finlayson. It is recorded in the November number of 
this Journal, 1884. In it the foreign material was decomposing 
pus coming from the opposite (the right) pleural cavity ; this 
entered the left bronchus, and seemed to set up suppurative 
inflammation at the base of the left lung. 

Dr. Finlayson then described a fourth case which he had 
recently seen. It was that of a child who had been brought 
to the Western Infirmary, suffering from symptoms of croup, 
but with the history that its illness was due to the swallowing 
of a button of pyramidal shape. Dr. H. C. Cameron was of 
opinion that the button was in the trachea, basing this 
view on the history and on the croupy symptoms. Dr. 
Finlayson thought it improbable that such a large object 
could have lodged there without at once causing violent 
symptoms of irritation and coughing. Tracheotomy was 
performed, but no button came up into the operation wound 
with the cough which followed, nor could it be grasped with 
forceps. On examination after the death of the child, it was 
found that both physician and surgeon were right ; the button 
had passed into the oesophagus, where it had lodged, while its 
pointed end had caused ulceration, and had forced its way 



Glasgow Souther n Mrdlcal Society. 7S 

into the trachea. The position of the button was such that 
probangs introduced during life had passed by its side into 
the stomach. 

Mr. T. F. Gihnour spoke of having met with one case of 
pneumonic abscess, with recovery. The patient was a woman, 
a,ged oO, wlio presented all the symptoms of abscess of the lung; 
she had high fever, and expectorated purulent matter having a 
most fa'tid odour ; she had vomiting with the cough, much 
dyspmra and jactitation. The sputa were sometimes prune- 
juice coloured. She was much emaciated, and perspired freely, 
and suticred from severe pain in right side at the base of the 
lung. In the way of treatment the drugs chiefly relied on 
were sulphide of calcium and morphia. Only one lung was 
affected, the right, at the base. 

Mr. Gilmour gave some details of another case in which 
abscess had followed acute pneumonia, the latter appearing to 
subside by lysis instead of by crisis. The consolidation per- 
sisted, and abscess formed. Soon after she developed strumous 
osteitis of the ankle, for which an operation was performed, 
and the patient died. 

Dr. R. Pollok related the case of a girl of seven, who was 

supposed to have caught cold while playing in a draught}^ 

close. This was followed by cough and fever. Loud sonorous 

mucous rales were heard in the apex of the right lung; there 

was very rapid breathing, and abundant mucous expectoration 

tinged with blood. The child seemed to be sufferino- from 

. . . . ^ 

acute phthisis, and a bad prognosis was given. The symptoms, 

however, were rather alleviated, when, on the 14th day, after 
the patient had had several doses of a "carbonate of ammonia 
mixture, there was suddenly expectorated a piece of earthen- 
ware, which had been broken off a doll. Then it was remem- 
bered tliat on the day the child fell ill the doll had been 
bought, and it was found that the piece coughed up corresponded 
to a deficiency in the doll. The child recovered. Dr. Pollok 
mentioned the taking of the carbonate of ammonia mixture as 
a coincidence, rather than as causing the expectoration of the 
foreign body. 

l)r. Ghilster had some difficulty in making the clinical 
history of Dr. Napier's case fit in with all that was discovered 
on post-'niortem examination. He fancied there must have 
been abscesses in the upper lobe of the lung, as the pith 
(which formed the foreign body in this instance) would swell 
and prevent any pus coming up from below. The sneezing 
cough, also, he associated with irritation of the pneumo-gastric 
nerve. As in the case described there had been some difficulties 



74 Meetings of Societies. 

in diagnosis, he described a case in which simihxr difficulties 
had been encountered, and differences of opinion elicited. The 
patient was a young woman, who suffered from right pleurisy 
with effusion. She was making favourable progress when 
suddenly the temperature went up, and empyema was found 
to exist. Some consolidation was also detected at the right 
apex. A consultant, whose opinion was taken, took a different 
view of the case, found only apex mischief, and stated that there 
was no fluid in the chest. The patient was sent to the 
country, when the practitioner who was in attendance there 
shortly afterwards evacuated through the chest wall an 
enormous quantity of purulent matter. 

Dr. Stirton remarked that the specimens of pith shown were 
certainly the pith of a species of elder but not that of the 
sambucus nigra, which was smaller and denser. He assured 
Dr. Glaister that such pith would not swell in fluid, nor would 
it contract, or soften, or putrefy. In this particular case he 
thought it not unlikely that a certain amount of air might 
pass the obstruction inwards, but as the expiratory forces were 
less only a very little would pass it outwards ; still, that some 
air would pass upwards was certain, simply from the elasticity 
of the air itself. 

Dr. James Morton thought that the appearance of a foetid 
purulent discharge after a mucous discharge should always 
make us suspect the presence of a foreign body. But the 
diagnosis in such cases as the present, with no history to aid 
us in coming to a conclusion, was always difficult. In the 
matter of operations on the chest one could not be too cautious; 
he had very often been asked to puncture the chest, but 
in the majority of cases he had declined, and had seen no 
reason to regret following such a course. No puncture should 
be made unless the diagnosis was absolutely certain. It was 
well to be sure that the fluid did not permeate the whole of the 
body as well as the chest, as in anasarca. He had been asked 
to puncture the pericardium, but had declined, even after con- 
sultation ; and at the post-morter)i examination in that case 
there was but little fluid found in the pericardial sac. He 
thought that abscess of the lung might occasionally be very 
properly treated by surgical means, by evacuating the cavity 
externally. 

Dr. Napier replied shortly on the discussion. 



Media d Items. 7-"> 

MEDICAL ITEMS. 

UNDER THE DIRECTION OF 

ALEX. NAPIER, M.D. 

Cocaine : The New Local Ansesthetic. — The followinf^ 
account of this new druo-, by Dr. W. Murrell, appears in the 
London Mrdiail Record for loth December, 1884. 

The literature of this subject has ah^eady attained such 
extensive proportions that it is no easy matter to cope with it. 
Cocaine appears to have been first isolated and extracted from 
the leaves of the coca plant {Erythroxylon Coca) by Niemann 
in 1860, although some would claim the honour for Gadeke. 
In 1862 Lossen discovered in the same leaves a second prin- 
ciple which was named hygrin, and was found to be of a 
volatile nature. The other constituents of the plant are 
ecgonine, coca-tannin, and a peculiar wax. It is said that the 
yield of cocaine from the leaves is not more than from 0"02 to 
0"2 per cent. 

Cocaine has a bitterish taste, and crystallises in shining 
monoclinic prisms.* Its chemical formula is C^^ H.,^ NO^. It 
is soluble in 704 parts of water, and also dissolves readily in 
alcohol, chloroform, ether, oil of cloves, vaseline, and castor-oil. 
When treated with strong hydrochloric acid, it forms ecgonine. 
It unites with acid to form salts, the best known being the 
hydrochlorate, the citrate, the salicylate, the nitrate, the sul- 
phate, the oxalate and the tannate. The muriate or hydro- 
chlorate is the salt in connnon use. It consists of small, white 
needle-shaped crystals, which in some specimens are so minute 
that the powder appears to be amorphous. It has a peculiar 
characteristic odour, and is soluble in water (1 in 4) and in 
alcohol. It possesses antiseptic properties, a 5 per cent aqueous 
solution delaying the putrefaction of meat for some days. The 
citrate occurs in the form of .small white crystals, and is the 
salt best adapted for dental operations. 

Respecting the physiological action of the drug, it may be 
said that comparatively little is known. Niemann, as long ago 
as 1860, noted the fact that when applied to the tongue it 
produced anaesthesia. Schroft", in 1862, found that doses of 5 

*"The History and Properties of Cocaine." — The Medical Record (New- 
York), Nov. 8, 1884. "Hydroclilorate of Cocaine, the New Local Anaes- 
thetic."— Z?ri<?sA Medical Journal, Nov. 29, 1884. " Cocaine and it.s Salts." 
By E. Merck, Darmstadt. 1884. "Cocaine and its Salts." By William 
Martindale. London : 1884. 



76 Medical Items. 

centio-rammes administered to rabbits gave rise to disturbance 
of pulse and respiration, and also produced temporary 
mydriasis. Fronmliller, a year later, showed that doses of 3 
to 33 centigrammes caused in man little or no disturbance. In 
1874, Dr. Hughes Bennett* published his well known experi- 
mental incjuiry into the physiological actions of theine, caffeine, 
guaranine, cocaine, and theobromine, and demonstrated that 
cocaine exerted its influence chiefly on the sensory nerves, and 
was an ansesthetic. In 1876, Dr. Ott published a paper on 
cocaine, and showed that it dilated the pupil.-f- These obser- 
vations, however, appear to have been forgotten ; and although 
various preparations of coca have been largely employed as 
therapeutic agents, the active principle itself was rarely used, 
and its very existence was probably unknown to the majority 
of medical practitioners. Suddenly, however, the whole aspect 
of affairs was changed. On Sept. 15, 1884 — a date long to be 
remembered in the annals of therapeutics— Dr. Karl Koller, of 
Vienna, demonstrated through his friend. Dr. Brettauer, of 
Trieste, at the Ophthalmological Congress at Heidelberg, the 
action of a solution of cocaine when applied to the eye. Dr. 
Koller, it appears, had long been aware that cocaine acted as a 
local anaesthetic to the larynx, and it occurred to him that similar 
results might be obtained if it were used for other mucous 
membranes. At the Heidelberg Clinic two drops of the solu- 
tion were dropped into the eye of a patient experimentally, 
and in a few minutes it was noticed that the sensitiveness of 
the surface was below normal. A drop or two more and the 
anaesthesia was complete ; a probe was pressed upon the cornea 
until its surface was indented, it was rubbed over the surface 
of the cornea, it was rubbed over the conjunctiva, a speculum 
was introduced and separated the lids, and they were stretched 
to their utmost, the conjunctiva was seized with a pair of 
forceps, and the globe was moved about in various directions, 
but there was no pain, and the patient declared that he 
experienced no inconvenience of any kind. Before the experi- 
ment the eye had been tested, and was shown to possess the 
normal sensitiveness ; the other eye, which was not treated, 
remained in this respect perfectly normal. At lii'st a 2 per 
cent solution was used, but sulisequently it was increased to 4 
per cent. 

A knowledge of this wonderful discovery spread quickly, 
and in a few days there were hundreds of workers in the field 
which had been so suddenly opened to them. Cocaine was 

* Edinburgh Medical Journal, Vol. xix, 1873-4. 
t The Medical Record, New York, 1876. 



Medical Iteintt. 77 

dropped into the eye, rubbed into the skin, applied to the 
larynx and pharynx, and even injected into the rectum and 
^■agina. The price of the drug rose rapidly, and physicians 
were found only too pleased to pay half-a-crown a grain for 
the privilege of trying it. Every one seemed anxious to do 
something to associate his name, in however small a degree, 
with so momentous a discovery. The result has been the 
publication of a host of papers and articles, many of them dis- 
playing only too obviously the signs of haste and crude 
experimentation. Many of these productions are best left 
unnoticed, but there are several important papers which will 
well repay attention. 

Professor Agnew,* of New York, in recording his experience, 
says : — " We have used the new agent in our clinic, at the 
College of Phj'sicians and Surgeons, with most astonishing 
and satisfactory results. If its further use should prove to be 
equally satisfactory, we shall find that we possess an agent for 
the prevention of suftering in ophthalmic operations of inesti- 
mable value. It is difficult to avoid expressions of extreme 
enthusiasm in view of what we have to-day seen, and in view 
of what we may rationally expect from further applications 
of the agent." He gives details of six cases in which various 
operations on the eye were performed with no other anaesthetic 
than cocaine, the results in every case being most satisfactory. 

Professor Knapp, of New York,-f- as the result of obser- 
vations made on himself and members of his family with a 4 
per cent solution, found that cocaine possesses well marked 
mydriatic properties. The pupil begins to dilate in from ten 
to twenty minutes, increases slowly in size, attains its maxi- 
mum in from thirty to forty-live minutes, and then slowh' 
diminishes. The diminution of sensibility becomes manifest 
in about three minutes, increases for from ten to twenty 
minutes, then decreases, and is over in about half an hour. 
The range of accommodation is shortened, the near point being 
moved from the eye whilst the far point is stationary. Similar 
results have been obtained by Dr. William Oliver Moore,-f-:|: Dr. 
James L. Minor,| Dr. E. 0. Shakespeare,-f- Professor William 
Thomson,-f- and Dr. R. J. Levis,§ of New York ; by Dr. Bradford,! 
of Boston; by Mr. Cowell, Mr. Anderson Critchett, and Mr. 
Juler, of London,^ and by Professor Gayet, of Lyons. Many 
of these gentlemen have performed important operationx 
under its influence. 

• The Medical Record, New York, Oct. 18, 1884. 
+ Ih-id., Oct. 25, 1884. + Ibid., Oct. 25 and Nov. 8, 1884. 

§ Ihid., Oct. 18, 1884. || Ibid., Nov. 8, 1884. 

^British Medical Journal, Dec. 6, 1884. 



7<S Medical Items. 

Dr. St. John Roosa,* Dr. Semon,-f- Dr. Goodharfc,^ and other 
observers, have used it to produce aua3sthesia of the larynx, 
pharynx, and other parts, and one and all declare that the 
effects are most remarkable. In many forms of ear-disease it 
has been found especially beneficial. Mr. Brock and Mr. 
Arkle,-|- of University College Hospital, London, have used 
it hypodermically in two minor operations, and speak well of 
it. In cases of supra-orbital neuralgia, a 10 or even a 20 per 
cent solution in oil of cloves rubbed into the part affords 
almost immediate relief. There is no case of poisoning on 
record, and in one instance a gramme and a half produced 
very little effect. There can be no doubt that it is a most 
useful remedy, and that it will prove of great value in the 
treatment of a large number of painful affections. 

Diffuse Peritoneal Tuberculosis with Local Abdominal 
Intumescence. Treatment by Operation. — Konig (of 
Gottingen) in Centralbl. f. Chir. for 9th Feb., 1884, describes a 
special form of tubercular peritonitis to which his attention 
has been drawn liy the close analogy it presents to synovial 
tuberculosis of joints. 

" There is a class of apparently cystic tumours, which I have 
as yet met with in women only, which present great difficulties 
in diagnosis. Usually there is the gradual formation of a 
tumour, "which may be sitiiated anywhere in the abdominal 
cavity, and which, when small, may be strikingly movable, 
but if larger and subtending the abdominal parietes loses its 
mobility and will then sinmlate an ovarian cyst. In all cases 
there is fluctuation, .but of a special character — viz., undulation 
{weUenhewegung), which serves to distinguish them from 
ovarian cyst. That is to say, that there being but slight ten- 
sion in the cystic cavity, the fluid moves from side to side wdth 
larger waves, clearh^ visible as undulations beneath the 
parietes. Not seldom one finds besides a large tumour one 
or more smaller ones, not always continuous with it. Some- 
times these latter become after a time merged into the larger, 
so that they can no longer be felt separately. These tumours 
occur in old and young, in those obvioiisly suffering from other 
tubercular diseases, and in those apparently otherwise healthy. 
The local condition, when such signs exist, is usually a diffuse 
peritoneal tuberculosis, with the formation of locally encysted 
eff'usion." Reasoning by the analogy to tubercular synovitis 

* Boston Medical and Surgical Journal, Nov. 6, 1884. 

t British Medical Jo'/rnal, Nov. 29. 1884. 

I The Medical Record, New York, Nov. 8, 1884. 



lior>h-'<, <{•(•., Rrceivnl 70 

referred to above, Konig has on several occasions adopted t'oi- 
the peritoneal aftection the same method of treatment that 
he uses for joints — viz., incision, washing out with carbolic 
solution, and rubbing the diseased surface over with iodoform. 
In the original paper, details of several cases are given where 
this treatment resulted in cure of the disease. In all three 
the encysted collection of fluid was opened by laparotomy, the 
adhesions examined, miliary tubercles seen, and their true 
nature ascertained by microscopic exaniination of portions 
removed for that purpose. One patient was dismissed from 
hospital a month after the operation, but had in the interval 
developed signs of incipient phthisis. Another, aged 30, at the 
time of the operation, was in good health two years afterwards, 
and had in the interval passed through an acute attack of 
pleurisy with effusion. The third remained well fifteen months 
after the operation. 

This form at least of tubercular peritonitis Konig suspects 
originates in the bursting of mesenteric or retroperitoneal 
caseated (tubercular) glands. — D. JVl'P. 

Aseptic Suture Silk. — According to Partsch {Deutsche 
Med. Zeitwng., 1883, p. 217) ordinary silk for sutures may be 
rendered perfectly aseptic by steeping it for two days in a 
ten per cent solution of iodoform in ether, and then drying 
it between two folds of blotting paper in a warm room. 
This aseptic silk is specially useful for wounds about the 
mouth, face, or genitals, does not cause suppuration when 
left long in the tissues, and has the great advantage that it 
can be kept in stock dry. — Centralhl. f. Ghir. 19th April, 
1884.— D. M'P. 

A New Gra.fting Material for Ulcers. — Dr. Wilson, of 
Louisville, has used with success the inner membrane of a 
hen's egg for skin grafting. One egg will supply an indefinite 
number of grafts. — Bosfoii Med. and Surg. Juurn. 26th 
June, 1884— D. M'P. 



Books, Pamphlets, (2fc., Received. 

Clinical Lectures on the Practice of Medicine. By the late Robert 
J. Graves, M. D., F.R.S., to which is prefixed a Criticism by 
Professor Trousseau, in two volumes. Vol. I. London : The 
New Sydenham Society. 1884. 



80 Books, &c., Received. 

A Treatise on the Science and Practice of Midwifery. By W. S. 

Play fair, M.D., F.R.G.P., in two volumes. Fifth edition. 

London : Smith, Elder & Co. 1884. 
Dental Caries : a Critical Summary ; and the Prevention of Dental 

Caries. By Henry Sewill, M.R.C.S. and L.D.S.Eng. London : 

Bailliere, Tindall, & Cox. 1884. 
Elements of Practical Medicine. By Alfred H. Carter, M.D. Lond. 

Third edition. London : H. K. Lewis. 1884. 
Aids to Public Health. By J. L. W. Thudicum, M.D. London : 

Bailliere, Tindall, & Cox. 1884. 
The Condition of Gaols, Hospitals, and other Institutions as described 

by John Horan. By Jas. Blake Bailey. London : H. K. 

Lewis. 1884. 
insanity and Allied Neuroses, Practical and Clinical. By George H. 

Savage, M.D. With 19 illustrations. London: Cassell & Co. 

1884': 
On Mammalian Descent: the Hunterian Lectures for 1884. By W. 

Kitchen Parker, F.R.S. With addenda and illustrations. 

London : Chas. Griffin «fe Co. 1885. 
A Text-book of Human Physiology, including Histology and Micros- 
copical Anatomy, with special reference to the Requirements of 

Practical Medicine. By Dr. L. Landois. Translated from the 

fourth German edition. By Wm. Stirling, M.D., Sc.D. With 

very numerous illustrations. Vol. I. London : Chas. Griffin 

t Co. 1885. 
The Transactions of the Edinburgh Obstetrical Society. Vol. IX. 

Session 1883-84. Edinburgh : Oliver k Boyd. 1884. 
Spinal Deformity in Relation to Obstetrics. By A. H. Freeland 

Barbour, M.A., B.Sc, M.D. Edinburgh and London : W. k 

A. K. Johnstone. 
Health Lectures delivered in Manchester 1882-83, 1883-84. Sixth 

and seventh series. Manchester and London : John Heywood. 

1885. 
Lectures to Women. By Dr. Alice Ker, Leeds. Manchester and 

London : John Heywood. 1884. 
Hints on Health to the Over-worked. By Dr. Stewart. Manches- 
ter and London : John Heywood. 
The Harviean Oration delivered at the Royal College of Physicians, 

London. By J. Russell Reynolds, M.D., F.R.S. London : J. 

k A. Churchill. 1884. 
The Pharmacopeia of the British Hospital for Diseases of the Skin, 

London. Third edition. Edited by Balmanno Squire, M.B. 

London : J. & A. Churchill. 1884. 
The Most Delightful Voyage in the World. England to the Cape 

of Good Hope, and South Africa as a Health Resort. By A. 

Wilmot, F.R.G.S. London : Richards, Glanville cfe Co. 1884. 



THE 



GLASGOW MEDICAL JOURNAL. 



No. II. February, 1885. 



ORIGINAL ARTICLES. 



CASE OF ECZEMA FOLLOWING THE COURSE OF 
THE SMALL SCIATIC AND SHORT SAPHENOUS 
NERVES. 

By frank SHEARAR, M.B., 
Dispensary Physician, Paisley Infirmary. 

( ^y^th a PliotograpJtic Plate.) 

This eruption, a photograph of which is appended, is a very 
interesting one, because of its exceptional character, its evident 
neurotic origin, and its lengthened duration. It is essentially 
eczematous in its nature ; it extends, as a continuous ribbon- 
shaped band, from the left Ijuttock to the base of the little toe : 
it corresponds, to a considerable extent, with the courses of the 
small sciatic and short saphenous nerves ; it has been in 
existence, in part at least, for nearly eighteen months ; it 
began without any apparent cause, and it has not been 
associated at any time with neuralgic pains, or with any 
alteration in sensation. 

27th Xov., ISSJi. — The subject of this peculiar eruption is a 
thin, but fairly healthy, boy of thirteen, who has never hitherto 
suffered from any neurotic affection. Nearly eighteen months 
ago he noticed that the skin behind the knee joint had become 
thickened and roughened, and that it was red and itchy. This 
condition slowly extended downwards to the prominence of 
the calf and upwards to the buttock, and latterly, within the 
last six months or so, it has spread still farther downwards 
to the little toe, and for four or five months it has undergone 

No. 2. G Vol. XXIIL 



82 Mr. Shearar — Case of Eczema follounng the 

little or no change. As it spread, it was red, itchy, and leeted 
a good deal. 

At present the appearance of the eruption is very striking. 
It is dark red in colour ; it is covered in many parts by thin 
scales or scabs ; it is distinctly raised above the general surface 
of the skin ; its margins are well defined ; it extends as one 
unbroken band from the buttock to the toe, and the neighbour- 
ing skin, except at a few points, is perfectly healthy. Its 
breadth varies from i^th of an inch to 2 inches. It is broadest 
on the most prominent part of the buttock, and here its appear- 
ance suggests the idea that it has become frayed out into three 
diverging portions, each little narrower than the parent stem, 
and separated at their upper extremities by little V shaped 
patches of healthy skin, the outer division reaching higher upon 
the buttock than the middle one, which, in its turn, extends 
hig-her than the inner one. At the margins above there are 
some smaller isolated patches. From this head, the stem of 
the eruption extends downwards, with a slight inclination, at 
first inwards, and then slightly outwards, along the inner 
aspect of the back of the thigh to the popliteal space, and in 
its course is gradually narrowed till, at the middle of the 
thigh, it is about f of an in. broad, and so continues till the knee 
is reached. It now broadens out somewhat irregularly till it 
reaches the prominence of the calf, when it begins again to 
narrow, and forms a regular curve at first downwards and 
inwards, almost to inner aspect of leg, and then downwards 
and outwards to a point over the insertion of the tendo Achilles, 
reaching its narrowest at the point of greatest convexity of 
this curve. It then bends sharply round the heel, and passes 
along the outer margin of the foot till the proximal end of the 
metatarsus is reached, when it curves upwards on to the 
dorsum of the foot, and ends abruptly at the base of the little 
toe, where it is about i an inch broad. 

Immediately below the knee, where the eruption broadens 
out, the margins are broken by little detached points, and 
there are two quite separate portions external to and parallel 
with the main band of the eruption. The superior of these 
two is in the lower part of the popliteal space, and is a narrow 
line about 1^ inch long; the inferior is on the prominence of 
the calf, and is more irregular and patchy, but its long axis 
corresponds with the commencing curve inwards of the main 
line of the eruption, and it measures 3 inches in length. 

On the buttock, as elsewhere, the eruption consists in a con- 
siderable thickening and elevation of the skin ; it is deeply 
furrowed in all directions ; the upper portion consists of 



Course of the Small Sci((tic (did Short Saphenous Nerves. 83 

irregularly circular patches of a dark red colour, and of a 
slightly raw appearance, whilst the other portions and the 
margins of these patches are covered by thickish white patches 
of dead epidermis. On the back of thigh the eruption is very 
regular, and has hardly any outh'ing portions : the furrows are 
nearly all transverse ; there are fewer patches of red unpro- 
tected epidermis, the most of the eruption being covered by a 
thin scale of yellowish scab, which, at the margins and transverse 
furrows, has partially separated, and there presents a narrow 
irregular white line. Below the knee the scabs are somewhat 
thicker, in the upper portion they are quite unbroken, and the 
transverse furrows and markings are very distinct, but in the 
lower parts, here and there, large patches have been denuded. 
and the markings are rather indistinct. Aloncr the outer 
aspect of foot the eruption is less vascular ; where the red 
base is exposed it is much paler, and, for the most part, is 
covered with thickish scales, at parts yellowish in colour with 
white markinojs, but towards small toe with white, dry, and 
almost silvery scales like those on a patch of psoriasis. The 
margins of the eruption are nearly everywhere marked by a 
narrow bronzed line of discolouration. 

The patient complains only of itchiness, especially at night 
when he takes his stocking off and in the morning when he 
rises, and of the stiffness of knee, arising from the thickened 
and hardened state of the epidermis. There is at present 
very little leeting. 

17th Dec., 1S84- — Since last note the patient has been under 
the care of Dr. Richmond in the Paisley Infirmary, and the 
eruption, in spite of varied treatment, essentially retains the 
characters described above. There are now, however, here and 
there along a large part of the margins of the eruption, small 
isolated patches, irregularly circular or linear in form. The 
small detached portions on buttock are now somewhat larger 
and more irregular, and have become attached, in all cases, to 
the main mass of the eruption. For about two inches above 
the heel the eruption has assumed a warty character, and 
immediately above the insertion of the tendo Achilles it is very 
much elevated, dried, and cracked. Looking at the eraption 
as a whole, one is struck with its regularity except, speaking 
roughly, in its middle third, where its outer margin is com- 
plicated with the detached portions above described. 

Two days ago an attack of herpes zoster Ijegan to develop on 
the opposite thigh. Near the sacral end of the crista ilii, and 
parallel with it, is an oblong patch of characteristic vesicles, 
two inches long and one broad. A similar patch is situated 



84 Mr. Shearak — Case of Eczema. 

live inches vertically below the great trochanter. Another 
broad patch extends almost continuously downwards and in- 
wards for seven inches, from a point four inches below the 
anterior superior spine of the ilium ; and a smaller patch, 
arranged in a parallel line to this, is placed over the lower part 
of Scarpa's triangle. The patient says that the eruption on 
the other leg commenced in the same way, but asserts that it 
was not accompanied, as in the present case, with burning 
pain ; and he is quite confident that it was not at any time 
scattered over the surface of the thigh. 

This interesting case differs from one of herpes zoster not 
only in its character and lengthened duration, but also, and that 
very essentially,' in the relation of the eruption to the nerves 
affected. In herpes the eruption corresponds with the cutan- 
eous distribution of certain scattered twigs, whilst in this case 
it corresponds, in a rough way, to the course of the main 
trunks of the nerves. For, whilst both in the thigh and in 
the leg a considerable portion of the eruption is decidedly 
internal to the usual course of the nerves which may be sup- 
posed to be affected, those portions on the buttock and behind 
the knee correspond, the former with the external cutaneous 
branches of the small sciatic, and the latter with the lower 
branches of the same nerve, and that portion on the outer as- 
pect of the foot with the last part of the short saphenous nerve. 
It is more difficult to understand, in this way, how it could 
have been brought about. It would almost seem, indeed, as if 
the cutaneous twigs were not in themselves primarily affected, 
but were influenced in some way by the altered molecular con- 
dition of the nerve trunks acting directly through the sub- 
cutaneous tissue on the nerve endings in the skin. The 
disease was apparently confined at first to the small sciatic 
nerve, but afterwards attacked the short saphenous nerve, and 
so may be supposed to be dependent on some central changes 
in the ganglia of the cord. The recent occurrence of herpes 
zoster on the opposite leg forms an instructive sequel to the 
case, and no doubt throws some light upon its true nature, 
whilst it affords an interesting contrast to it. 

The occurrence of eczema in connection with injury to 
nerves is, of course, not unknown, but the principal literature 
of nerve or skin disease does not bear evidence of the frequent 
occurrence of such cases as the above, and hence it may be 
thought worthy of record. 



Prof. Macleod — On the Medical Societies of Glasgoiv. 85 



ON THE MEDICAL SOCIETIES OF GLASGOW, AND 
RECENT ADVANCES IN MEDICAL AND SURGI- 
CAL TREATMENT. 

By G. H. B. MACLEOD, M.D., F.R.S. Ecliii., 

Regius Professor of Surgery in the University of Glasgow, ami Surgeon in 

Onlinary to the Queen. 

(Being his Inaugural Address as President of the Medico-Chirurgical Society 

of Glasgow.) 

Gentlemen, — I avail myself of this, the first, opportunity 
afforded me of thanking you for having placed me in this 
chair. To be singled out by one's fellows and associates for 
such an office is an honour and distinction which I assure you 
I greatly value and esteem. A quarter of a century has 
passed, with all its activities and anxieties, since I became a 
member of this Association ; and I now find myself thrust, by 
the relentless course of time, more, I honestly believe, than 
by any merit of my own, into the place of honour in its ranks. 
It adds much to the gratification which your choice of me 
as your president has afforded, to think that many of you have 
been familiar with my career during these years. Alas ! it is 
but too true that many of those who were most active in the 
Society when I joined it have gone from among us. Lawrie 
and Macfarlane, Pagan and Easton, Andrew Buchanan and 
Rainy, Macgregor and Ritchie, Weir and Watt, Lyon and 
Fleming, Coats and M'Ghee, Stewart and Reid, and many others, 
were very regular attenders both here and in the old Faculty 
in St. Enoch Square, of which now not one stone remains, where 
the more ancient " Medical Society " (of which, by the way, 
I wa.s myself the last president) used to hold such pleasant 
meetings. The old Pathological Society, too, which met in the 
Royal Infirmary, is long defunct, but in the present Patho- 
logical and Clinical Societj' it has found a worthy successor. 
We have now, also, the Southern ]\Iedical Society, an aspiring 
and vigorous association, year by year lengtheniilg its cords 
;and strengthening its stakes. The establishment within the last 
few years of these societies would, at first sight, seem to imply 
that the parent one had not fulfilled its purpose. But I do not 
think that this is their true raison d'etre. Perhaps the field is 
now too large to be worked over by one society. When we look 
to the prominence which pathology has recently assumed, this 
may be held as a sufficient reason why a special society should 



86 Prof. Macleod — On the Medical Societies of Glasgow, and 

he established for its more proper cultivation. But when this 
has been said, I still regret the division of our forces which 
has necessarily arisen from the institution of these associations. 
It seems to be the tendency for each generation to set on foot 
something new — to throw off as eftete what they have found 
ready to their hand — and to encourage every new venture, 
which, for a time, at least, is upheld with much enthusiasm. I 
would have greatly preferred if our pathological friends had 
thrown their superabundant energy into our cauldron, and 
established a pathological section of this, the central Society. It 
would have been easy to secure a special evening now and again 
for the consideration of purely pathological questions, and in 
this way to avoid the divorce which has taken place between 
that most important department — pathology — and the main 
stream of medical and surgical science which we follow here. 
As to clinical work, this Society has always been, as it is now, 
essentially a clinical society. By this I mean that it is to bedside 
observations, and the lessons there learned, that this Society has 
chiefly looked for the materials it collects. Our existence as a 
useful institution is inseparably bound up with our attention to 
clinical work. Whenever we depart from the closest reference 
to bedside work, we are apt to get lost in barren and unprofit- 
able discussion. This is why I have always deprecated the 
foundation of another society, when, within the bosom of this 
one, all its ends and aims could easily have been attained, and 
at the same time the weight, influence, and vitality of the 
parent association augmented and secured. I cannot help 
thinking that the Glasgow medical community is too small to 
allow of the useful multiplication of societies ; and the institu- 
tion of new ones must necessarily weaken those already in 
existence. Again, I fear that some of our brethren have 
desired the establishment of smaller and less formal societies 
chiefly because they find themselves there less embarrassed in 
speaking and more at home, as it were, than in large meetings 
such as this. The Southern Society has met this feeling ver\' 
pleasantly by their small re-unions, held late in the day when 
work is over ; and with these I have much sympathy. I 
have always regretted that so few of the younger members of 
the profession take part in our discussions. It is disheartening 
to see how few contribute papers and join in our debates. Many 
seniors, I am sure, like myself, interpose to carry on the dis- 
cussion, when we would rather see younger members take it 
up. But after all this has been said, I am proud to think that 
the old Medico-Chirurgical Society — dealing with the whole 
round of the medical sciences — is still strong, healthy, and 



Recent Advances in Medical and Surgical Treatment. 87 

vigorous ; and though it is not always easy to ensure a large 
attendance in a city in which men have occasion to deal so mucli 
with the "bread and butter sciences," still we have, as you know, 
every season many important, instructive, and useful papers 
and debates. It requires no small enthusiasm, in this rigorous 
and uncertain climate of ours, to leave the fireside after a hard 
day's work, and come here to be " refreshed " by a discussion 
on subjects which saturate one's whole existence. A good con- 
cert would to many, I suspect, often prove more attractive and 
useful. 

I have often heard it stated as a reproach to the members of 
our profession in this city that they pride themselves too much 
in being what is called " practical " — that they have little taste 
for discussions on the more abstruse and recondite subjects of 
their art, and confine their attention more to what directly 
bears on the treatment of disease. I do not believe this allega- 
tion to be true in the unfavourable sense in which it is intended. 
Anyhow, the claim to be practical cannot be made on the 
assumption of Disraeli's definition of a practical man, " a man 
who practises the errors of his predecessors." We seek every- 
where, as our first requirement, for those remedies which will 
prove of greatest service to the sick, and for such improved 
methods of treatment as careful observation may suggest. 
But it is essential that we keep ourselves familiar with the 
movements of opinion, the constant changes and fluctuations of 
professional views as expressed in the theories and dogmas on 
which medical science is so largely built, and it is only by 
discussion and the interchange of ideas that our errors can be 
corrected, and the full bearing and value of different systems of 
treatment secured. Again, another assertion I have heard not 
unfrequently made regarding our profession is that it does not 
command that influence in the community to which its aims 
and objects would entitle it. In sanitary matters, which surely 
belong specially to the domain of medical science, it is alleged 
that the views of the profession are often little heard, and not 
attended to. It is, I wot, only in Glasgow that a man, wdiolly 
unconnected with medicine, unacquainted with its studies and 
ignorant of its gains, could be found who would venture, as 
on a recent notable occasion, to controvert both at a public 
meeting and also in the newspapers, the conclusion come to 
by our most competent medical authority as to the source of 
that very serious outbreak of enteric fever which lately played 
such havoc in our hospitals. I think that it is a mistake that 
the medical organisations which exist among us (our Society 
with the rest), do not assert themselves more in these matters, 



88 Prof. Macleod — On, the Medical Societies of Glasgow, and 

and compel the public, as it were, to listen to them. Individual 
medical men in Glasgow do not interfere sufficiently in public 
affairs. Here it seems that few have the time or the inclination 
to take part in the discussion of many public or social 
questions, which in other towns attract a certain proportion 
of our brethren. Certainly it is not in our local municipal 
parliament that men having regard to their own happiness 
would mingle ; but in the wider general movements, in 
gatherings for the promotion of philanthropic and charitable 
objects ; in the consideration of educational and other social 
questions of importance ; the members of our profession in 
Glasgow rarely take an active part. I cannot help thinking 
that in this we are wrong, and if there be truth in the state- 
ment that the profession has not due social weight and 
influence, it is to be in some measure traced to this abstinence. 
Are we not too narrow in our sympathies, or too much 
engrossed in our professional interests, and are there not too 
many jealousies and divisions among us ? 

The stud}^ of our science in its proper spirit cannot but 
prove most elevating and enlightening. It ought to raise us 
out of the miry pit of those petty wiles which debase and 
vulgarise men, and make us capable of leavening with good a 
community such as this, which is for the most part given up 
to commercial gains. Putting it, too, in the other way, every 
member of the profession cannot fail to reap great benefit by 
mixing freely with the general community in relations distinct 
from that in which they generally come into contact with 
them. It is by meeting men in the larger and wider arena of 
national and social questions, in taking part with them in the 
discussion of subjects which carry us out of our particular 
domain that we can acquire that most important element of suc- 
cess, even in our own profession, namely, being "men of the 
world." After a knowledge of general literature, and the 
views and opinions of the great thinkers of our own and other 
countries, who have done so much to " lighten the burden 
and sore travail with which men are exercised," nothing- 
tends more to give us that liberal grasp of thought and that 
generosity of judgment, so requisite to the proper exercise of 
our profession, with its intricate relations and delicate 
sympathies, as mixing freely with men. Too exclusive a 
devotion to our calling, too much attention to those little arts 
which promote, in a way, professional advancement, cannot 
fail to beget a mean spirit, and encourage small and insignifi- 
cant cares. Richter says, "A doctor should be one-third of 
knowledge and two-thirds of savoir-faire." A knowledge of 



Recent Advances in Medical and Surgical Treatment. 89 

the world cannot fail to help us greatly in understanding 
and combatting those derangements of the nervous system, 
which in our day, when the speed of living is so express and 
wearying, have come so much to the front, and in the manage- 
ment of which gross drugs, and the mere routine treatment of 
the schools, can be of little service. 

The public are ever (quoting the phrase, "doctors differ," 
against us, as if lawyers, clergymen, civil engineers, and 
members of any profession but ours agreed with one 
another. It is true we differ on many points, and it is well, 
perhaps, that we do so ; but on the other hand it is not requisite 
that we always make our disagreements so palpable and so 
notorious as we generally do. It is in the expression of these 
differences behind one another's backs that the true evil lies, 
and this it is which gives occasion to our enemies to blaspheme. 
If we realised more than we do that in every act of our pro- 
fessional life we are representatives of a great and worthy 
profession, the members of which should, by their devotion to 
a common calling, feel themselves united in a brotherhood 
against which it were little short of treason to allow any dis- 
paragement to be made, then much of the reproach aimed at 
us would vanish, and our profession would secure that con- 
sideration and influence which its objects deserve. 

But to pass from such thoughts, which were suggested to 
me by remarks I lately read in the public prints, I would 
observe that medicine has of late years been widening her 
boundaries, and that in some directions with a rapidity and 
elan which is quite startling. We seem, in truth, to be on the 
eve of a reconstruction of our science. Discoveries of the most 
remarkable character have, within the last few years, threatened 
to overthrow and revolutionize all our cherished beliefs. What 
we have hitherto hopelessly sought for as to the causation of 
disease, by the most laborious and careful observation of effects 
and by the extensive induction of facts, has apparently all 
the while been under our very eyes, but in forms so minute 
and delicate as to escape our observation. Most, if not all, of 
the most formidable diseases to which men and animals are 
liable can now be "cultivated," sown and grown under our 
observation. Their habits and development — their life history^ 
in short, can be studied like that of any tender plant. When 
grown under proper conditions these germs of disease can, as 
I lately saw, be easily recognised from one another, and that 
with little aid can be seen to assume their characteristic 
appearances to the naked eye. Disease after disease has thus 
been traced back to its initial element — an element which is 



90 Prof. Macleod — On the Medical Societies of Glasgow, and 

capable of reproducing only its kind by inoculation. The 
differentiation of disease can thus be made by the cultivation of 
these apart from the body, and the potential elements of vast 
epidemics can be gathered up and placed in test tubes. The 
sowing on previously prepared suitable and sterilized surfaces 
(that is, surfaces deprived of all accidental elements of life) 
of the various grains or seeds which are the sources of 
different diseases, and the raising or growing of them to 
maturity — each distinct, each only reproducing and propa- 
gating itself, but each terribly potent, after its source, to 
originate the affection from which it has come — is a study of 
the most attractive nature, and opens up to the most un- 
imaginative vistas of such far-reaching application, as 
positively to overwhelm the mind with wonder. When 
one sees all this taking place under his very eye, and 
realizes it, he is struck with dismay. He feels all his 
boasted knowledge slip from him, and he comes to the 
pitiable conclusion that he must begin his studies anew. 
He feels that hitherto he has been looking, as it were, into 
the air when, in truth, what he sought for lay beneath his 
eye. He sees how ignorant, and childish, and purblind he 
has been, and how almost hopeless it is to combat influences 
which are so subtle and so diffused. Making every allow- 
ance for error, for the mistaking of effects for causes, it 
must be admitted that recent discoveries, made for the most 
part by the microscope and in the closet, have gone far to lay 
bare the secret source and origin of many of our most obscure 
and deadly maladies ; and it is undoubtedly in prevention, in 
the destruction of these fatal organisms, that the future rdle 
of medicine will lie. Many of our most cherished remedies — 
weapons on which we thought we could place reliance — must, 
I fear, disappear. The danger is that men's opinions will 
oscillate to the other extreme, and that they will become so 
sceptical of the good to be got from drugs, that they will content 
themselves with throwing all their energy into the prevention 
of disease, from a feeling of the hopelessness of curative 
measures. They will ask themselves whether in all these years 
they have not in their ignorance been deceiving themselves, and 
ascribing erroneously to their remedies the amendment and 
recovery which came only from that inlierent recuperative 
power which we designate natural effort, or, as of old "The 
physician within the skin." Nay, may not the thought some- 
times obtrude itself that we have too often in our blindness 
opposed ourselves to that beneficent and gracious agency, and 
in our self-complacency and reliance on our resources refused 



Recent Advances in Medicul and Siuyical 'Treatment. 91 

the guidance which a careful observation of nature's ways might 
have ottered us ; and so have overlaid, confused, and thwarted 
the issue ? But in dealing with phenomena so delicate, so 
variable, and so open to misinterpretation as vital and morbid 
processes, it is not to be wondered at that we have often fallen 
into error. 

In the light of these recent discoveries, what is to be the 
future of our art ? Are all the carefully collated and anxiously 
garnered experiences of the past to be thrown over, and a new 
system of therapeutics founded on a new pathology to take 
the place of tlie old ? Have long years been misspent, and is 
their labour fruitless ? This cannot be ; yet I fear much of our 
science will have to be reconstructed, and a new direction 
given to our investigations and studies. Lord Beaconsfield 
was not far wrong when he designated the future problem to 
be sanitation. If the elements generating and propagating 
disease are shown to be so subtle and insidious, our only help 
in dealing with them will be to learn their nature and habits in 
order to prevent their generation, or destroy them before they 
can exert their potency. That, in accomplishing this, the role 
of the surgeon will be more important than that of the 
physician seems evident. Alread}' this has been the case. In 
the management of wounds we have reaped a great reward. 
I consider it one of the greatest privileges of my professional 
life that my personal experience has bridged over the interval 
between the old and the new systems of wound treatment, so 
that I have been able to compare them by personal trial, and 
now, looking back and comparing what surgery is at the present 
day with what it was a quarter of a century ago, I declare the 
difference to be simply miraculous. I vividly remember how 
rare a thing it was for a bad case of compound fracture to 
recover, and with what dread we performed many of those 
operations on bones and joints, and the great cavities of the 
body, which we now undertake without hesitation, — nay, with 
a conviction of success if we observe those principles strictly 
which are combined under the general term, "antiseptic 
surgery." It may be said, I think, without exaggeration, 
that surgeons have reaped almost as much advantage from 
these improvements as have their patients in the augmented 
confidence they have gained ; in the vastly increased resources 
of their art; and in the absence of that most distressing of 
all feelings, the sense of failure, which, under the old system, 
so frequently oppressed them. It is not, however, alone, or 
perhaps even mainly, from the use of antiseptic appliances 
that this "new method" has derived its advantages. In the 



92 Prof, Macleod — On the Medical Societies of Glasgow, and 

working out of the " system " of which these appliances form 
but a part many old and fundamental principles which, if 
not discarded, did not at any rate always receive the constant 
care and attention which they deserved, have been accentuated 
and put in due prominence. Disjointed and unconnected 
with the special treatment which enforced their fulfilment, 
they were often little heeded. Cleanliness of the most scru- 
pulous description in the wound, its surroundings and dressings, 
— drainage so complete as to prevent any tension or any delay 
in the escape of secretions, and that by means which, while 
they avoid all irritation, give absolute rest of function, — 
a position which relaxes the structures and allows of the 
most perfect apposition and the removal of all pressure from 
irritated or inflamed parts, — the exclusion of substances which 
can take up decomposing secretions and keep them in contact 
with highly absorbent surfaces, — these are all old and well 
recognised principles, but they were never so combined, — 
so emphasised and so pointedly shown to be essential as when 
connected with this " system " which all men in every land 
now study and desire to practise. This has given an authority 
and a weight to these and kindred principles which otherwise 
they lacked. Men have been told that they must practise 
this system as a whole, — that it will allow of no serious or 
important "modification " or evasion in the carrying out of 
its most minute details, and thus, fortunately for the progress 
of surgery, a true and real good has come to the practice of 
that art over and above the use of any special class of local 
agents with which erroneously its name has been supposed to 
be exclusively associated. 

(Dr. Macleod gave here some illustrations of the careless 
way in which he had seen what was called the antiseptic 
method carried out in British and foreign hospitals.) 

In its true interpretation, antiseptic surgery, when properly 
carried out, just gives "nature" eva'y^ chance, — removes all 
obstacles to her beneficent actiax, — places wounds in the most 
favourable conditions to heM and so I'ulfils the main aim of 
surgical science properly so called. 

If I were beginning' professijcmal life again, I would study 
preventive medyj^/je with ^11 my power. It will become the 
great stepping' CP,ne to advancement in the near future. 

Hitherto J^^k '>ns have been asleep ; anyhow, they have shut 
their eyes 't *^ ^ ave acted in profound ignorance of the con- 
ditions wl^^A ^^ej ijlato the health of persons or that of the 
communitj^'Go^vLS t habits and prejudices, errors begotten of 
ages of sh'o^ affi laissez faire have stood in the way of all 



Recent Advances in Medical and Surgical Treatment. 93 

iraproveiuent : 1 a;t witli tlio awakened intelligence and keener 
scrutiny of these times ; with the improved knowledge and 
means of investigation which now exist, all such barriers will 
be removed. The supreme value of health (without which life 
is a burden), is now better appreciated. Men come to under- 
stand that the sources and elements of disease are not occult or 
inappreciable influences, but entities which can be recognised 
and demonstrated, artificially cultivated, and made to act as we 
bid them; and are capable, when their ways have been studied, 
of being prevented, or destroyed or neutralised. Thus, the 
paramount importance of such science (because lying at the 
very root of the individual and the nation's existence), will be 
fully acknowledged. 

Hitherto, in all sanitary matters, notwithstanding sporadic 
attempts at legislation, every conceivable error has been per- 
mitted to arise. Houses and towns have been built in direct 
violation of the nio'^t fundamental sanitary principles. In the 
inmost recesses of our dwellings we have nursed and cherished 
our secret and deadly enemies. The sources of our food and 
water supplies are too often poisoned, and our social habits 
have been allowed to debase and destroy our people. Help- 
less infants are cut ofi' in thousands, and the vigour of our 
adults is quenched in premature old age. The happiness of 
living is too frequently destroyed and converted into a burden. 
Endless contrivances, the product of what we term civilization, 
have tended to promote disease and death rather than health 
and happiness, and this goes on with but scanty attempts at 
arrestment. To help, even to a small extent, to correct all 
this, and so to diminish the gross evils which surround us, 
is well worthy of any man's ambition. 

Again, does it not appear (read by the light of the discoveries 
as to the causation of disease to which I have before referred), 
something more than ridiculous how various medicinal pre- 
parations have multiplied of late years ? Day after day we 
receive notices of some new preparation, heralded by unstinted 
recommendations, the productions of some inventive druggist 
in Great Britain or America, which we are told is to cure or 
assuage every ill. This surely does not indicate advancement 
but retrogression. Is not this ready use of whatever is " new " 
not too often but veiled quackery? I have no intention of 
underrating the advantages of securing more palatable forms 
of well established remedies. But this is quite a different 
thing from the craze, so much in vogue, of prescribing new 
and untried remedies for no reason but that they are new. 
Do men always prescribe these ephemeral productions from 



94 Prof. Macleod — On the Medical Societies of Glasgoiv. 

an honest conviction in their improved efficiency ; or is it not, 
in part at least, to impress their patients with the superior 
knowledge and skill, which an acquaintance with these 
" elegant " preparations would seem to imply ? I fear this is 
one of the many insidious ways in which irregular and 
unworthy methods of practice are Ijecoming established 
among us. 

It requires both courage and self-reliance to tell patients 
that their ailments demand no elaborate or comjslicated 
pharmacy, but the application to their own habits of that 
common sense which they exercise on every other affair in 
life, but which they throw aside whenever their health and 
that which pertains to it come into consideration. In some 
harmful indulgence — in not adapting themselves, it may be, 
to some new condition of life, or to the advances of age, 
frequently lie the sources of their suffering. To recognise this 
and explain it — to guide them to health by simple, un- 
mysterious ways — by trying to get them to see the rationale 
of our orders, and enlist them in their execution — it is thus, 
as it seems to me, that an honest man should act, and not by 
having recourse to constantly changing complicated combina- 
tions of drugs foisted on our attention by advertising 
chemists. 

But, to draw these discursive remarks to a close, let me 
express the hope that the coming session will prove a useful 
and profitable one. I think it would be a good plan if 
occasionally we had a " full dress discussion " on some of the 
many subjects which a,re of most general interest to the pro- 
fession. There are many topics which could with great 
advantage be thrashed out in a Society like this. I would 
mention, as one that occurs to me. The duty of medical men 
as witnesses in courts of law. It would be well that the way 
in which these duties are performed was more canvassed 
and discussed. Certainly the evidence hazarded in some 
cases before a non-medical audience is most deplorable and 
unworthy of our calling. I have heard opinions confidently 
stated in courts of law which would not for a moment be 
tolerated in a Society such as this, i.e., before a professional jury. 
I have always strongly advocated a plan which was some time 
agfo suGf2fested — viz., brin<.dno; before our medical societies 
the opinions given by medical witnesses in law courts when 
these have been grossly at variance with those which are well 
established and settled. If such a course were taken, it would 
increase the sense of responsibility in giving skilled evidence, 
and make medical witnesses more careful of what they say, 



(hi)- rent Topics. 95 

as it would expose them to the censure of their professional 
brethren. Any way, the duty of medical men in their relation 
to the public and to litigants, and the best plan of rendering 
medical evidence less erratic, more reliable, and more worthy 
of confidence, appears to me a subject we might well consider. 

Again, the best way of diminishing the terrible evil of 
giving free medical aid to well-to-do persons in public hos- 
pitals and dispensaries, by wliieh the general practitioner is 
robbed, the public demoralised, and the hospital defrauded, is 
another important subject wliicli we might debate. Further, 
the working of provident and sick clubs and societies, the fees 
paid, and the services exacted in such combinations, by which 
means, if I mistake not, the profession is not only robbed and 
defrauded, but egregiously insulted ; improvements in medical 
education, both as to what the present system fails to do, and 
how it ought to be amended ; the results of excision of bones 
and joints ; the relative advantages of the microscope, and of 
clinical histories and open-eye appearances of tumours as 
connected with their prognosis ; the causes of rickets as seen 
in our great cities, and in none more than in this in which we 
dwell ; these are a few of the subjects which at the moment 
occur to me as being worthy of our discussion. Many others 
will occur to yourselves. 

With these remarks, gentlemen, I conclude, but not before 
again thanking you for the honour you have done me in ask- 
ing me to preside over this Society. 



CURRENT TOPICS. 



New Zealand Notes. 

(From a Correspo7}dent.) 

In my last notes I mentioned that Dunedin could at last boast 
of having a complete Medical School — the only one in New 
Zealand. Well, the winter session has just ended, and the 
results have been published. They show that lectures have 
been delivered in Anatomy, Physiology, Chemistry, Surgery, 
together with Clinical Instruction at the Hospital. A summer 
session will shortly be commenced, when lectures will be 
delivered upon Materia Medica, Botany, and Anatomy. The 



96 Current Topics. 

new staff of teachers are enthusiastic in their work, and a large 
increase of students is expected by next winter session. The 
chair of Medical Jurisprudence is not as yet tilled up, the 
University Council having decided to send home for one 
specially qualified in jurisprudence and public health. This 
decision has given great ofience to some local aspirants, but 
generally the decision is considered wise. 

The medical world here has been considerably puzzled by the 
doings of one Milner Stephen, the "Australian Magnetic Healer." 
Stephen is a man of 70 summers, a barrister by profession, and 
until lately one of the judges of the Supreme Court of New- 
South Wales. Many persons of undoubted veracity have posi- 
tively declared that they were cured of their ailments by 
Stephen, His mode of cure simply consists in the laying on 
of hands, and thereafter the diseased anoint themselves with 
magnetized olive oil, just to make sare the cure is complete. 
All diseases are alike conquered by him, but cancer and joint 
diseases are his particular forte. Curious to relate, he brought 
a case into court to recover fees for treatment, and positively 
recovered them. I had a long chat with this wonderful 
prophet, and believe him to be an exceedingly cunning, clever, 

? You will have him shortly in Glasgow, as he is now 

on his way to England. 

Loud complaints have been made lately by invalids landing 
in Dunedin durincj the winter months at the cold and chanffe- 
able weather. There is some truth in this, the climate along 
the seaboard of Otago being very changeable during the 
months of June, July, August, and September. Medical men 
recommendino' invalids to s^o to New Zealand should inform 
their patients of this, and if they must go during these months, 
let them land, if possible, in the North Island, where there is 
practically^ no winter. 

September, October, and November are by far the best 
months of the year for an invalid to leave Scotland for New 
Zealand. There is an extraordinary variety of climate in New 
Zealand, from three to four months of cold, wet, wintry 
weather in Otago and Southland to perpetual summer in 
Auckland in the North Island. The hot springs in Auckland 
Province have become famous as a health resort for invalids, 
and the direct steamers have considerably increased the influx 
of visitors from England and the Continent. 

The scare about the rabbit pest and tubercle bacillus has 
subsided. Still no one thinks of eating a rabbit, because, 
possibly, the bacillus may be there, and if not, some poison is 
sure to be. I have not heard of the troublesome bacillus find- 



Revieivs. 97 

ing its way into the sheep or cattle, though soiue fears were 
entertained that such would be the case. 

The following is a bona fide advertisement which recently 
appeared in one of our local papers : — " Wanted, a doctor for 

district, guaranteed to be a total abstainer." Shortly 

after this, a member of the House of Kepresentatives got up 
and wished a clause inserted into the Medical Act Amendment 
Bill, that all doctors once found drunk be struck oft" the New 
Zealand medical register ; the clause did not pass. 



REVIEWS. 



The Pathology, Diagnosis and Treafnient of the Diseases of 
Women. By Graily Hewitt, M.D.Lond., F.R.C.P., Pro- 
fessor of Midwifery and Diseases of Women, University 
College, &c., &c. Fourth edition. Kevised, enlarged, 
and in great part re-written. With numerous Illustrations. 
London : Longmans, Green & Co. 1882. Pp. 908. 

In the preface to this, the fourth edition of his work, the 
author tells us that he has re-written a great part of it, and 
that the idea in regard to the causation of most cases of 
uterine disease, which he enunciated in his last edition, he is 
now able to reduce almost to a demonstration — viz., that 
■' Changes on the shape and position of the uterus are directly 
or indirectly responsible for the sufferings and discomforts 
attendant on the affections peculiar to the female sex." 
Further, he believes that these structural changes are in almost 
all cases due to " chronic starvation," not limited to those who 
have insufficient or improper food, but also cases VN^here women 
actually, for various reasons, do not take such food as is 
necessary for the proper upbuilding and upkeeping of the 
tissues. This he seeks to prove by the histories and results 
of casco of flexions and displacements of the uterus, and it 
must be said that he makes out a fairly good case. 

The volume opens with chapters on the general considera- 
tions respecting the diseases of the sexual organs, and the 
natural history of the uterus and ovaries, followed by one 
on the methods of examination of the uterus and ovaries. 
We feel some surprise that in giving directions for making 
vaginal examinations, the author does not refer to the use of 

No. 2. H Vol. XXIII. 



98 Reviev)ii. 

antiseptics, as a defence alike to the examiner and patient. 
The little extra trouble so caused is likely to be well repaid. 
Amona: the means of examination of the uterus, there is 
described one which is neither so well known nor so often 
practised as it deserves — i. €., the passage of a sound into the 
uterus, and a finger into the rectum, so as to bring the uterus, 
by means of the sound, well within reach of the examining 
finger. 

Dr. Hewitt is «, if not the, great advocate of the tnechanical 
theory of uterine disease, and we cannot do our author and 
our readers greater justice than by letting the former speak 
for himself. 

"The conclusion to which I had arrived in substance 
amounted to this, that the large majority of the discomforts, 
pains, and inconveniences complained of by patients, and 
referred to the o-enerative organs, can be traced to, and shown 
to be dependent upon, the presence of mechanical changes 
in the uterus, and to the effects of such mechanical changes. 
The distortions of the uterus, together with the displacements 
of the organ more or less associated, are thus made responsible 
for such pains and discomforts and various other s3''mptoms as 
make up, when put together, the greater part of the affections 
known as diseases of the generative organs in women. 

" The conclusions seemed at first of so sweeping and general 
a character, that I hesitated for some time to believe that such 
simplicity belonged to a subject which had always appeared 
so difficult ; but as time went on, it was plain that there could 
be no mistake about it, and the more cases I saw, the more 
exactly and truly did the principles in question seem to apply 
themselves naturally to the observed fresh facts. These 
conclusions were embodied in the three following proposi- 
tions : — 

" 1. Patients suffering from symptoms [of uterine inflamma- 
tion] (or more properly, from symptoms referable to the 
uterus) are almost universally found to be affected with 
flexion or alteration in the shape of the uterus of easily 
recognised character, but varying in degree. 2. The change 
in the shape and form of the uterus is frequently brought 
about in consequence of the tissues of the uterus being fre- 
quently in a state of unusual softness [or what may be often 
•correctly designated as chronic inflammation]. 3. The flexion 
once produced is not only liable to perpetuate itself, so to 
speak, but continues to act incessantly as the cause of the 
-chronic inflammation present. 

" Since that time nothing has occurred to shake my confi- 



Reviews. 99 

(lence in the substantial trutli of the conclusions just stated. 
I have had, on the contrary, more reason than ever to be 
satisfied of their accuracy. The parts enclosed in brackets, 
and which refer to inflammation alone, require to be altered, 
as I have now a more complete and satisfactory explanation 
to give of that condition alluded to as ' softness.' 

" There has been much misconception in reference to the 
word ' mechanical ' as used in the phrase, ' mechanical sys- 
tem of uterine pathology ' — a misconception which it is neces- 
sary I should at once deal with. The word mechanical is here 
employed to convey an idea as to the origin and nature of the 
disorder. By it is intended to be conveyed the importance of 
the share which acquired distortions and alterations of posi- 
tion of the uterus — in a word, mechanical changes — have in 
the production of uterine suffering. The word mechanical 
lias, however, apparently led some to imagine, quite unjusti- 
fiably, as I shall by and by show, that it has been my inten- 
tion and desire to inaugurate the universal and indiscriminate 
employment of instruments and mechanical appliances in the 
treatment of uterine disease. Nothing can be further from 
my object. 

" The principal argument employed by those who still 
resist the idea of accepting the mechanical system of uterine 
pathology is that, admitting the frequency with which altera- 
tions of the shape of the uterus occur, these alterations are 
never of any consequence unless associated with ' chronic 
inflammation,' or as some prefer to term it, 'congestion' of 
the uterus. They affirm that the patient suffers not from the 
flexion, but from certain accompanying conditions, and go 
even so far as to say that flexion by itself produces no symp- 
toms. 

" The whole question will be discussed later on ; here, how- 
ever, it may be mentioned that the point really in dispute is 
the connection which subsists between the flexion and the 
other condition (termed variously chronic inflammation, con- 
gestion, &c.). There is no dispute as to the importance of this 
' other condition ' (in the three propositions above quoted 
reference is specially made to it). It is incumbent on those' 
who controvert the mechanical theory to explain how and why 
it is that the uterus becomes afl'ccted with this ' other con- 
dition,' which they consider, and from one point of view justly 
so, as so potent in producing suflering. No attempt has been 
made, so far as I am aware, to give this explanation. The 
only substantial criticism which has been made is to the effect 
that patients are relieved by treating the congestion alone, 



100 Reviews. 

the distortion of the uterus being allowed to take its course. 
That relief to a certain extent is thus obtained is no doubt 
true. But this is no answer to the statement, demonstrable 
by clinical facts unlimited in number, that flexions are indubi- 
tably the principal cause of the congestion. Indeed, the 
congestion may often be at once removed by restoring the 
uterus to its proper shape. These subjects will, of course, be 
fully discussed later on. 

" The question as to the nature of this ' other condition,' so 
liable to he associated with flexions, is of the greatest interest. 
It is one which has occupied my attention very particularly, 
and an intellig-ible account of it can, I think, be now sriven. 
In substance the explanation is : — 

" 1. The uterus is very liable to fall into a state of passive 
congestion when it has become distorted, and bent upon itself, 
though it may become congested from other causes. 

" 2. The uterus is very much more liable to become distorted 
when its tissues are in a soft flaccid condition. 

" 3. Softness and flaccidity of the uterus generally indicate 
malnutrition of the organ. 

"4. The so-called 'chronic inflammation' is generally chronic 
cono;estion, the result of flexion of the uterus." 

We think there can be little doubt but that those are wrong 
who hold that displacements of the uterus are due alone to 
previous hypertrophy or to accident, and are to be cured alone 
by treating not the position, but the condition of the organ. 
In the chapter on Flexions the following statement is made — 
" Respecting the connection existing between tenderness of the 
uterus and alteration of its shape, I claim to have established 
a most important generalisation and conclusion, which is to 
the effect that tenderness of the uterus to the touch is rarely 
observed except in cases where flexions are present. The more 
acute the flexion the more acute, as a rule, is the tenderness. 

"Tenderness is not invariably present in cases of acute flexion, 
and, indeed, when cases have become quite chronic, there may 
be little or no tenderness. My proposition, therefore, is not 
that cases of flexion of the uterus are always attended with 
tenderness, but that, when tenderness is present, it is in all but 
a very few cases (I have not myself met with more than one 
really exceptional case) associated with the presence of uterine 
distortion. Possibly this may be considered a bold assertion, 
but I confldently make myself answerable for its substantial 
accuracy." 

While we admit that a flexed uterus is very often a very 
sensitive one, there are nevertheless frequent exceptions to the 



Reviews. 101 

rule here laid down, as in the case of uteri containing small 
fibroids and those atfected by the various forms of congestion 
and subacute inHammation. 

In regard to the curability of uterine flexions Dr. Hewitt 
takes a rather more sanguine view than most authorities. The 
following general statements are made — " The apparently in- 
tractable character of certain forms of the affection has led 
some authorities to conclude that flexions are incurable. As a 
general statement this is undoubtedly a mistake, althoujjh in 
some cases a complete cure is no doubt very difficult to obtain. 
(L One source of difficulty is weakness of the uterus from mal- 
nutrition. So long as the tissues of the organ remain soft and 
give way to pressure, the cure of the flexion is a matter of 
impossibility, h. Another is the atrophy often present in long 
standing flexions at the seat of the bend, which has this effect, 
that while it may be easy to maintain the organ artificially in 
its normal shape, the moment the assistance ceases the flexion 
recurs. The uterus has virtually lost its stem. c. Another is 
the rigidity of the uterus. It has become set in a certain 
abnormal shape, and though it may be unbent by means of the 
sound, the flexion recurs directly it is withdrawn. This 
rigidity ma}"- be accompanied with atrophy around the interna 
OS, or not. d. Another difficulty is the presence of adhesions 
tying the fundus down in its abnormal position, e. The most 
common difficulty, however, is the absence of an exact and 
appreciative diagnosis of the exact physical condition of the 
uterus present in the particular case ;" and, " The cases are 
most amenable to treatment in which the affection is of not 
over two years' standing, and the uterus not very resistant to 
the restitution of proper shape by the aid of the sound. 

" Cases are tolerably amenable to treatment up to the age of 
thirty, even when the affection has lasted some years, provided 
that there is no considerable parietal atrophy, that the reposi- 
tion by the sound is not very difficult, and that there are no 
other complications. 

"After the age of thirty the cure of long standing flexions 
beeomps more and more difficult : and the cure at the aofe of 
forty, for instance, of a severe retroflexion of ten years' stand- 
ing would be very difficult. 

"As a rule it may be stated that the time required to 
effect a cure is in direct proportion to the duration of the 
disease. Recent cases are cured most readily. Recent cases, 
too, are cured most completely; for long standing flexions, 
even when cured, have a great tendency to recur. Thus, 
I could give particulars of cases both of anteflexion and 



102 Reviews. 

retroflexion cured so that the patients conceived and had 
children, and the flexion recurred intermediately three or four 
times — /. e., once after each labour was over — requiring treat- 
ment which was again and again successful. It seems probable 
that when proper attention is paid to the general treatment, 
the cure of uterine flexions will become more complete." 

The treatment of flexions by intra-uterine stems is pretty 
fully discussed, and we believe the conclusion come to in 
regard to their use is a wise one. " There can be no question 
that the uterine stem can be quite safely employed by an 
expert fully alive to the nature of the accidents which may 
occur, and who properly selects the cases on which to employ 
them ; and it is equally certain that the treatment is a great 
help in the cure of certain difficult cases. On the other hand, 
it must be admitted that, owing to the impossibility always of 
exercising the needful supervision, other methods of treatment 
will very frequently be preferred. When the uterus has 
attained to the condition of toleration of the stem, and it is 
well fitted, it may be worn without trouble of any kind often 
for months together. According to my own experience it is 
best borne in cases where the flexion is least severe ; and this 
is to be remembered in considering the question as to the 
general applicability, or rather as to the general superiority of 
the stem method of treatment." 

In the treatment of retroflexions and versions, the author 
lays strain on position as an important part of the mechanical 
treatment. " The patient should lie, not upon the back, but 
upon the side, or still better, upon the face. This is effected 
by making a kind of inclined plane with pillows placed under 
the chest and abdomen, one arm being placed quite behind the 
patient's back. By a little management a very comfortable 
position is thus attained. The result is, that the weight of the 
fundus uteri is in a great degree thrown forwards instead of 
backwards, and great assistance in the mechanical treatment is 
thus afforded. In severe cases this position of the body is, in 
fact, absolutely necessary, and I have seen patients who before 
had been in a state of absolute torture while lying ffat on the 
back restored to comparative comfort by the simple procedure 
of enforcing the position on the face. The length of time 
during which it is necessary to maintain this position of the bod}' 
depends upon the acuteness of the case. But when there is 
much irritation about the uterus, it is absolutely necessary for 
the patient to remain in this position for some weeks. The 
upright position is destructive of progress in the right 
direction. The knee-and-breast position should be used several 



Reviews. lOS 

times a day for three or four minutes at a time. All exertion 
must be absolutely interdicted for a time varying- according to 
circumstances. In this manner we carrj' out, as far as possible, 
what may be termed the treatment of red, a most important 
element in the treatment of these cases." 

In tlealing with flexions, it is stated that all the decided 
forms of sickness in early pregnancy are due commonly to ante- 
flexion, rarely to retroflexion of the uterus. Including a 
chapter on the sickness of pregnancy, 249 pages are devoted to 
the displacements of the uterus, from which it may be gathered 
how largely the subject bulks in the author's view. A full 
description of the various methods of treating inversion of the 
uterus is given, but curiously there is no mention made of the 
necessary treatment when reposition fails. Of the methods 
now practised, the best is probably the galvano-caustic wire, 
doing away to a great extent with the two chief dangers, 
haemorrhage and septicaemia. 

In speaking of the various methods of leucorrhcpal discharge, 
the following somewhat extraordinary statement is made : — 
" In the vaginal umcus, Donne found on examination by the 
microscope, a number of trichomonata, which are oval, shaped 
like a pear or biscuit, and are from six lines to an inch and 
four lines long. Respecting these animalcules, however, 
Scanzoni makes the remark that their presence is connected 
with a certain alteration of the product of the vaginal 
secretion, and that they do not develop much except in a 
mucus incontestably of pathological nature. Beigel also failed 
in finding them." 

We have examined such fluids very often indeed, but, like 
Beigel, have never found ourselves in the presence of tricho- 
monata of such proportions. Donne might have dispensed 
with his microscope in hunting animalcules — or, as we would 
say, animals — from an inch to an inch and a half long. 

Dr. Hewitt follows Scanzoni in recommending a liniment of 
chloroform and almond oil for pruritus vulvae, but he uses it 
as strong as one part of chloroform to six of oil. He also 
advises frequent bathing with cold water. This, we think, is 
a mistake. The cold gives relief for the moment, but excites 
reaction, and the itching becomes worse than before. 

Dr. Hewitt's knowledge of gynaecological surgery does not 
seem to be of the most recent sort. In dealing with the 
subject of vesico-vaginal fistula, he advises as follows : — " When 
the base of the bladder is entirely gone, it is necessary to close 
the vagina completely, the patient afterwards menstruating 
through the bladder." Few there are who have performed 



104 Reviews. 

this operation once, and have followed the after history of the 
patient, wlio would be readily tempted to repeat it. The 
patient remains very well for some time, but in spite even of 
great care, urinary salts and the debris of menstrual blood 
gather below the level of the urethra, giving rise to inflamma- 
tion, which spreads to the kidney, and soon destroys the 
patient. There is no objection to simply turning the cervix 
into the bladder if the vaginal canal be not included, but this 
is rarely necessary, and cannot truly be called closure of the 
vagina. There are appendices on " Differential Diagnosis of 
Pains referable to the Internal Generative Organs, including 
Dysmenorrhoea," " Differential Diagnosis of Pelvic Tumours 
and Enlargement of the Uterus, including Pregnancy, by 
Digital examination of the Vagina," " Diagnosis of Abdominal 
Tumours, including Pregnancy. Examination of the Abdomen," 
and on " Sterility." These are in a general way very good, but 
have a drawback which is common to the whole work, they 
are unduly verbose. Here and there are some specially sensible 
and practical remarks, such as the following : — " The diagnosis, 
as made out by an abdominal examination, should be corrected 
and checked, so to speak, by a vaginal one ; a positive opinion 
should hardly ever be given as to the nature of any case, 
however clear it may appear to be, simply on the results 
obtained by the former method of investigation. Mistakes, 
ludicrous or serious, or both, have not by any means unfre- 
quently followed the neglect of this important rule." 

The book purports to be illustrated by 211 woodcuts. We 
say purports advisedly. There is a growing tendency in 
modern manuals to profess themselves freely illustrated, and 
this freeness consists largely in the reprinting of the same 
woodcut in different parts of the text. 

There could be no olvjection to this if it were stated in so 
many words that such was the case. We are sorry to see 
that Dr. Hewitt has fallen a victim to this weakness for free 
illustration, which savours of want of perfect candour. Thus, 
Figs. 8 and 31, Figs. 12, 18, and 84, and Figs. 20 and 35, are 
prints from the same block. Again, Fig. 40 is Fig. 39 turned 
on its edge. The woodcuts are almost all good, and are of 
great use in rendering the text more easily understood. 

There are one or two odd misprints, as on page 849, where 
a " mass of this kind, of the size of a bead, in its shape and 
position resembled an ovarian tumour." Head, of course, is 
the word intended. 

We hardly feel justified in recommending this work to a 
student, on account of its prolixity. To the practitioner, how- 



Reviews. 105 

ever, who wishes to be well iiit'ornied on this special branch of 
his profession, it wdll be found both interesting and instructive. 
In particular, we know of no manual in which the subject of 
uterine displacements is so fully discussed, and the treatment 
of them so clearlv laid down. 



The Extra Pharmacopceia of Unofficial Drugs. By W. 
Martixdale, F.C.S., and W. Wynn Westcott, M.B.Lond. 
Third Edition. London: H. K. Lewis. 1884. 

That the third edition of this invaluable consulting table 
" companion " should be called for in less than tw^elve months 
from the appearance of the first, is ample testimony to the 
value of the work and evidence of the need there was for some 
such publication. It is now too late in the day to criticise this 
book in detail, or to point out specifically its many merits; we 
content ourselves with commending it strongly to our readers. 
The following extract will indicate its nature and scope ; it is 
from the " supplement " to the book, and its length may be 
readily justified by its great interest at the present time : — 

" Cocaine and its Salts. — Although the mydriatic effects of 
cocaine and cocainge hydrochloras are noted in the 'extra 
pharmacopoeia,' the subsequent uses to which these drugs have 
been put since the publication of the last edition have brought 
them more prominently into notice than was then considered 
probable. I had overlooked the curious property cocaine 
possesses of producing local anaesthesia, although this was even 
noted by the discoverer of the alkaloid — Niemami, who, so far 
back as 1860, wrote : — 'It produces tempoi'ary insensibility on 
the part of the tongue with which it comes in contact.' 
{Watt's Dictionary, i, 1059, ex Ann. Ch. Pharm. cxiv, 215.) 
This interesting fact seems to have lain dormant for 24 years, 
until a few months back, when Herr Koller, a medical student 
in Vienna, was led to test the local anaesthetic action of the 
hydrochlorate of the alkaloid, on account of the effect he had 
witnessed when cocaine in solution was pencilled upon the 
pharynx to render it less susceptible in laryngoscopic exami- 
nation. A vial of the solution was given by Herr Koller to 
Dr. Brettauer, of Trieste, who, on 15th Sept. last, demonstrated 
its properties at the meeting of the Ophthalmological Congress 
in Heidelberg. Several experiments were made with the two 
per cent solution, which showed that when two drops of the 
liquid were placed upon the surface of the normal cornea, and 
the application repeated after an interval of ten minutes, at 



106 Reviews. 

the end of ten minutes more the sensibility of the cornea was 
so far diminished that it could be pressed with a probe ; the 
cornea and the surface of the eyeball and eyelids adjoining 
could be rubbed ; a speculum could be inserted and the lids 
widely separated, and the conjunctiva could even be seized 
with fixation forceps, and the eye moved in various directions 
without causing the patient notable discomfort. 

" Since then many trials of it have been made, both here and 
in America, and it has been shown that its action is not con- 
fined to the region of the eye and throat, — the ear, mouth, 
tongue, pharynx, nose, larynx, trachea, urethra, rectum, and, 
in fact, the whole mucous membrane, as well as cut surfaces 
and open sores, are affected by it ; but solutions of it are little 
absorbed by the skin, even a chloroform solution is scarcely at 
all absorbed ; although injected hypodermically the aqueous 
solutions of its salts deaden sensibility around the puncture, so 
that the deep prick of a pin is not felt — the surrounding part 
is reddened, but after thirty minutes it resumes its normal 
conditions. 

" The solutions have been employed topically in excision of 
the tonsils, cauterising the terminal bone of the nose, painting 
chancres previous to the application of nitric acid or other 
caustics, opening abscesses, removing polypi, and many cases 
of iridectomy and operation for cataract. For the eye an 
aqueous solution of the hydrochlorate of cocaine of 2 to 4 per 
cent is generally used, and a 4 to 20 per cent for other pur- 
poses ; of the weaker solutions it is necessary to repeat the 
application three or four times, at intervals of three to five 
minutes. At a discussion on anaesthetics at the Medical Society, 
on the 25th Nov., a speaker advocated the use of the strongest 
solution. No injurious effects, either local or constitutional, 
seem to follow its use. Its action commences in three minutes, 
increases from ten to twenty minutes, and mostly disappears 
within half an hour. On the eye it paralyses the accommoda- 
tion, which passes off sooner than the dilatation of the pupil, 
and even this does not at lono;est last more than twelve hours. 
The sensitiveness of the iris is less affected than that of the 
surface of the eye. 

"References. — Eleven successful cases, including three of 
operation for cataract, one double iridectomy, one removal of 
tumour from lid, and three for converoent strabismus. In cases 
of intolerance of light it acts like magic. — C. Bader, Lancet, 
22nd Nov., 1884, p. "911. 

"In papillomata of larynx, interior painted with 20 per 
cent solution of hydrochlorate of cocaine once, in five minutes 



Reviews. 107 

was able to introduce the forceps four times and remove large 
portions of tumours without patient experiencing any pain or 
subsequent shock. — F. Semon, Lancet, 22nd Nov., 1884, p. 912. 

"Physiological effects on the eye. — Lucien Howe, Lancet, 
22nd Nov., 1884, p. 911. 

" Two cases of operation on cervix uteri, the cervical canal, 
and adjacent parts, three times painted with 4 per cent 
solution at intervals of two or three minutes, little or no pain 
felt, till in one case towards end of prolonged operation. — W. 
M. Polk, Med. Bee. (N.Y.), 1st Nov., 1884, p. 481. 

" Seven eye cases under its influence. — W. O. Moore, Med. 
Rec. (N.Y.), 8th Nov., p. 510. 

" Use in the nasal cavity, cotton wool soaked in 2 per cent 
solution applied at the end of a probe in over forty cases, 
including hypertrophy of the nasal mucous membrane (twenty- 
seven cases cauterised), acute coryza, nasal polypus, and hay 
fever, all having marked swelling of the nasal mucous mem- 
lirane, both from chronic and acute causes ; in every case there 
was complete subsidence of the turgescence of the membrane, 
and the sinuses were emptied of their blood. — F. H. Bosworth, 
Med. Bee. (N.Y.), 15th Nov., p. 538. 

" As regards the toxic properties of cocaine, its effects appear 
to be mild and not cumulative. It causes cessation of respira- 
tion, small doses have an exhilarating effect on the nerve- 
centres and other parts of the nervous system. In a case of 
attempted suicide, a dose of 1*5 grammes (23 grains) seemed to 
have no seriously injurious effect. 

" Cocaine, as before stated, was first isolated by Niemann in 
1860. From analysis he gave it the formula of C32 Hg^ NOg 
(old notation), but Lossen, in 1862, assigned it the now accepted 
formula of C-^- H.,^ NO^ (new notation). It has a bitterish 
taste, and crystallises in shining monoclinic prisms. It requires 
704 parts of water to dissolve it, it is more soluble in alcohol, 
freely so in chloroform and ether, and 1 in 20 respectively of 
melted vaseline and castor oil. The two last solutions have 
proved serviceable in eye cases. Manufacturers infonn us 
coca leaves yield from 0*02 to 0"2 per cent. The leaves also 
contain hygrin (a volatile principle) with ecgonine, coca-tannin, 
and a peculiar wax. Ecgonine (together with benzoic acid and 
methyl-alcohol) may also be obtained as a derivative from 
cocaine when the latter is heated with strong hydrochloric 
acid. 

" CocAiNiE Hydrochloras. — This salt has been most used ; 
it appears to be a white amorphous powder, which, in reality, 
consists of slender white needles, usually having a peculiar 



108 Reviews. 

odour, more marked than that of the alkaloid itself, and its 
action on the tongue and mucous surfaces is more intense than 
that of the latter. It is soluble 1 in 4 of water, and freely 
soluble in spirit. It is an antiseptic, a 5 per cent aqueous 
solution delays the putrefactive changes in an extract of meat. 

" Cocaine Citras is in deliquescent small white crystals. 
This has been recommended for the use of dentists, as it can be 
kneaded into pills, which, after being wrapped in cotton wool, 
moistened, and placed in the cavity of a carious tooth, 
anaesthetises the sensitive pulp, and renders filling and extrac- 
tion almost painless. A strong solution of the pure alkaloid in 
oil of cloves has also been used similarly. 

" Cocaine Salicylas is recommended for the use of oculists, 
as it forms a solution which keeps well. 

"Dose of Cocaine and its Salts — -^^ to 1| grains, 

" Other Preparations of Coca. — Extractum Gocce is im- 
ported from South America. Prepared from the green leaves. 
Dose — 5 to 15 grains, in pills or pastils. 

" As coca leaves lose much of their virtue by keeping, this 
and the next following are the best pharmaceutical preparations 
of it. 

" Pastillus Gocoi Extracti. — 2| grains of the extract in each. 
Dose — One every two or three hours. 

" A Wine of Coca, containing about 1 in 30 — dose, a wine- 
glassful — and a liquid extract, and an elixir, about 1 in 6 — 
dose, 1 to 4 drachms — are prepared. Extractum Erythroxyli 
Fluidvbin, U.S. — Dose, | to 2 drachms ; 1 = 1 part of leaves, is 
about six times stronger than the above mentioned liquid 
extract, which is a French nostrum. 

" The uses of the coca leaf by the native Indians of Bolivia 
and Peru have been described by many travellers who have 
seen it chewed. It is used, in conjunction with the ashes of a 
plant or with lime, as a remedy for, or preventive against, the 
effects of extraordinary physical exertion, to relieve the diffi- 
culty of respiration in ascending mountains, and to appease 
hunger, thirst, and fatigue. 

" The discovery of the alkaloid cocaine led to the belief that 
it possessed properties allied to caffeine, but this has not been 
confirmed. As a medicine, coca has been more used in France 
and America than in England. In Vienna, cocaine has been 
recommended for use internally in cases of great exhaustion, 
such as loss of blood, sunstroke, or diarrhoea, also by mouth or 
hypodermically as a cure for morphia and alcohol craving. 
Morphia and cocaine appear to be mutually antagonistic. 
Cocaine has been used in some cases of melancholia and in- 



I 



Hciuc'ws. JO!) 

soiiinia ; it also possesses aphrodisiac properties. It was like- 
wise found to lessen the desire for sleep and feeling of hunger, 
and to be a stimulant which quickly increases and sustains, in 
a harmless manner, the physical powers of the body, such as 
are required in long marches, mountain ascents, &c., in dose of 
•] to li grains. 

" Cocaine is a stomachic, useful after excess either in eating 
or drinking ; it also improves the condition of the stomach in 
atonic indigestion and nervous affections of this organ, as well 
as in phthisis and cachectic cases, especially those arising from 
the use of mercury. 

"A sensational telegram from Vienna appeared in the Standard 
of 21st Nov. last, stating the effects of cocaine as demonstrated 
before some scientific men, — one operation on an old polypus 
being performed with complete success in hve minutes. The 
great demand for coca and cocaine has caused a corresponding- 
advance in price, although here it has not reached so high a 
price as in New York, where the hydrochlorate of cocaine used 
at Dr. Merrill's College Clinic, Albany, cost equal to 3s. 6d. per 
grain English. Holders of stock of either are now reaping the 
profits of an ' unearned increment,' but in a short time a 
plentiful supply of the drug will arrive. 

"According to a writer in the British Journal of Dental 
Science, 1st Nov., p. 1030, tincture of cannabis indica possesses 
a somewhat similar local anaesthetic action. Previous to ex- 
traction he applies it diluted three to five times with water to 
the cavities of the teeth, if any, and about the gums, on cotton 
wool ; it is said to be effectual and devoid of the possibility of 
harm." 



Intestinal Obstruction, with, an Apjjendix on the Action of 
Remedies. By Hugh Owen Thomas, M.R.C.S. Abdominal 
Hernia. By'Ru.sHTON Parker, B.S., F.R.C.S., Professor of 
Surgery in University College, Liverpool. London : H. K. 
Lewis. 1883. 

.Mr. Thomas' style of writing is, as will be seen from the 
following note " To the Reader," very faulty : — 

" Since my first contribution to the literature of the subject- 
matter of this volume, seven years have elapsed, and as tin- 
two previous editions have been exhausted, this, combined 
with my having noticed that my teaching has already influ- 
enced practice in the treatment of intestinal lesions, induced me 
to rewrite and remodel the present editions. In hopes that 1 
might succeed in further demonstrating the need of reform, 



110 Reviews. 

and of perceiving still greater amelioration in treatment, so 
that I shall not continue an isolated advocate, even though, as 
hitherto, my efforts may be ignored by writers who have 
adopted my teaching, these have been my incentives to return 
into the arena." 

In the arena, moreover, Mr. Thomas is a perfect giant, 
dealing his blows lustily around, and knocking over his 
opponents like ninepins. Everybody is wrong, and has been 
wrong, in the treatment of intestinal obstruction till now. 
The only physician who ever had the faintest glimmering of 
the truth as to the management of such cases, according to 
Mr. Thomas, was Sydenham. That eminent man " reformed 
the dietetic treatment, a matter of fundamental importance ; 
he also detected the value of sedatives ; but I do not find that 
up to our own day the reforms which he taught have widely 
influenced practice." (p. 5). In support of this position Mr. 
Thomas quotes numerous cases from the Journals of the last 
few years, in which he asserts that the patients either died 
from the treatment, or only did well when the treatment was 
stopped in time, and the patient left to nature. He also finds 
fault with the refinements of differential diagnosis which 
bulk so largely in all recent papers, as they seem to lead men 
to " decline to classify as intestinal obstruction cases not pre- 
senting urgent symptoms," and also because he " cannot see 
the aid differential diagnosis would give in the absence of 
therapeutical principles applicable to the actual or impending 
symptoms resulting from obstruction." 

Under the head of Intestinal Obstruction Mr. Thomas 
includes all cases fi'om ordinary constipation up to complete 
strangulation of the bowel, and he bases his treatment 
of the more severe forms on what he considers the spon- 
taneous method of cure in constipation— namely, "that the 
general malaise caused by the constipation tends to alter 
the proportion between the solids consumed and the fluids 
imbibed — the imbibition of fluids being increased by thirst 
and the consumption of solids l)eing decreased from loss of 
appetite, the two prominent signs of genuine constipation." 
Mr. Thomas' theory, then, is to let the bowels remain undis- 
turbed as long as possible in all cases. He therefore restricts 
the diet to starvation point, and if necessary, gives opium as a 
sedative. He avoids all purgatives, either by mouth or rec- 
tum, while if shock be present he gives belladonna. His 
dietary is as follows : — 

" Arrowroot, sago, ground rice cooked with water, with the 
addition of brandy or wine and nutmeg, with sugar, salt, and 



Rnuews. Ill 

butter; pea, lentil, or bean Hour cooked with water, then 
carefully strained, wlien Itutti'r, salt, and a little pepper are 
added. For a change I perinit any of the tiesh broths, these 
being administered in small quantities as seldom as the thirst 
and hunger of the patient will permit. All solids and milk 
should be prohibited." 

Under these simple remedies, and with proper attention to 
nursing, warmth, &c., the great majority of cases of obstruc- 
tion tend spontaneously to get well. Occasionally, Mr. 
Thomas allows that cases require the aid of the surgeon, 
though he thinks that the high death-rate that has hitherto 
resulted from their treatment by medicine has tended to their 
being of late too frequently relegated to the domain of 
surgery. Thus, he allows that an operation may be required 
for internal or external strangulation, or for cancerous ob- 
struction, but it should never be performed for intussusception. 
On this last point he falls foul of Mr. Hutchinson in a very 
terrible way, making mincemeat of his various papers on the 
subject. Moreover, in certain cases of enteritis and of 
typhoid fever, he thinks an operation should be performed. 
The reason for this is stated in a very obscure paragraph which 
we really cannot understand. The operations generally i-ecom- 
inended are one or other of the incisions into the abdominal 
wall. But here Mr. Thomas is much more vague in his 
directions than when on the subject of diet. He objects to 
inflation of the bowel per rectum in intussusception ; and, 
though in cases of obstruction he has himself punctured th(i 
bowel with a trocar to relieve distension, he does not seem to 
think much of it, and he emphatically denounces as rude and 
impracticable the proposal made by Prof. G. H. B. Macleod 
{British Med. Journal, 25th November, 1876) to enlarge, 
by means of a tangle tent, the puncture made by the trocar 
so as to serve as an artificial anus. 

The last chapter of the book is an essay on hernia, with 
cases by Mr. Parker. Besides its own particular interest, it 
seems intended to show the advantages to be derived from 
following a restricted regimen in the after treatment 
of such cases. In this there is nothing very new ; and, as 
most of the cases recorded have already appeared in print, 
we shall make no further reference to the paper except to 
quote what Mr. Parker considers a perfect antiseptic dressing 
for the hernial wound. He says (p. 323), " The wound may 
be left unsewn, well smeared with a suitable antiseptic, say 
eucalj-ptus petroleum ointment, and covered with a piece of 
gutta percha tissue, bound on with a folded draw sheet. This 



112 Reviews. 

dressing permits perfect aseptic healing by granulation, with 
constant innnediate access for inspection, and is as safe and 
comfortable to the patient as it is convenient to the surgeon." 



On Mamimalian Descent : the Hunter ian Lectures for 188 J/. 
By Wm. Kitchen Parker, F.R.S., Hunterian Professor, 
Royal College of Surgeons of England. 

It is not very often that a Journal so purely medical as ours 
is called on to review a work so totally unconnected witli 
professional matters as that wliich is now before us. The 
link of connection is to be found in the genius of John Hunter, 
who was even more a scientific man than a surgeon, and in 
memory of whom the Hunterian professorship exists for the 
advancement of comparative anatomj^ 

The author of this work is well known in science by the 
large number of elaborate and copiously illustrated mono- 
•j-raphs which he has contributed to osteology, and especially 
to the development of the vertebrate skull. Those monographs 
are works of very great importance — the observations being- 
laborious, and the drawings with which the skilful pencil of 
the author has enriched them being of great value, happily 
rendering the study of the text less difficult than it would 
otherwise be. 

It is absolutely necessary to pay this well deserved tribute 
of praise to Mr. Parker's work and his untiring energy ; for 
otherwise we might not be justly understood when we say 
the present book is unworthy of him. It is a beautiful book 
so far as the printing and paper are concerned ; and the wood- 
cuts are artistically excellent, but the style is unique, and the 
object by no means plain. Bad style is a long standing fault 
of Mr. Parker's. His genial desire to be funny, to be striking, 
and his love of picturesque and bizarre expressions, some of 
them original, and others culled indiscriminately from all 
sorts of sources, sacred and profane, all these things tend to 
distract the reader who sits down with an earnest desire to 
get scientific information, perhaps to master some difficult 
matter of detail. But never in all our experience of his 
previous compositions have we known the learned professor 
to toss his cap so recklessly in the air as now. Take the 
following sentences as specimens : — " If in human society th(> 
toe of the peasant now and then galls the ribs of the courtier, 
so in this class the toe of the irrational beast treads, in some 
cases, very close upon the heels of rational man. It is 



Reviews. 113 

worthy of remark that this keeper of the inammals — hhnself 
a maimnal, is, in size, a good practical mean between the 
extremes. On one hand, we have 'the smallest monstrous 
mouse that creeps on floor,' and on the other, the unwieldy 
whale — large as an island. Taking the class as a whole, as 
to intelligence, we have * the extremity of both ends ' — man 
at one end, and the frog-witted duckbill at the other." 
Again, after mentioning that three groups of labourers, the 
zoologists, the paheontologists, and the emljrj-ologists, are 
working at the mammalia, he makes the following unhappy 
remarks : — " These three divisions of the swarm of biological 
bees are rifling the treasures of the planet, ' which pillage 
they with merry march bring home.' They are all Darwinians 
to a man ; and they scout the ' lazy, yawning drone ' who eats 
of tlieir honey, buzzing the while dissatisfaction at their work 
and their song." What need be said of such writing as this, 
except that even if it were true, it would be in bad taste ? 

But let it not for a moment be supposed that this strangely 
inaccurate style is reserved simply to point shafts against 
those who may happen to differ in their speculative views 
from the author. At page 224 there is a remarkable account 
of the history of a seal which he once dissected, and the 
reader is informed that this dissection showed " that it would 
be possible for an accomplished anatomist to write an accurate 
account, using somewhat general terms, but naming every 
muscle, bone, nerve, artery, and vein — every sense organ, and 
every one of the soft viscera within the body — and that 
description might be made to serve both for the seal and for 
man." It is unnecessary to point out to any one who 
knows the anatomy of the seal, that this is a statement which 
will altogether mislead any one who does not know it. But 
he proceeds : — " More than this — far more — the same supposed 
biologist might take up the embryology of the seal, tracing 
the confluence of the two primary germ-points, their mutual 
engrafting, the growth of the foundations of the embryo (the 
' blastoderm '), then the diflerentiation of the various tissues 
and organs- — and this second piece of descriptive anatomy 
might serve equally well both for the seal and for man." 
There are points mentioned in this sentence which, so far as 
we are aware, have not been actually observed either in the 
seal or in man, or, for that part, in any mammal ; if Mr, 
Parker has observed them, a detailed description of his 
observations would be a magnificent contribution to science ; 
if he has not, it is a pity that he has condescended so to 
write. 

No. 2. I Vol. XXIII. 



11-i Reviews. 

The book consists ot" a course of nine lectures, with addenda 
to each, not distinguished from them in the table of contents. 
The author, as one would expect, believes mammals to be 
descended from ancestors which diverged from those of 
reptiles, a view first, we believe, put forward by Mr. Huxley, 
and with which we find no fault as a speculation on the assump- 
tion of common ancestry of all vertebrates ; while, for the 
assumption itself, there is much to be said, although many 
difiiculties remain to be overcome before it can be entitled to 
be considered as ascertained fact. But the distinction between 
fact and theory is just exactly what Mr. Parker, with dogmatic 
vehemence, shuts his eyes to. 

Of the nine lectures, the first and last are an introduction 
and conclusion, while of the remaining seven, one is devoted 
to the monotremata, another to the marsupials, a third to the 
edentata, three to the insectivora, and one to the remaining 
orders of mammalia ; but it would be a mistake to suppose 
that there is any continuous attempt to demonstrate the 
particular doctrine of the descent of mammals to which the 
author gives his adhesion. Many exceedingly interesting 
isolated bits of information are to be found ; but their bearing 
on the theory upheld is not always obvious. We are repeatedly 
told that this, that, or the other thing is so delightful to the 
Darwinian, or favourable to his views ; but, in point of fact, 
the details so described, at most, can only be held as favourable 
to the doctrine of common ancestry, which originated not with 
Darwin, but with Lamarck ; wdiile they have no bearing at all 
on the question as to what the agency was by w^hich progression 
was brought about. 

The monotremata, we are told, are archseic, whatever may be 
meant by that ; but it happens that all the light which palaeon- 
tology has yet thrown on these animals is to tell us of a 
gigantic species, without known predecessors, found in the later 
formations. As to their anatomy, the pterygoids take part in 
their hard palate, a state of matters found in crocodilia, which 
are the highest of reptiles, and in cetacea, the affinities of 
which are to be traced through mammals less aberrant than 
themselves. In certain of the edentata, the pterygoids, we 
are told in this book, enter into the formation of the palate ; 
but that is just an argument against the notion that edentata 
were among the earliest mammals. We should be inclined, 
with all deference, to suppose that they were late to appear, 
partly on account of the palgeontological evidence, but still 
more on account of those peculiarities in the dentition, which 
Professor Flower pointed out a good many years ago. It 



I 



Reviews. 115 

must have required a great deal of evolution to produce 
gradatim any of the giant species of the past ; and the 
edentata are an order rich in fossil giants. 

We have mentioned that each lecture is followed by 
" addenda." These present a great variety of subject. The 
first of theui shows the author's acquaintance with Brahuianism 
and Lucretius ; others contain a diversity of useful information, 
including bibliography ; and the last invokes the authority of 
Lord Bacon and Goethe against metaphysicians and that 
terrible bugbear, teleology. Has it still to be pointed out that 
although science progresses by the search for efficient causes, 
it does not follow that there is no such thing as design in the 
Universe ? But if there is design, it is worth while to study 
of what sort it is, instead of sneering at the imperfect notions 
of earnest men who have gone before us. 

When Mr. Parker confines himself to describing, in plain 
language, what he has seen, he is always good ; and in that 
direction, but not in florid writing, he will find the path to 
such greatness as is open to him. 

" Ne sutor supra crepidam," at p. 217, ought to be " Ne 
sutor ultra crepidam;" and an uncommonly good maxim 
it is. 



On Visceral Neuroses, being the Gulstonian Lectures on 
Nevbralgia of the Stomach and Allied Disorders, delivered 
at tfie Royal College of Physicians in March, 1884- By 
T. Clifford Allbutt, M.A., M.D., F.R.S. London : J. & A. 
Churchill. 1884. 

De Quincey tells us that the last Lord Orford said of his 
stomach, that it was so strong that it seemed likely to survive 
the rest of his person. If his Lordship could have read intelli- 
gently the little monograph before us he would have seen the 
fallacy of his suspicion. We say intelligently, because it was 
written not for him but for us. It is written to correct a 
general but erroneous view of a great class of stomach dis- 
orders, and ought to correct many fallacies much more real 
and much more pernicious than that of the deceased noble- 
man to whom we have just referred. Our author's object is 
to show that the pains and storms of the abdominal viscera 
generally, but more especially of the stomach, are for the most 
part symptoms, and not substantive diseases. More particularly 
that dyspepsia is, generally speaking, a symptom, not a definite 
malady ; a symptom of a disordered state of the wdiole man, a 
disorder of function, a neurosis. 



116 Revieivs. 

With a large experience of this class of ailments, and 
endowed with a mind that instinctively seeks the true origin 
of things, Dr. Allbutt found that he was almost unconsciously 
using the term dys'pepsia less and less every year. He 
recognised that on all sides there were antecedent or more 
general conditions of which the dyspepsia is but the result or 
a part. To be sure this is just the tendency of increasing- 
knowledge. We no longer rest content with such terms as 
ascites or apoplexy, and many others will go the same way — 
epilepsy, we often think, most deservedly among the first. But 
we need to be specially reminded how largely, how directly 
the function of the stomach depends on our general physical 
state, and how greatly it is influenced by particular mental 
or moral conditions. How that the disease is not really in the 
stomach, but in the errors, the hardships, and the cares that 
press so heavily on so many. A special reminder we do need, 
for it has long appeared to us that, with the exception of the 
routine cough mixture, no line of treatment is so blindly, and, 
therefore, so futilely followed as that of the regular stomachic 
tonic. 

Dr. Allbutt is, of course, aware of the confessedly difficult 
nature of the study of stomach diseases. He feels, as an 
earnest inquirer after truth, how hard it is to get at the real 
nature of a vast number of such ailments. It is easy to 
eliminate on the one hand those which depend on primary- 
structural change, and on the other those that are obviously 
neuralgic, " but between these positions," he says, " lie a great 
number of cases which are hard to classify. Is pyrosis, for 
instance, some local and primary aftection of the coats of the 
stomach, or is it a neurosis ? Is flatulence, are all acid risings 
in the stomach due to some irregular transmutation of the 
contents of the organ, or are some of them consistent with the 
course of normal, if feeble, digestion ? In the former case such 
derangements may fairly be called dyspepsia, for the process of 
digestion goes wrong, not as a detail or subordinate part of 
larger or systemic irregularities, but as a simple and local 
error in the digestive work of the stomach itself. In a word, 
is stomach derangement in a given case but an expression of 
some general derangement, or is it a substantial ailment, and 
the cause rather than the consequence of any more general 
perturbations ? " He argues out such questions in favour of a 
neurotic rather than a local orioin ; but, looking at the matter 
fairly from all sides, he propounds the other difficulty that a 
local irritant may call out a latent neurosis. " We know, for 
instance, that the touch of a bronchial attack, or of an acute 



Reviews. 117 

pneumonia, may first reveal an asthma till that moment wholly 
latent — latent, it may be, till middle, or even later life ; or 
latent it might have been, like the unwept tear, for ever. 
How are we to succeed as ministers to the sick if we crowd 
into one chapter, and almost into one point of view, the pure 
neuralgias of the stomach, the neuralgias awakened by local 
irritations within the viscus, the disordered secretions or meta- 
bolisms within it due to perturbed innervation, and the primary 
dyspepsia of local origin, which concerns the nervous system 
but little or not at all ?" But we must refer the reader to the 
work itself for an elucidation of the subject. 

One deeply read critic has said that it is not altogether an 
original work. Dr. Allbutt does not put it forward as such ; 
but the profession has already accepted it as a fresh, clear, and, 
we would say, pure light on an obscure field of practice — a 
field of much mistaken practice, and too often of something 
worse. For within the scope of his subject comes fairly the 
question of uterine neuroses, and he does not spare the 
gynecologist. We have observed there is a pretty general 
agreement on the part of reviewers with the author on this 
point, and we also would endorse his opinion. " L uterus cest 
lafeinme, is a proverb," he says, " which has received a new 
development in these days ; for if, by courtesy rather than by 
conviction, woman be granted the possession of a few sub- 
sidiary organs, these, at best, have no prerogative nor any 
order of their own." It will be apparent from this one 
sentence that what our author condemns at some length is the 
ultra-specialism that undoubtedly attaches to this department 
of medicine, a practice fraught with danger to our profession 
no less than to the hapless patient. 



Vorlesungen ilber Pathologie und Tltera'ple der Syphilis, von 
Prof. Eduard Lang. Erste Halfte, mit Holzschnitten. 
Wiesbaden: Verlag von J. F. Bergmann. 1884. 

[Lectures on the Pathology and Therapeutics of Syj^hilis. By 
Prof. Eduard Lang. First half, with Woodcuts.] 

This work is a typical one of the careful German style, which 
is serious reading, at least for an Englishman. It has little of 
the literary merit which happily distinguishes much modem 
medical writing in Germany, but consists of a grave, earnest, 
exhaustive treatise on the subject. As a book of reference it 
is admirable ; but, although cast in the form of lectures, it 



118 Reviews. 

scarcely partakes of the readability which one looks for in such 
a form of writing. 

The work is divided into a general and a special part. In the 
former the author gives a historical sketch of the literature 
of STphilis, dividing it into three periods — namely, from the 
origin of the disease till the epidemic of 1495, from that 
date till Philippe Ricord, and from Ricord till the present time. 
This part of the book is well done, and we are able particularly 
to commend his exposition of the process hy which the present 
state of our knowledge has been reached. 

After the historical part the author takes up the present 
views as to the contagia of the venereal diseases, and in this 
lectui-e he discusses among other things the C|uestion of the 
origin of syphilis. In dealing with this question the author 
has little more than old wives' fables to give us. He refers to 
the practice of sodomy among the ancients, and to the custom 
which he infers to have existed of manipulation of the organs 
of generation with heterogeneous .substances, and he supposes 
that by one or other of these practices the contagium may 
have been first communicated to man. All this is mere specu- 
lation, and the book would have been stronger without it. 

The third division under the general part of the work deals 
with the general pathology of syphilis. The exposition here 
is very full and complete. The author first takes up the 
question of the dui-ation of the stage of incubation. After the 
primary infection the local manifestations only appear after a 
certain period, called here the period of the first incubation. 
These local signs are induration at the piimary seat and in the 
corresponding lymphatic glands. After another period the 
general constitutional signs manifest themselves, and this 
period is here designated the second incubation. In elucidation 
of this subject the author gives a table of collected cases in 
which these periods have been observed. His conclusions from 
this table are that the first incubation has a minimum of 10 
days, and a maximum of 42, with an average of 24 days, or 
3 to 4 weeks. The second incubation has a minimum of 8 to 
14 day.s, a maximum of 159 days, the usual duration being 6 
to 12 weeks. 

The special part of the book occupies the greater part of the 
portion before ils, and wiU take up the whole of the remaining 
half which is yet to be issued. In this pait there is a full 
discassion of the clinical and pathological characteri.stics of the 
initial sclerosis or induration, a section being devoted to vacci- 
nation syphilis, and another to the comparison between the 
syphilitic and venereal chancres. The latter is summed up in 



Reviews. 119 

parallel columns. After a lecture on the generalisation of the 
syphilitic contagium, the rest of the book is devoted to the 
cutaneous manifestations. 

On the whole we may say that, without much pretension to 
freshness or clearness in exposition, this work will take rank 
as a fair representation of the subject with which it deals. 



Diseases of the Spinal Cord. By Byrom Bramwell, M.D., 
F.R.C.P. Edin. Second Edition. Edinburgh : Young J. 
Pentland. 1884. 

As fewer changes have been made in this edition than the 
author at one time contemplated, and as (although every page 
has been subjected to careful revision) the original plan of the 
work has as far as possible been adhered to, it is unnecessary 
after the somewhat exhaustive and lengthy review which we 
gave of the first edition that ^^'e should deal with the present 
at any great length. We note, however, that in bringing out 
a second edition, the author has changed his publisher, and we 
take this opportunity of expressing our admiration of the 
artistic and excellent manner in which Mr. Pentland has 
performed his part of the work. We observe also that in a 
footnote, under the heading of Lateral Sclerosis, attention has 
been drawn to a remark of ours in which we ventured the 
opinion that primary lateral sclerosis was not so extremely 
rare as Dr. Bramwell would have us believe. Dr. Bramwell 
adheres to his opinion, and we are on the whole inclined to 
adhere to ours. During the present session, in hospital 
practice, we have seen at least two examples of the disease, 
one in an early and one in a very advanced stage. We 
admit that the disease is not a common one, and perhaps 
seldom seen in private practice, but sufficiently often observed 
in hospital to prevent it being classed as an extremely rare 
affection. It gives us great pleasure heartily to recommend 
this work to the medical profession as a careful exposition of 
the main facts concerning symptoms, pathology, and diagnosis 
of affections of the spinal cord. 



Elements of Surgical Diagnosis. By A. Pearce Gould, 
M.S., M.B.Lond., F.R.C.S'.Eng. London, Paris, and New 
York: Cassell & Company, Limited. 1884. 

This small volume forms one of the series of manuals at 
present being issued for medical students and practitioners. 



120 Reviews. 

From a somewhat rapid and superficial glance through the 
book, Mr. Gould seems to have efficiently effected his object, 
and if the subject of surgical diagnosis demands a separate 
and distinct treatise, then this little manual may be warmly 
commended to both student and practitioner. We confess, 
however, that this book more than any of the series which 
have up to the present come before us, impresses us with still 
graver doubts as to the value of the system adopted. Osten- 
sibly these manuals are for students, and that this object 
might be carried out to the best advantage, we are told 
that " the authors will be found to be either examiners or 
leading teachers in well known medical schools." Now, tak- 
ing the subject of surgery alone, as being that with which we 
are immediately interested, there are no fewer than four 
books upon the subject, and in order that a student may 
become efficient in this particular branch of his profession, he 
must consult each. But surely this is a somewhat clumsy 
method, involving necessarily much needless repetition and 
trouble. Thus, in studying any particular disease, the 
symptoms or diagnosis must be sought for in one book, the 
anatomy of the part in another, the pathology in a third, and 
the operative treatment in a fourth. The most scientific 
method of teaching demands that where symptoms are given 
their explanation as far as possible should be found either in 
anatomical relations or pathological processes ; but how can 
this possibly be carried out unless each disease is complete in 
description as to diagnosis, anatomy, pathology, and treat- 
ment ? We venture to think that the really leading teachers 
of medical schools would be far from inculcating such discon- 
nected and unscientific principles as the present system 
portends. 

If instead of adopting an analytic process, as this might be 
termed, a synthetic one were instituted, and out of the four 
present books a manual of surgery in four volumes were 
constructed, a really valuable work might be placed in the 
hands of students and practitioners, and this without in any 
way detracting from one intended object of these books — their 
convenience for the pocket. 



Transactions of the Academy of Medicine in Ireland. Vol. 
11. Edited by W. Thomson, M.A., F.R.C.S. General 
Secretary, Dublin: Fannin & Co., Grafton Street. 1884. 

We have much pleasure in directing the attention of our 
readers to the second volume of the Academy's Transactions. 



Reviews. 121 

Some time aofo we o-ave in our notice of the iirst volume a 
sliort account of how the Academy of Medicine in Ireland 
originated, and expressed our approbation of the manner in 
which it had been organised. The present work is of con- 
siderabl}' larger size than its predecessor, and a glance over its 
contents shows that medical work of an excellent and enduring 
kind is beincj carried on in the sister isle. We cono^ratulate 
the Academy on the appearance of this valuable record of its 
year's work. 



Lectures on some Important Points connected tuith the Surgery 
of the Urinary Organs, delivered in the Royal College of 
Surgeons, London. By Sm Henry Thompson, F.R.C.S., 
M.B. Lond. Students' Edition. London : J. & A. Churchill. 

1884. 

These lectures have, in a scattered form, already appeared in 
the various Medical Journals, but issued thus in a collected 
edition, and at a price which renders them attainable by the 
most impecunious, they will be welcomed by all. 

The substance of the lectures — six in number — are so well 
known to the profession, that there is little need for criticism 
or exposition. The views therein contained, have, on previous 
occasions been publicly expounded hj the author, either in his 
Clinical Lectures, or at the different London Societies. Briefly, 
however, it may be stated they are : — the advantage of 
internal urethrotomy over external : the value of digital 
exploration of the bladder, and the greater safety and success 
of lithotrity as compared with lithotomy. As with all Sir 
Henry Thompson's works, we can heartily recommend this, 
his latest contribution to vesico-urethral surgery, and believe 
it will be found as interesting and instructive, if not more so, 
than any of his earlier works. 



Practical Pathology. A Manual for Students and Practi- 
tioners. By G. Sims Woodhead, M.D., F.R.C.P. Ed. Second 
Edition. Edinburgh : Young J. Pentland. 1885. 

The second edition of Dr. Woodhead's Manual has just come 
to hand, and we have much pleasure in bringing it under the 
notice of our readers. It is unnecessary again to discuss the 
volume in detail, especially as a quotation from the preface 
to this edition will fully show wherein it differs from the 
former. " Every page has been carefully revised, parts have 



122 Hospital Practice. 

been re-written, and much new matter has been introduced. 
The number of illustrations has been increased, many of 
the plates have been re-drawn, and several which, in the 
first edition, were copied from other sources, have been 
replaced by original drawings. The author hopes that he 
has thus been able to make this edition an improvement 
on the first, and trusts that it may be regarded as 
worthy of at least equal favour by those for whom it is 
intended." It will thus be seen that, while the general plan 
remains much the same as before, the size of the volume has 
been considerably increased. The author has also adopted 
some of the suggestions which appeared in the various reviews 
of the first edition, whilst others he has passed over as, had 
they been introduced, the plan of the book would have been 
very materially altered. We cannot bi-ing this short notice 
to a close without complimenting the publisher on the 
excellence with which he has accomplished his task. We 
wish the volume every success. 



REPORTS OF HOSPITAL AND PRIVATE 
PRACTICE. 



WESTERN INFIRMARY. 

Reports under the Supervision of JOHN LINDSAY STEVEN, M.D. 

From Professor W. T. Gairdner's Wards. 

case of very obscure abdominal disease, in which multiple 
hepatic abscesses, with complete occlusion of the portal 
VEIN, WERE FOUND AFTER DEATH. [Reported by John Bever- 

idge, M.B., Resident Physician.] — William M'L , aged 35, 

iron moulder, admitted 25th November, 1884 (reported 26th), 
.suffering from acute febrile symptoms of six weeks' duration, and 
complaining of pain in the abdomen, the pain lasting through- 
out the six weeks, and accompanied by fever. Expression 
now not so much of fever as of pallor and emaciation ; trace 
of herpes on lower lip ; tongue, furred, but not dry ; tempera- 
ture on nio-ht of 25th reachino- 104<*2° F. at midnisfht, and on 
26th at 8 a.m., 98*8° F ; pulse, 100, regular, small ; respirations, 
16, with perhaps less than normal movement of abdomen. 



I 



Wester)t Infiriuari/. 123 

■» 
Patient's symptoms entirely limited to abdomen. Bowels veiy 
costive for six weeks before admission, but with nothing like 
obstruction, and no diarrhcea at all at any time. Thinks he 
got magnesia, which acted on the bowels without increasing the 
pain. Once or twice felt nauseated, but has had no consider- 
able sickness nor vomiting, and the appetite still good. 

Abdomen generall}' t^'uipanitic, and perhaps a little distended. 
To a minimized percussion-stroke there is relative dulness on 
right side below umbilicus, which, however, can be easily 
penetrated, so as to give an ecjually tympanitic note with the 
left side. Decidedly dull in both tianks in dorsal decubitus ; 
epigastrium, both to right and left, is relatively dull as 
compared with umbilical region, but on left side dulness can 
be readily penetrated, and although no edge can be made out, 
it does not seem impossible that the dulness in right hypo- 
chondriac and epigastric regions is due to extension downwards 
of right lobe of liver. 

Careful palpation of whole abdomen gives generally dim- 
inished elasticity, though no localized intumescence, and, in 
particular, no well marked difference between the right and 
left iliac region corresponding to the difference of percussion 
in these regions. 

Gravitation tests do not alter the above signs, and particu- 
larly when placed on face, the umbilical region continues 
tympanitic. 

Previous Treatment. — Three fly blisters were applied when 
outside the hospital, and opiates were extensively given, on 
account of pain (which was very severe), but without pro- 
ducing sleep. He states that pain commenced " low down on 
right side," and afterwards became general' over whole abdomen. 
Previous history excludes febrile disease preceding the local, 
e. g., typhoid. 

Patient, till last July, v.as a very healthy man, and no sign 
of constitutional disease in chest or elsewhere is apparent. 
He has four children, all healthy. Between last July and 
the present time twice affected with slight degree of same 
symptoms, but these passed off in two or three days without 
the general health being impaired. 

Present illness commenced suddenly with shivering, rapidly 
followed by the local symptoms, abdominal pain, &;c.* He 

* It was at this stage of the case that the extremely local character of 
the pain which, according to the patient, wa.s low down in the abdomen, 
and to the right side, suggested to Dr. P., who saw him outside, the 
diagnosis of perityphlitis, afterwards communicated to Dr. Gairdner by 
letter. [See remarks at the end of this report.] 



124 Hospital Practice. 

has sweated heavily, mostly at night, during this illness. The 
urine has been high coloured, but there has been no difficulty 
in passing it. There is no evidence of splenic enlargement. 

Between '26th and 29th, patient had opiates at irregular 
intervals, but sufficient to combat the pain to a great extent. 

Patient has sense of being better (29th November, 1884), 
especially as regards pain, which has been absent for two 
days ; and as regards the temperatures, which, although 
lower, a,re still, however, febrile. There is no well marked 
periodicity, and accordingly Dr. Gairdner ordered 1 gr. opium, c, 
4 grs. quinine every four hours, but there was no marked 
effect from this as regards the temperature, except on the 
30th, when temperatures registered were lower than on the 
preceding and succeeding days ; the maximum on the 30th 
being 101'2°; and the minimum on 1st December at 8 A.M. 
being 98° F., although after that it had a continuous rise, till 
at 2 P.M. it reached 103-2° F. 

3nd December.— Bowels moved for the first time, and that 
spontaneously, since admission. Noted on that date by Dr. 
Gairdner, " that it is impossible to make out any impaction 
in the right iliac region, although the impaired percussion 
note is still present. The percussion dulness in the right 
hypochondrium and right part of epigastrium are to-day more 
perceptible, and Dr. Gairdner examined particularly with 
respect to possible hepatic abscess, but without any stronger 
evidence than above stated. Tenderness on pressure in this 
region is very inconsiderable." 

6th December. — No new local symptom ; rigors daily since 
the 3rd inst. On a critical examination with respect to 
fluctuation, nothing was discovered to justify a positive opinion 
in this direction, and patient is not sensible of any pain 
specially recognisable as hepatic. Question of jaundice raised, 
but it is impossible to say more than that there is a sallow 
countenance, and conjunctivae doubtfully tinged. 

10th December. — Although still complaining of pain in 
abdomen badly, so as to require an additional dose of opium, 
there is no change on percussion over abdominal wall, and 
to-day it would be very difficult to detect any difference on 
percussion in the two iliac regions. 

12th December. — Dr. Gairdner notes that, although no rigors 
since 8th, pulses now tend not to fall in frequency with 
diminished temperatures — now below 100, and ranging from 
this to 140. Patient is very prostrate, tongue dry and brown, 
requiring opium to be kept in restraint as much as possible ; 
and yesterday a little delirium. 



Weston Infirmary. 125 

24th December. — Patient unconscious since 5.30 this morn- 
ing. Had a restless night, trying to get out of bed several 
times. There is no evidence of this being due to any com- 
plication except progressive weakness. Pulse at 8 a.m., 150 ; 
at morning visit, not perceptible. Cardiac sounds quite 
regular, although weak, and giving a rate of 124. Tempera- 
tures subnormal now, and nothing like fever since IGth 
December. Since 12th has been only occasionally delirious, 
and at one part of every day was perfectly intelligent. 

No trace of chest affection all through the illness, and 
respiration now quite tranquil, though 28 per minute. Patient 
lately has been having nothing but liquid food, but it has not 
failed to be observed that he was losing ground, facies 
hippocratica becoming most marked. 

Physical examination shows that liver dulness has dimin- 
ished considerably, but with nothing like abscess pointing, 
although abdominal wall quite relaxed. No rigors since 8th. 

Patient died at 2'30, after continuing in the same uncon- 
scious state till death, no other symptom arising. 

The temperatures, reduced to a chart, show^ considerable 
oscillations, but with no regular periodicity as regards the 
rise and fall, sometimes even reaching as maximum 103° F., 
and 103"2'' F. on an afternoon of one day, with a dip to 
99*8° F. between these maxima. These exacerbations of 
temperature were generally accompanied by very severe 
rigors, during wdiich the patient was in an exceedingly 
collapsed condition. The rigors at first were not so constant 
as between 8rd and 8th December, wdien he had a rigor every- 
day, excepting on the Gth December ; but as if to make up for 
this, he experienced tw^o very severe rigors on the 7th. 
During the first part of residence in Hospital, between 25th 
November and 2nd December, he had only tw^o rigors — viz., 
on the 25th and 26th, after which he had no rigor till 3rd 
December, as above mentioned. After 8th Decendjer no 
rigors were experienced. On that date he had 10 grains 
quinine, in place of the opium and (juinine pills which he was 
having up to that date, when they were stopped, and opium 
in 1 grain doses given whenever the pain became severe. 
On three consecutive days succeeding the 8th December, the 
10 grains (juinine were administered at 11 A.M., with 1 grain 
opium every six hours, and after this date, as stated, the 
rigors ceased to occur, the daily oscillations of temperature 
became less, and after the 16th Decemljer seemed to be 
approximating to normal, never exceeding 100°. 

The pulse, however, which had been, up to the 8th DecemV)er, 



126 Hospital Pnuiice. 

closely keeping pace with the rise and fall of the temperature, 
as shown by the chart, suddenly took a different tack in tlie 
direction of acceleration, just as the temperatures were 
moderating, and their daily oscillations becoming less — i. e., 
from the 9th to the 16th December. The divergence of the 
two lines shown by a chart became even more marked when 
the temperature fell to almost normal, with a few exceptions, 
never rising even to 100° F. for the last nine days 
before death, while the pulse during that period was ranging 
between 145 shortly before death, and 92. A pulse as low 
as 80 was registered on one occasion on the 19th December, 
but this was quite exceptional ; the average, even with normal 
temperatures, at this period being 110 to 120. 

A post-mortem examination was made on the 26th Decem- 
ber, 1884, by Dr. Joseph Coats, who has made the following 
report. The body is excessively emaciated. The heart is 
almost entirely devoid of external fat ; its muscular tissue is 
dark brown in colour, and the whole organ is unduly small, 
weighing only 7f ounces. The left lung is not adherent, and 
is somewhat deeply pigmented, but otherwise not remarkable. 
The right is slightly adherent behind, and presents consider- 
able hypostatic engorgement posteriorly. 

The spleen is considerably enlarged, weighing d\ ounces, 
but its tissue is normal in appearance. 

The peritoneum presents very little in external appearance 
that is abnormal. There is considerable adhesion and some 
matting of intestine in the neighbourhood of the liver; but no 
recent inflammatory formation. There are numerous cal- 
careous masses in the mesentery of the small intestine. 

The portal vein at the porta of the liver is completely 
obstructed by a thrombus, and behind it there is a large 
cavity filled with pultaceous material. This cavity is found 
to extend on the one hand into the substance of the liver, and 
on the other downwards behind the pancreas as far as its 
lower border, being of a ver}^ irregular outline throughout. 
On tracing up the portal vein into the liver, it is found to 
open out and communicate, by a large aperture, with the 
cavity before mentioned. This cavity extends somewhat 
deeply, and has ramifications into the substance of the liver ; 
and on dividing the organ, numerous more or less isolated 
abscess cavities are found, many of them with a lobulated 
outline. These cavities contain for the most part an orange- 
coloured, somewhat viscid material. On cutting into the head 
of the pancreas, a cavity containing a viscid pus is opened 
into. This abscess does not extend far into the organ, and 



Western Infirmary. 

there are no isolated ones discovered in it. On tracing the 
portal vein downwards, a branch of it is I'onnd to open up and 
connnunicate with tliis cavity in the pancreas, the wall of the 
vein being here irregular, indefinite, and of a slaty colour. 
The gall bladder presents nothing remarkable, and the gall 
duct, as well as the hepatic duct, are traced, the latter into 
the substance of the liver, without any alteration being 
perceived. 

Both kidneys are considerably enlarged, and present occa- 
sional yellow inhltrations extending for the most part from 
the apices of the pyramids to the surface, where, on removal 
of the capsule, they appear as slightly prominent yellow 
patches with irregular outline. On the cut surface they 
sometimes present at the margins little rounded outlines, 
as if they were extending at separate centres. The ureters 
are very slightly dilated. The bladder presents a moderate 
hypertrophy of its muscular coat and some pigmentation, as 
well as hyperasmia of the mucous membrane. 

Clinical Beviarks by Dr. Gairdner. — The primary diagnosis 
in this case, as communicated to me in a letter from the very 
intelligent physician who was called in six weeks before the 
patient was admitted to the Western Infirmary, was " perityph- 
litis, followed by peritonitis, which extended over nearly the 
whole abdomen," and this was treated by calomel and opium, 
also by blistering, with apparent success ; but a second attack, 
confined to the upper region of the abdomen, occurred after 
his convalescence from the former, and between tlie two attacks 
the bowels were so much obstructed as to give rise to a 
suspicion of " constriction of some part of .the intestine." The 
condition of the patient on admission, although not affording 
positive support to any of these views, was not inconsistent 
with them,* and it will be observed in the report that the 
physical diagnosis, while inconclusive as to the alleged 
"perityphlitis," gave some colouring to the idea strongly 
entertained and expressed by the patient himself, that the 
" inflammation " had begun low down in the right iliac region, 
and from that extended over the right side of the abdomen. 
I am well aware of the fallacies of observation possible in 
such cases, but it is noteworthy that even the facts of the 2^ost- 
mortem examination, and the absence of recent peritonitis 
anywhere in the dead body, have not removed from the mind 

* It is, perhaps, worthy of remark that the rather vague, but still 
probably triistwortliy, account of two previous slight attacks of abdominaJ 
inrtamuiation between July and October, was quite in accordance with 
what is known of typhlitis and perityphlitia. 



128 Hospital Practice. 

of Dr. P. the belief that he had to deal with a perityph- 
litis in the first instance. Confining remarks now to what 
occurred under my own observation, I would say that the 
probabilities of an abscess, or deep suppuration of some kind, 
in the hepatic region was present to my mind almost from the 
first, and still more so when the irregularly oscillating tem- 
peratures and the frequent rigors concurred with the evidences 
of slight enlargement of the liver, as mentioned in the report. 
In lecturing on the case, I said that abscess of the liver might 
have been expected to give rise to much more localised pain 
and tenderness on pressure than could ever be verified in this 
case ; but yet, that the temperatures and the history together 
were almost conclusive as to suppuration someiv]iere,mxd that the 
only organ where it was specially to be looked for according to 
the evidence of physical signs, was in the liver or its appendices. 
The connection of hepatic abscess with diseases of the intestine 
(perityphlitis among others) was also discussed, and the un- 
favourable prognosis of pysemic and septic abscesses in this 
organ was mentioned. The phenomenon of subsiding tempera- 
tures, with accelerating pulse, was particularly noticed, and 
the absence of all persistent vomiting, and of diarrhoea, and 
indeed all the usual symptoms of acute inflammatory disease 
of the viscera of the abdomen only served to make it more 
probable that the abscess, or abscesses, were latent and deep 
seated. The idea of pylephlebitis or pylethrombosis (ob- 
struction of the portal vein) did not obtrude itself, chiefly 
because there was at no time the slightest trace of dropsy, 
either of the abdomen or of the lower limbs, nor was there 
any evidence at all of a circuitous or anastomotic venous 
circulation such as occurs in obliteration or obstruction of 
the portal vein. (See Von Schlippel's article in Zlcunssenx 
Gyclopcedia of Practice of Medicine, translation, vol. ix, p. 802.)* 
Looking now at all the facts of the case in the light of the 
post-mortem exanunation, the first source of the suppuration 
still remains very obscure. There was no history of gall-stone. 
nor were any traces of them found in the dead body. The 
abscess-cavity between the liver and pancreas, however it may 

* " The diagnosis of portal occlusion depends upon tlie demonstration of 
ascites, enlargement of the spleen, diarrhoea, bloody stools, hsematemesis, 
and upon the presence of dilatation of the abdominal veins. If these 
symptoms of stasis are combined, there can be no doubt that the portal 
vein is impermeable. On the other hand, the diagnosis may be very 
difficult when ascites or several of the symptoms mentioned above are 
absent." Loc. cit. In this case all of these characteristic symptoms were 
absent, except a moderate, simple hy]5ertrophy of the spleen ; yet the 
portal vein was completely occluded by a thrombus. 



Private Practice — Medico-Gkirtirgical Society. 129 

have originated, must have become the source of the multiple 
secondary abscesses in the line of the vena portfB, by opening 
into its main trunk, and so diffusing purulent and septic 
debris throughout the organ ; after which the vena portae itself 
must have become occluded by coagulation of its contained 
'blood. The case is, thus far, unique in my experience. 



PRIVATE PRACTICE. 



We regret that, owing to an oversight, the case reported in 
last month's journal of " Gouty Kidney resulting in a sudden 
outburst of ursemic poisoning without any manifest premoni- 
tory symptoms " was ascribed to the wrong person. The case 
was reported by James Parker, M.B., Glasgow. 



MEETINGS OF SOCIETIES. 



MEDICO-CHIRURGICAL SOCIETY. 



Session 1884-8.5.- 

^Ieeting II. — 7th November, 1884- 

Dr. G. H. B. MACLEOD, President, in the Chair. 

The President, Dr. Macleod, gave his inaugural address, 
which appears at p. 85. 

Dr. John MTntyre exhibited a new form of portable 
INCANDESCENT ELECTRIC LAJVIP, and showed its application to 
the various specula. (A description of the lamp will be found 
in the Jourivd for January, page 17). 

Dr. W. L. Reid showed a scarf pin, which had passed 
through the intestinal canal of a child. Dr. A. L. Keli-Y 
also showed various articles, including SCARF pins, a darning 
No. 2. K Vol. XXin. 



180 Meetings of Societies. 

NEEDLE, &;C., which had passed through the human body. In 
Dr. Raid's case the child, five years of age, was given a 
hearty meal of porridge, and the pin was voided in a large 
soft stool. 

Dr. Gairdner said that the results in cases in which such 
bodies were swallowed were not always so satisfactory ; and 
in the case of his own children he was always in dread of 
fish bones. He had encountered two or three cases in which 
the swallowing of fish bones had been followed by a series 
of ill effects. In one case it had produced an abscess in the 
liver, and this was followed by a secondary abscess of the 
brain, which caused death. A man died of chronic peritonitis, 
and on examining the body he found between two coils of 
the intestines a fish bone. In a third case a fish bone got 
into the back of the pharynx, and led to an abscess and 
septic poisoning ; an abscess of the lung also formed, and he 
was brought to the hospital as a case of typhus fever. On 
post-miortem examination the true state of inatters was 
disclosed, and the fish bone was found lying under the 
vertebrae. 

The President said that the old treatment of purgatives 
in such cases was bad, and there could be no doubt that the 
true method was to try to get the foreign body enveloped in 
food. 

Dr. J. L. Steven read a paper on rupture of the heart, 
which will be found in the Journal for December, 1884, page 
413. 

Br. Coats coincided generally with the view of the patho- 
logy of these cases which had been enunciated by Dr. Steven. 
He was convinced that disease of the coronary arteries was 
more frequently concerned with cardiac mischief than was 
usually supposed. Since his attention had been specially 
directed to the subject, he had seen a great many cases in 
which these arteries were diseased. 

The President mentioned two cases within his own experi- 
ence of sudden death from rupture of the heart. He thanked 
Dr. Steven for his communication. 



Medico-Chiriii'gienl Soeiefy. 131 

Meeting III. — Stli December, 1884. 



Dr. Macleod, President, in the Chair. 
Dr. H. C. Cameron read on certain bad effects which 

FOLLOW IN SURGICAL PRACTICE THE SUDDEN WITHDRAWAL OF 
COUNTER PRESSURE TO DISEASED BLOOD-VESSELS. 

Dr. Newman said that it should be borne in mind that the 
withdi'awal of counter pressure from healthy vessels would 
not probably be followed by bad effects. The main factor in 
these cases was the diseased vessels. In cases of stricture of 
the urethra with distension of the bladder, there was usually 
associated with the condition hypertrophy of the muscular 
coats of the vessels and distension of the capillaries. In all 
these cases there was present an anaemic or hyperaemic con- 
dition of the wall of the vessel. After death, the fact that no 
lesion could be detected counted for little. Even in cases of 
rupture of the aorta there was often no apparent disease of 
the vessel wall. 

Dr. FergVjS gave some details of one of the cases referred to 
by Dr. Cameron. 

The President said that in regard to the removal of counter 
pressure as a cause of haemorrhage, there could be no doubt 
that it must be reckoned as one of the causes tending to pro- 
duce bleeding in the class of cases referred to by Dr. 
Cameron. But cases were constantly occurring in which the 
sequence of events points to other causes. That morning he 
had opened a psoas abscess, evacuating a large quantity of pus, 
which came away without any bleeding, but some time after- 
wards there was a smart attack of bleeding As to abscesses 
of another kind, he remembered a case in which, in a large 
abscess of the thigh, he made a free opening, evacuating a 
large quantity of pus, and afterwards put in a large drainage 
tube. In a few days there was violent haemorrhage ending 
in death. On post-moriein examination there was found an 
ulcer, caused by the pressure of the drainage tube on the 
femoral artery. In regard to passing a catheter into the 
bladder he disapproved in toto of the practice recommended 
by Dr. Cameron of using a small instrument. This was a 
dangerous practice, and he had seen the worst results from it 
in the hands of medical practitioners. His teaching had 
always been to use the largest instruments. The stream of 
urine could easily be diminished, and at first only a small 



132 Meetings of Societies. 

quantity drawn off. Careless catheterisation he was con- 
vinced was the cause of many deaths. It was to this that the 
occurrence of hsemorrhage was largely due ; much more to 
this cause, resulting in lesions of the neck of the bladder, 
than to removal of counter pressure. The fact that in the 
anatomy of the bladder there were two veins for every artery, 
convinced him that cases due to the cause assigned by Dr. 
Cameron, though sometimes met with, were not common. 
The state of matters depicted in the plate in the work of 
MM. Guyon and Bazy, which Dr. Cameron had sent round, 
he had never seen. It must be very rare. He strongly 
deprecated the use of metallic instruments. With the use of 
a French catheter, and great care, the danger of catheterisation 
was minimised. Of course it was inevitable that the bladder 
should rapidly fill again in these cases of old retention. 

Dr. Cameron said that in reference to Dr. Newman's 
remarks that gentleman evidently thought that he had laid 
too little stress on disease of the vessels in these cases, he 
would point out that in the title of his paper — " On certain 
bad effects which follow the sudden withdrawal of counter- 
pressure to diseased blood-vessels," he had sufficiently indi- 
cated that this was, in his opinion, an essential element in the 
cases. He had never seen such a thing occur in a young man, 
or even in an old man, unless suffering from an old retention. 
He had known regular catheterisation going on for many 
years without evil results. In regard to the size of the 
instruments he admitted that what Dr. Macleod now taught 
he had been taught, and had long practised. But he was now 
persuaded that there was no great risk in using a soft black 
catheter (corresponding perhaps to No. 6). He could not 
believe that wounding of the neck of the bladder was the 
cause of haemorrhage in such cases as he had instanced. Such 
a cause was palpably insufficient to explain the phenomena. 
In an old man with a long retention he drew off a quantity of 
urine unmixed with a single streak of blood from the begin- 
ning to the end. With a wounded bladder was this likely to 
happen ? On the very next occasion of passing a catheter into 
that man's bladder the urine from first to last was like claret. 
Could this be due to a lesion of the neck of the bladder ? He 
was quite prepared to believe that in such a case there was 
weeping of blood ex vacuo from the whole of the mucous 
membrane. 



Pathological and Clinical Society. 138 

GLASGOW PATHOLOGICAL AND CLINICAL SOCIETY. 



Session 1884-85. 
Meeting IV. — 12th January, 1885. 



The President, Professor George Buchanan, in the Chair. 

Dr. David Newman showed a lamella of bone which was 
impacted in, and removed by forceps from, the left 
VENTRICLE OF THE LARYNX OF A MAN, and stated that he was 
called to see the patient about eight hours after the accident. 
The sj'-mptoms were those usually indicative of the presence 
of a foreign body in the larynx. The irritation produced by 
the piece of bone was so great that a laryngoscopic examina- 
tion was quite impracticable. The larynx and fauces were 
brushed with a 20 per cent solution of cocaine, and this was 
repeated at intervals of about half an hour. After six appli- 
cations, the larynx was so anaesthetised that an examination 
could easily be made, and instruments could be introduced 
within the glottis. The appearance of the left side of the 
larynx was as follows : — the mucous membrane was swollen 
and hypersemic, and just below the false cord a clear glistening 
body was seen, w^hich presented the appearance of a true vocal 
cord of unusual brilliancy and breadth. During a movement 
of the false cords, this glistening body became displaced, and 
its true character was revealed. It proved to be an irregularly 
shaped lamella of fish bone. The margin lying over the true 
cord was broad and regular, while the edge lying against the 
false cord was sharp and spiked. The bone was about half an 
inch long and three-eighths of an inch broad at its widest part. 
The irrecjular margin was found to be buried in the mucous 
membrane, crossing the lower aspect of the false cord, so that 
the spiculum was firmly attached and retained in the position 
just described. Schrce Iter's laryngeal forceps was introduced, 
and with some difiiculty the bone was removed by the mouth 
without making any external incision. After the removal of 
the foreign body, the patient was directed to use steam inhala- 
tions containing the compound tincture of benzoin, and in a 
few days recovery was complete. The patient now speaks 
with a natural voice, and there is nothing indicative of any 
harm having been done by the operation or the piece of bone. 



134 Meetings of Societies. 

In connection with the operation, Dr. Newman remarked on 
the great advantages obtained by the employment of cocaine. 
Without its use, the removal of the bone by the operation just 
described would have been quite impossible, and thyrotomy, 
with all its evil consequences, would have been necessary. The 
solution of cocaine was applied by means of an ordinary 
laryngeal brush, but on account of the expense of this drug, 
Dr. Newman had been applying the cocaine in a different way 
in recent cases. The method he now employs is to wash out 
the fauces and upper portion of the larynx with a weak 
alkaline solution, and afterwards with water, so as to remove, 
as far as possible, mucus from the parts. When this has been 
done, a fine spray of a 25 per cent solution is directed against 
the fauces and interior of the larynx for a few seconds, and 
the patient is directed to avoid swallowing and remain at rest 
as far as possible for quarter of an hour, when the spray is 
again applied and repeated at short intervals as often as may 
be found necessary. By this method not only is a smaller 
quantity of cocaine used, but the necessary irritation produced 
by the brush is avoided. The patient suffered from considerable 
prostration immediately after the operation ; but whether this 
was due to the physiological action of the drug, ten grains of 
which had been used, or to the accident and manipulative 
interference, it is difficult to say, but was probably due to both 
causes. 

Mr. Maylard showed a foreign body, extracted, through 
A tracheotomy wound, from the larynx of a child. — 
Mr. Maylard said that he brought the case before the Society 
because of the somewhat unusual position in which the body 
was impacted. The report of the case as taken by the House 
Surgeon, Mr. Brownlie, was as follows : — D. M., set. 13 months, 
was admitted into the Western Infirmary on 1st September, 
1884. The child was brought to the Hospital on account of 
croupy symptoms in his breathing, and on the supposition 
that he had some foreign body in his trachea. The first 
thing that attracted the mother's attention was a loud cry as 
though the child was in pain, then followed a fit of choking 
and coughing. He was held feet upwards and slapped on the 
back, whereupon he vomited, but with no relief to the 
symptoms. He also appeared to be making futile attempts 
to swallow something. Every few minutes a paroxysm of 
coughing would set in, and both parents noticed what 
appeared to them like a metallic ring in the cough ; the cry 
also had a peculiar whirring sound, and the voice seemed to 



Pathological and Clinical Society. 185 

be doubled or split in two. On enquiry, one of the other 
children stated that the baby had had a fragment of tin in 
its mouth. This bit of metal was part of a toy knife that 
had been broken. A search was made for the different parts 
of the toy, and all were found but the one which had been 
seen in the baby's mouth. This evidence, together with the 
strange cry and cough, convinced the parents that the missing- 
fragment had been swallowed by the child. An examination 
was made, but nothing could be discovered. The following 
mornins: the breathin^j became thick and laboured, and the 
cough seemed to give rise to pain, as it always made the 
patient cry. All this time he could swallow his food without 
any inconvenience. Towards night the breathing became 
worse. Patient, on admission, was breathing wjth some slight 
difficulty : the respiration being thick and wheezing, and the 
voice hoarse. An examination was made under chloroform, 
but nothing being detected, the mother was told to remain in 
the Hospital with the child. In the evening the breathing- 
became much worse ; the child was restless and feverish, and 
there was marked episternal and intercostal sucking-in. Mr. 
Maylard decided at once to do tracheotomy. The trachea 
being opened, and respiration free, examination was again 
made by the mouth, when a body with sharp edges could be 
detected by the tip of the index finger, apparently just below 
the vocal cords. An attempt was made to remove it from 
above, but without success. A bent probe was then inserted 
upwards through the wound, and a distinct metallic click was 
audible ; but in endeavouring to move the foreign body, it was 
found firmly impacted. The wound was then slightly enlarged 
upwards, and the exact position of the fragment being ascer- 
tained by the bent probe, a pair of dressing forceps was intro- 
duced, the piece of tin grasped on the flat and easily extracted. 
A small tracheotomy tube was inserted into the wound, and 
the child kept in an atmosphere of steam. 

2nd Sej)teniber. — Patient doing well, passed a good and 
quiet night. 

4.th September. — Tube removed this morning, patient pro- 
gressing favourably. 

12th September. — Patient was dismissed to-day doing well. 
The hole is closed up, but not quite healed to the skin yet. 
No impairment of voice. 

The piece of tin removed was flat, U inch long, and ttt inch 
broad ; rounded at one end, but straight at the other. The 
rounded extremity occupied the lowest position. 

Mr. Maylard, in remarking upon the case, said that so far 



136 Meetings of Societies. 

as the symptoms were concerned, they were very typical of 
this particular class of injuries. The peculiar shape and 
structure of the foreign body explained its easy passage 
between the vocal cords, and the extreme narrowness of the 
trachea in a child of 13 months, with the slightest deviation 
of the fragment, would also account for its impaction high up. 
As regards the treatment, he thoug-ht that, considering the 
nature and position of the impacted body, any persistent 
endeavour to remove the fragment by the mouth would have 
entailed serious damage to the vocal cords. An endeavour 
was made thus to remove it, but it was a question whether in 
cases of impaction of a foreign body below the vocal cords, an 
easy extraction from a tracheotomy wound was not always 
preferable to a difficult one by the mouth. A tracheotomy 
tube was left in for three days, so as to give perfect rest to 
the injured part above. 

Br. Alexander Robertson asked if any constitutional effects, 
such as pallor, exhaustion, &c., had followed the application of 
the solution of cocaine to the fauces and larynx. 

Professor George Buchanan said that some time ago he had 
dealt with a somewhat similar case, in which a child had 
swallowed an Indian corn bean, which became impacted in the 
trachea. After consultation with Professor M'Call Anderson, 
to whose ward the child had been admitted, it was determined 
to perform tracheotomy, and when the trachea was opened, 
the bean was expelled through the wound with great force. 
He related this case now in order to make the observation 
that, whenever a young child, believed to have swallowed 
anything, was brought to a surgeon suffering from dyspnoea, 
the proper practice was to perform tracheotomy without 
delay. 

Br. Bavid Neioman replied to Dr. Robertson that after 
the extraction of the foreign body there was a good deal of 
exhaustion, but whether this was due to the cocaine alone or 
not, he was not prepared to say. 

Dr. Knox showed a tumour removed from the abdominal 
WALL OF A LADY AGED 55. The family history of the patient 
was excellent. She was the mother of 12 children, and had 
always enjoyed good health. Last May she first noticed a small 
nodule, about the size of a pea, growing at the lower margin of 
the umbilicus. This grew rapidly larger, but without pain or 
tenderness. Its increasing size at length led her to call atten- 
tion to it, and Dr. Knox was asked to see it in consultation 
with Dr. Walker, of Pollokshaws, on the 16th Sept., 1884. 



Pathological and Clinical Society. 137 

The tumour was then the size of a small orange, the umbilicus 
was stretched over it and bound to it, and it appeared as if it 
were o-ro\ving from the under surface of the true skin. As to 
the deeper attachments of the tumour, it was impossible to 
make out these owing to the immense thickness of the abdominal 
wall, but the tumour could be grasped by the fingers and it 
felt quite movable and free. The patient had complained for 
a short time of slight pleuritic pain in the left side, but that 
had been relieved by belladonna plaster. Otherwise she felt 
quite well. It was therefore decided that the tumour should 
be removed, though it was most probable that the abdominal 
cavity would require to be opened to remove it completely. 
The operation was done next day. An ovoid incision was 
made through the skin so as to embrace the tumour, the 
finger ^s'as then used to separate it from the fat and cellular 
tissue until the margin of the umbilical opening in the 
fascia was reached. To this the tumour was found to 
be adhering firmly all romid, but by carefully scraping 
through the fascia this attachment was separated, and the 
abdominal cavity opened. The opening would be about two 
inches in length. When the tumour was now held up it was 
seen that the greater part of the omentum was incorporated 
with it, being drawn together so as to form somethino- like a 
thick pedicle. This was then pulled gently through the 
opening and first ligatured and then cut through. The liga- 
tures of chromicised catgut were made to tie small portions at 
a time, each portion being ligatured separately. About 10 
ligatures in all were used owing to the breadth of omentum 
involved. After the tumour was thus completely freed, and it 
was seen that no bleeding was taking place from the omental 
stump, this was allowed to slip back into the abdommal cavity. 
There was very little bleeding from the sides of the wound, 
and every care having been used to stop it, the edges were 
sutured. The peritoneal edges of the opening in the fascia 
were first of all carefully brought together by catgut sutures, 
and then strong silk sutures were inserted so as to bring the 
surfaces of the wound accurately together throughout their 
depth. A few strands of catgut inserted at the lower angle 
of wound formed an efficient dram. The operation was, of 
course, performed antiseptically and gauze dressings applied. 

The further progress of the patient was most satisfactory. 
There never was any inflammatory action to speak of. The 
temperature never rose above 99'' F., and though flatulence was 
rather distressing, the patient made an uninterruptedly good 
recovery, and was well again in three weeks. She remained 



138 Medical Items. 

well until within the last few days, when symptoms of a 
return of the disease immediately al3ove the former situation 
have shown themselves, and there is also most probably some 
secondary deposit in the liver. While the operation, therefore, 
as such, was quite successful, the progress of the disease has 
not been stayed, or only for a short time. 

Microscopic sections of the tumour were shown, but an 
opinion as to its real histological structure was deferred until 
the next meeting of the Society. 



MEDICAL ITEMS. 

UNDER THE DIRECTION OF 

ALEX. NAPIER, M.D. 

Thallin, a New Antipyretic : being a Report to the 
Society of Physicians by Dr. Rudolph v. Jaksch, Assistant in 
the Medical Clinic in Vienna. — After a few introductory 
remarks, Dr. Jaksch said : — Our principal endeavours must be 
directed towards finding specifics for the various acute diseases ; 
from this goal, however, we are still far removed. But we 
must not forget to search after new antipyretics since we 
are still without a remedy which, without afi'ecting the nervous 
system, promptly and permanently lowers the temperature ; 
and also because the quinine preparations, which are recognised 
as excellent in their effects, do not always come up to our 
expectations. 

I should like, after these remarks, to make you acquainted 
with a new antipyretic. No doubt a long way from the ideal 
of which I have spoken, still, after the experience of it I have 
gathered together, I believe it to be not only equal to the 
hitherto known fever remedies, but in many respects to excel 
them. 

During the autumn of last year I examined the physiolo- 
gical and therapeutical properties of a number of chinolin 
bases, newly combined by my friend Prof. Skraup, I found 
that certain of these bodies, e.g., chinanisol, which, according 
to Skraup, forms the half of the quinine molecule, possesses 
only slight and inefi'ectual therapeutic power. Further, I 
observed that one of these bases — the tetrahydro-paraoxy- 
chinolin — possesses a poisonous influence on the lower animals. 



Medical Items. 139 

I alighted finally, after a number of experiments on the lower 
animals and on man, on a remedy which displays quite pro- 
nounced antipyretic effects. It is a chinolin base which is to 
be looked on as a hydrated parachinanisol. 

With the salts of this base I carried out experiments on 
rabbits, and convinced myself that doses of 0'6-0"8 grm. have no 
poisonous infliience on the lower animals. These results encour- 
aged me to repeat the experiments on man in doses of h-1 grm. 
I found that such doses in the healthy body, as in non-febrile 
diseases, had almost no influence. I established, further, that 
this remedy operates very energetically on a fever temperature : 
also that these salts possess tolerably strong antifermentative 
powers. In 0*2 per cent solution they retard the ammoniacal 
fermentation of the urine. A preparation of | per cent com- 
pletely suspends this fermentation. Similarly they tend to 
restrain the fermentation and decomposition of milk, and the 
alcoholic fermentation of sugar ; without, however, in the latter 
case completely suspending the process even in a 2 per cent 
solution. 

Before I communicate to you the observations I have made 
as to the effect of this remedy on fever, I should like to make 
you acquainted with a few physiological and chemical pro- 
perties of the salts of this base which I used in my experiments. 
I used for this purpose the tartaric, sulphuric acid, and 
hydrochloric acid combinations. All of these salts are easilj- 
soluble in water, have a strong, bitter, aromatic taste, and the 
solutions have an acid reaction. Of their chemical properties 
I mention in particular that treated with chloride of iron, or 
with oxidising substances generally, -they produce green 
coloured salts. In accordance with this property Skraup has 
named the base thallin, and we indicate the salts as thallin 
salts. Besides these .salts another thallin base was used in a 
number of experiments — viz., sethylthallin, and also aethyl- 
thallin in combination with hydrochloric acid. This body is 
distinguished from the thallin salts in that with chloride of 
iron it has not a green but a red colour. On high temperatures 
it operates similarly to thallin. With these salts I have treated 
86 consecutive cases of fever. Among these were all the 
febrile diseases occurring in these parts of the continent, inter- 
mittent fever, typhoid, acute articular rheumatism, measles, 
erysipelas, puerperal septicaemia, pneumonia, and tuberculosis. 
In regard to intermittent fever, when I gave this remedy 2-3 
hours before the expected attack I was able to subdue both the 
fever and all other symptoms of the attack, as headache, sweat- 
ing, &c. It is also possible, by prescribing a thallin salt, to cut 



140 Medical Items. 

short a fit of the fever ah'eady present. In spite of the 
favourable etfect on the malarial process, I could not by this 
remedy cure a single case of intermittent fever, the attack 
always I'eturned on suspending the remedy. I was forced 
finally to prescribe quinine, which, in its typical manner, 
brought about a cure. The administration of thallin produces 
no effect on the nervous system. Exactly as in the case of 
intermittent fever thallin has a powerful effect on typhoid, 
indeed, so far as the scanty material allowed — typhoid fever 
has of late become a rarity in Vienna — the remedy has proved 
excellent in this disease. On one case of fever which appeared 
at the clinic of Prof. Nothnagel during last summer session, 
and was most obstinate, being affected neither by baths nor 
quinine, I was able by exhibition of thallin salts to obtain in a 
few hours a fall of temperature of several degrees (Celsius). 
An exactly similar result followed the treatment of acute 
rheumatism : rapid fall of temperature with copious sweating. 
Before the temperature again rose there was a rigor. On the 
affections of the joints, as on the course of the disease, this 
remedy has no real influence. In a similar manner the thallin 
preparations behave towards measles, puerperal septicaemia, 
pneumonia, erysipelas, and tuberculosis. One symptom, the 
fever, is quickly reduced ; all other symptoms remain un- 
affected. It is noteworthy that thallin has proved itself partic- 
ularly successful in reducing the temperature of tuberculosis. 

I can shortly express the result of these experiments. The 
thallin salts, also aethylthallin in combination with hydrochloric 
acid, are excellent antipyretics, as in doses of \ grm., certainly 
in doses of ^-f grm., they produce a very noticeable fall of 
temperature — in most cases amounting to several degrees 
(Celsius). The fall of temperature is almost always accompanied 
by copious sweating. The lowest point is reached usually 
3-4 hours after exhibition of the drug, and the rise follows in 
the course of 4-5 hours, sometimes earlier, being in the latter 
case often accompanied by rigors. I must, however, mention 
that often in cases where the results are excellent, rigors and 
sweating are altogether absent. On the course and length of 
the disease these remedies are without influence. They are, 
therefore, not specifics, but merely antipyretics. 

As to the urine, it is noticeable that after exhibition of the 
drug it contains no pathological constituents — such as albumen, 
sugar, or biliary matter. Its colour is brown in a thick layer, 
in a thin laj^er it appears as green. With chloride of iron, it 
takes on a red colour. A further examination has shown that 
a'part of the thallin salt, the smaller part, leaves the organism 



Medical Items. 141 

unchanged, by far the greater part leaves the body united with 
an acid. Likewise, after administration of hydrochlorate of 
sethylthallin, there are no pathological constituents in the 
urine. The urine shows a dark brown colour, and gives with 
chloride of iron a red colour. Also the sethylthallin, during its 
passage through the body, is united to an acid, and appears 
as such in the urine. It is partly evacuated as thallin. 

If we compare the antipyretic effect of the three salts that 
have been employed, we cannot observe any important differ- 
ence between them. A closer examination, however, of the 
cases has proved that the salt formed by combination of 
sulphuric acid and thallin appears to act somewhat more 
energetically than the other two. The hydrochlorate of thallin 
is somewhat less active than the above named salts in its 
effects on fever. Accordingly, thallin in combination with 
sulphuric acid is most to be recommended for further experi- 
ments. 

Further, if we make a comparison between these salts and 
kairin (another antipyretic), it is evident that they act in man}- 
respects similarly to kairin ; they possess, however, many 
important advantages over it. The most important being that 
they act much more promptly ; and certainly observations by 
Dr. Rheintuss, in Prof. Nothnagel's clinic, prove that kairin in 
the fever of tuberculosis is almost worthless. Thallin, on the 
other hand, proves itself very powerful in this very fever. 
Further, all observers assert that kairin, besides producing 
sweating and rigors, which often occur with the thallin salts, 
occasions vomiting, cyanosis, and collapse. These very import- 
ant influences on the nervous system are not seen in the case 
of thallin. In the 86 cases that I have treated, I never 
observed vomiting, or cyanosis, or collapse. In short, thallin 
is excellently borne. Not the least important property of 
thallin which I should like to mention, is the fact that in the 
majority of cases the rise of temperature follows more slowly 
than in the case of kairin, and its effects remain longer than 
with kairin. 

In spite, however, of these advantages which the thallin 
preparations undoubtedly possess, at this stage of the enquiry 
I do not venture to assert that thallin will obtain a permanent 
place in our list of remedies. The very slightly encouraging 
results yielded by the other above mentioned antipyretics in 
the treatment of fever induce me to make this assertion. A 
fuller test, however, of this powerful drug in the hospitals and 
clinics may still be asked for. As for antipyretic it will assert 
itself. 



142 Medical Items. 

I should like to indicate to j^ou the manner of using thallin. 
The thallin preparations are strongly indicated in those cases 
where we cannot subdue the fever by quinine, salicylic acid, 
or other febrifuge, and where the height of the temperature 
alone places the patient in danger. In these cases thallin will 
always fulfil the indication — without noticeably affecting the 
nervous system it will lower the temperature. 

But besides these facts, important in the treatment of fever, 
it appears to me that through the discovery of the antipyretic 
influence of thallin, our knowledge of the chemical constitution 
of bodies that act antipyretically is increased. Thus, Filehne 
believed that only those hydrated chinolin derivatives act 
antipyretically, in which, to the atom of nitrogen united to 
two atoms of carbon, an gethyl or methyl residue is attached. 

My experience, however, vshows that this view is no longer 
tenable, since thallin is a secondary chinolin base, the nitrogen 
of which is united to no alcohol radicle, and in spite of this it 
possesses very prominent antipyretic effects. 

In conclusion, bringing my observations to a point, we may 

1. The thallin preparations are conspicuous antipyretics, 
still they are not specifics. 

2. Among the thallin salts, that one which is in combination 
with sulphuric acid chiefly recommends itself for further 
experiments. 

3. Their employment is indicated in those cases where fever 
is very persistent, or where, owing to the high temperature, 
the patient is placed in danger. 

Antipyrin in Children's Diseases. — As the result of 
numerous trials of this new anti-febrile substance on children 
at the Erlangen polyclinic, Professor Penzoldt arrives at the 
following conclusions: — (1) It is to be regarded as a very 
suitable means for diminishing the temperature in the febrile 
affections of children. (2) In proper doses it effects a diminu- 
tion of several degi-ees during several hours. (3) The 
diminution of the pulse does not always correspond to that 
of the temperature. (4) Its influence upon the general condi- 
tion of the patient is usually favourable. (5) Vomiting only 
sometimes attends its employment ; but when this persists 
the antipyrin must be given in an enema. (6) The proper dose 
to begin with is as many decigrammes as the child is years 
old, repeated three times, at intervals of one hour. If this 
dose does not suffice for the production of a decided effect, 
then it must be increased decigramme by decigramme. In an 



Medical Items. 143 

enema we may give at a single dose from three to six times as 
many decigrammes as the child has years. (7) After long 
use of it the child's system sometimes gets accustomed to the 
remedy. {Bevliner Jdlnische Wocheiischrift, 28th July, 1884.) 
— The Practitioner. December, 1884. 

Psoriasis — Verruca — Epithelioma, a sequence. — Dr. 
James C. White, of Boston, in the January number of The 
American Journal of the Medical Sciences, presents brief 
notes of two remarkable cases of disease — cases extraordinary, 
not for the rarity of the pathological processes they represent, 
but for the very unusual sequence of tissue-change exhibited 
in their course. There were three distinct pathological affec- 
tions of the cutaneous tissues : psoriasis, verrucous hypertrophy, 
and epitheliomatous new growth ; not occurring independently 
of each other, but as successive mutual transformations in the 
above order. 

The three dermatoses which enter into the clinical history 
of Dr. White's case, and which are in their nature apparently 
as unlike as their companionship is rare, have a close affilia- 
tion in their anatomical relations. The transformation of 
patches of psoriasis into horny or warty, permanent growths 
is not referred to in most works on dermatology as of possible 
occurrence even ; the transformation of verrucous growths into 
epithelioma is of not very infrequent occurrence ; but the 
uninterrupted sequence followed in this case, psoriasis — 
verruca — epithelioma, or in other words psoriasis, as a cause 
of carcinoma, is extremely rare or unparalleled in dermato- 
logical history. The practical lesson to be deduced is that the 
transformation of patches of psoriasis into verrucous hyper- 
trophy must be regarded as an ommous occurrence, and that 
the softening or other change of such horny growths demands 
thorough excision without delay. 

Pruritus Hiemalis. — The affection known under this title 
was described by Duhring (Phila. Med. TiTnes, 1874). It is 
characterised by a more or less violent itching of the skin, 
which comes on in the latter part of autumn, or the beginning 
of winter, continuing sometimes only a short time, sometimes 
during the entire cold season, but always ceasing before the 
advent of spring. After the age of puberty no period of life is 
exempt from its attacks, to which both sexes seem equally liable. 

The itching is usually felt in the neighbourhood of the hips 
and on the lower extremities, especially the calves of the legs ; 
the hands, feet, and scalp are never affected. 



144 Medical Items. 

In some cases this symptom is onl}^ slightly troublesome, in 
others it becomes unbearable, so that the patient's skin is in- 
jured by the constant scratching to which it gives rise. The 
itching is generally most intense in the evening, especially at 
bedtime, when it renders sleep impossible ; in the morning it is 
decidedly lessened, or may even cease altogether dui-ing the 
day. 

The above described condition may recur every winter for a 
period of years. 

The skin in these cases presents no outward indications of 
disease, excepting the lesions produced by scratching. 

No etiological influence other than that exerted by climate 
can be assigned for the production of this complaint. Condi- 
tions of regimen, clothing, &c., seem to have as little to do with 
it as differences in age or sex. Duhring states that pruritus 
hiemalis is of frequent occurrence in the United States, north 
of Philadelphia, while it has never been known to appear in 
more southern latitudes. During his I'esidence in Europe he 
never met with or heard of a single case of the disease, or of 
anything resembling it. 

In short, judging from the statements of such dermatological 
authorities as I have been able to consult, it might almost be 
concluded that this affection is exclusively confined to the 
northern portion of the American continent. 

I know of only a single case which militates against this 
supposition. It was one which came under my care some time 
ago in the person of a gentleman thirty-seven years old, and of 
very vigorous constitution, who resides at Cairo, Egypt. For 
several years he had suffered from an itching on both calves, 
which began regularly every October, became very intense 
during the winter, and ceased early in March. In the daytime 
it was quite endurable, but was greatly aggravated at night, 
and also by emotional disturbance. He had been unable to 
obtain relief in any way. 

On examination, the patient's organs appeared perfectly 
sound, and he presented not the slightest indication of skin 
disease — for, as it happened to be the month of August, even 
the marks of scratching were imperceptible. The normal sen- 
sibility of the integument was also unimpaired on the affected 
parts. 

The patient told us that he was of a healthy family, and had 
never been seriously ill. 

Two noteworthy circumstances are embraced in this history ; 
flrst : Cairo, where the patient had lived, is situated some ten 
degrees further to the south than Philadelphia. The tempera- 



Medical Items. 145 

ture ot" the former city never falls below 5° C. in winter, while 
the mean temperature in October, when, as M^e have seen, the 
pruritus commenced, is as high as 22'o" C The winter in Cairo 
is marked by no extremes either of humidity or dryness. It 
is not likely, therefore, that the complaint in this instance was 
due to the absolute degree of cold at the latter season ; it should 
rather be referred to the difference between the winter tem- 
perature of Cairo and that of its very hot summers. Other- 
wise, it might have been expected tliat the patient on his 
return to his natiye Vienna would have experienced the warn- 
ing symptoms of his disorder towards the end of September — 
which, however, was not the case. 

The other important fact to which I would call attention is 
the aggravation which was always caused in this instance by 
any considerable mental agitation. This I regard as confirma- 
torj' of the idea that the affection originated in neurosis. 

As regards the therapeutics of pruritus hiemalis, there is very 
little to be said. Duhring was unable to find any permanently 
effectual remedy. I am inclined to believe that treatment in 
this complaint with arsenic and the like can be successful only 
through its action upon the nervous system at large. From my 
patient I have heard nothing since his departure, and am there- 
fore unable to say how he got through the following winter. 

I must confess to having formed no very clear idea as to the 
mode in which the disease is developed, but probably its symp- 
toms take their rise from the peripheral nerves, and especially 
from the terminal organs of the latter. In what precise way the 
nervous .system is affected — whether chiefly by lownessof tem- 
perature or by other climatic circumstances — I am without the 
data which would justify me in deciding. 

I am in receipt of communications from a large number of 
my colleagues, havina^ reference to cases similar to the one 
above reported, which have been observed in this country. I 
regard it therefore as highly probable that pruritus hiemalis is 
not, as we have been accustomed to think, a malad}- met with 
only in America, but that it occasionally occurs among our- 
selves. (H. Obersteiner, Wien. Med. Wochensch., April 19, 
1884.) — Jour, of Cutan. and Vcn. Dis. August, 1884. 

Chloral as a Vesicant. — "A writer in the Southern 
(Jliv ic advocates the following plan of using chloral hydrate 
as a vesicant. Powdered chloral, sprinkled on adhesive 
plaster and melted by gentle heat (not more than enough to 
cause plaster to adhere to the flesh), is applied while warm to 
the part where the blister is wanted ; within a few minutes a 

No. 2. L Vol. XXIII. 



146 Medical Items. 

gentle heat is felt, increasing in intensity for a short time, 
then gradually easing off, and at the end of about ten minutes 
the part is free from pain. At the expiration of this time, or 
as soon as the pain has subsided, the plaster, if removed, will 
disclose a surface as effectually blistered as by a cantharidal 
plaster after six hours. Thus, within about ten minutes, the 
work of an old fashioned blister is accomplished, with many 
advantages over the latter: (1) rapidity of action; (2) the 
ease of application ; (3) the non-occurrence of strangury ; 
(4) it may never be taken off to have the blister dressed, but 
may be allowed to remain until the plaster loosens and comes 
off itself, the blistered surface in the meanwhile healing 
kindly." — Boston Med. and' Surg. Journ. 28th August, 
1884.— D. M'P. 

Hypodermic Injection of Nitrite of Amyl followed by 
Epileptiform Convulsions. — Dr. Sidney Ringer has noticed 
the occasional action of the nitrite of amyl upon the heart, and 
the strange effect sometimes produced upon the nervous 
centres. He says ; — " I have seen one case where a woman 
immediately after a drop dose turned deadly pale, felt very 
giddy, and then became partially unconscious, remaining so 
for ten minutes." And again — " A delicate woman, after one- 
thirtieth of a drop, passed in a few moments into a trance-like 
state." In a case described by Dr. Strahan, a chronic maniac 
aged fifty-three had suffered for several days from severe 
lumbago ; a 10 minim dose of a 10 per cent solution of nitrite 
of amyl in rectified spirit was injected hypodermicallj''. 
"Immediately after the injection the pain disappeared. He 
got up from the bed, and at my request stooped and touched 
the floor with his fingers. In, as nearly as could be guessed, 
about a minute and a half, he suddenly became deadly pale 
and sank back upon the bed." Then his face, head (bald), and 
neck V)ecame congested, and he was strongly convulsed for 
about half a minute. The convulsion affected the face and 
arms strongly, the legs slightly. The teeth were ground, and 
the breathing was suspended. In a few minutes after coming 
out of this fit he was attacked by a second one, during which 
the heart's action became very faint. He was made to inhale 
some chloroform, and the fits did not return. The lumbago 
entirely disappeared. This observation is interesting, as in- 
halations of nitrite of amyl have been recommended, both in 
this country and in Italy, to check the recurrence of epileptic 
convulsions. {Journal of Mental Science, July, 1884.) — The 
Practitioner. December, 1884. 



Medical Items. 147 

Guareschi, Mosso, &c., on Ptomaines. — In 1880 Selmi 
described the hydrochloride of a basic body, of an alkaloidal 
nature, resembling coninc. This he considered one of the 
bodies he had previously described as ptomaines. Marino- 
Zucco, however, states {Bericlitc der Deutschen CJiem. Ges., 
1884), that Selmi's so-called ptomaines are onlj" neurin. 
Guareschi and Mosso have lately done much tending greatly 
to the discredit of the work previously contributed to this 
subject. They also condemn DragendorfTs method for separ- 
ating the alkaloids in medico-legal analyses, as this method 
appears to them really to manufficture alkaloids. Coppola, for 
example, has found that fresh dog's blood, when extracted by 
DragendorflTs method, yielded alkaloidal reactions readily. 
Guareschi and Mosso also find that commercial alcohols are 
very often so impure as to give alkaloidal reactions ; and that 
the ether, chloroform, and benzine of commerce require 
purification. All experiments made with them are therefore 
of little or no value. From 80 lbs. of putrid human brains 
these observers obtained quantities of ptomaines too small to 
admit of analysis. They also found that, when doses averaging 
from one-fifth of a grain to five grains of the ptomaine were 
subcutaneously injected into frogs, effects were produced 
similar to those due to curara, the larger doses killing the 
animals. 

The putrefaction of enormous quantities of fibrin furnished 
a base with alkaloidal reactions, and forming double salts with 
gold and platinum chlorides. Guareschi and Mosso represent 
the composition of this base by the formulae Cio^is-^ ^'^'^ 
Cj^H^gN. This ptomaine acted similarly on frogs and birds 
to that obtained from putrid human brains. Fresh tissues 
yielded almost no ptomaines, although from fresh brains and 
muscles, treated by the Otto-Stas method, small residues could 
be got giving the general alkaloidal reactions. 

Taking into consideration the very large amount, often 100 
to 200 lbs., of putrid material that must be operated on to 
obtain ponderable (quantities of a ptomaine, and its compara- 
tively small toxicity, there is little likelihood of a ptomaine 
being mistaken for a vegetable alkaloid in a medico-legal 
investigation when the Otto-Stas method is adopted. — Lond. 
Med. Rec. loth Dec, 1884. 

A New Antiseptic. — A substance possessing strong anti- 
septic properties has been discovered by Dr. Filippo witch, 
of Odessa, and has been named by him trichloroacetic acid. 
A table, showing the various strengths of the different anti- 



148 Medical Items. 

septic substances, has been prepared by the author, in which 
the new acid takes a high place ; corrosive sublimate, carbolic 
acid, trichloroacetic acid, chloride of zinc, borax, permanganate 
of potassium, represent the order in which he has placed them. 
It is claimed for this acid that, in a solution of from 1 to 2 per 
cent, it destroys all organic life, while in a less concentrated 
form, from h to 1 per cent, though not affecting the develop- 
ment of yeast or mould, it yet completely arrests that of 
micrococci or bacteria. 

It is a crystalline body, easily soluble in water and alcohol, 
and of an agreeable odour. It coagulates albumen, and in 
concentrated solution it is a powerful caustic. 

The author has made use of trichloroacetic acid as an 
antiseptic in the treatment of a large number of diseases. He 
claims to have brought about rapid cure in cases of foul and 
callous ulcers, and holds that the acid, so far from causing 
irritation, suppresses that where it exists. Against chancre, 
he believes it to be a remedy in no way inferior to iodoform. 
By the internal administration of the acid in cases of gastric 
catarrh, and in cancer of the stomach, amelioration of the 
symptoms has been produced, while in the gastric enteric 
epidemics to which children are liable, complete cure has ever 
been obtained. Internally, also, M. Filippowitch employs the 
acid as a preventive of cholera, and as a local application, he 
has used it successfully against thrush. — {Medozinskoie Obo- 
sie'nie Ohosrenie, 1884, No. 18.) Gazette Medicate de Paris. 
1884, No. 47.— J. Y. M. 

Debove on the Treatment of Ulcer of the Stomach. * 
^ — Simple ulcer of the stomach — the ulcer of J. Cruveilhier, 
which is often called the round ulcer — is one of the most 
rebellious affections to therapeutic measures. Why is it that 
this simple ulcer, as it is called, persists for months and years 
without cicatrising ? What cause presides over the formation 
of the ulcer, and what influences preside over its development, 
its chronic course ? If one wishes to give to these questions a 
truly scientific solution, he is obliged to acknowledge that 
there is something connected with its origin and course which 
is still unknown. The theories of thrombosis, embolism, and 
of inflammation, if they explain the losses of substance, and 
the ulcerations of the mucous membrane, do not explain the 
form and characters of the round ulcer. So far as the action 
of gastric juice is concerned, if it contribute to the progress 
and extension of the ulcer by a sort of digestion, why is this 
* Le Progrh Medical and Canada Medical Record. 



Medical Iterins. 1 49 

digestion limited so often, and why does it not cause perfora- 
tion and destruction of the stomach ? It would seem that the 
acid reaction of the gastric fluids has a bad effect, since much 
good has been done by alkalies and Vichy water. 

The treatment of these ulcers is a more simple matter than 
the pathogenesis. The beneficial effects of strict diet have long 
been recognised, especially of the milk diet. But there are 
serious objections to the milk treatment. A person with ulcer 
of the stomach should take, if put on the milk diet exclu- 
sively, three or four quarts of milk every day. This enormous 
quantity may be well tolerated, and the gastric pains, the 
vomiting, and haemorrhages may cease. But one cannot with 
impunity introduce into a sound stomach, much less into one 
in bad condition, four quarts of liquid a day without causing 
dilatation of the stomach. Without doubt, this can be in a 
manner obviated if the patient be not allowed to take much 
milk at a time. But the morbid state and atony of the 
stomach make digestion more slow and difficult. If to this 
we add the fact this dilatation of the stomach may cause 
hasmorrhage and perforation of the ulcers, it is easily seen 
that the milk diet may be a source of great danger. 

For a long time, M. Debove has paid special attention to 
means for reducing the quantity of milk ingested. For this 
purpose he has used concentrated milk and powders of milk, 
representing in small volume considerable quantities of milk ; 
but these have not the nutritive value which is found in meat 
powders. It has been objected to M. Debove's theory that the 
dilatation of the stomach which he attributes to the quantity 
of the ingesta is due to the affection itself — to the ulcer of the 
stomach ; but, as Bouchard has seen (who has for a long time 
recommended a dry diet for dilatation of the stomach), and as 
Debove has also seen, the dilatation disappears under the influ- 
ence of this diet alone, so that it cannot be due to the ulcer. 

The dry diet of M. Bouchard consists in the administration 
of food very finely divided or very divisible, as powdered 
meat or cheese, and at the same time very nutritive. While 
the amount of dry food is reduced, only a minimum quantity 
of liquid is allowed, about a pint of water, or wine and water, 
in twenty-four hours. On this diet the stomach is never dis- 
tended by food, and the dilatation diminishes or disappears. 
It is by this dry diet that M. Debove treats ulcer of the 
stomach, but he adds an important factor to it. Before com- 
mencing treatment he washes out the stomach, in order to 
clear away the mucus and the debris of food which may be 
there. This washing is done with a rubber tube by the 



150 Medical Items. 

physician himself, as a little carelessness in its use might 
cause hasmorrhage. Duguet has reported a fatal case of 
hsematemesis, caused by the patient attempting to use the 
tube himself. Debove has never had a case of haemorrhage 
attributable to the use of the tube, but he very justly remarks 
that haemorrhages are quite frequent in ulcer of the stomach, 
and that when the tube brings up " coffee grounds " blood it 
cannot be said that the haemorrhage was caused by the wash- 
ing. If, however, during the washing the liquid brought up 
have a rosy tint, the operation should be at once suspended. 

M. Debove believes that, if gastric digestion and the action 
of the gastric juice can be suspended for some time, the cure 
of the ulcer will be greatly favoured. By rendering the 
gastric juice alkaline its digestive properties are taken away, 
and the transformation of albuminoid substances into peptones 
is stopped. In this manner, the matters undigested by the 
stomach pass into the intestines with an alkaline reaction 
very favourable to intestinal digestion. Debove has obtained 
effects which lead him to believe that he can make a patient 
take §vij of bicarbonate of soda, in three doses, in twenty- 
four hours. He has shown by his washings of the stomach 
that, under the influence of this treatment, the stomach liquids 
were never acid, and contained no peptones. The patients 
were given 3vjss of meat-powder and 5ijss of bicarbonate 
of soda three times a day. This mixture not being very 
agreeable to the taste, is introduced into the stomach through 
the tube. To this diet, which represents 5 l^x of meat and 
3vijss of bicarbonate of soda a day, is added a quart of milk, 
;ind taken in small quantities during the day. 

The alkaline cachexia, of which Trousseau and other phy- 
sicians have spoken, was seen in none of Debove's patients. 
This treatment has given most excellent results — results which 
have never been attained by any other method of treatment, — 
The London Medical Record, loth January, 1885. 

Treatment of Eczema of the Genitalia, and Leu- 
corrhoea. — In cases of eczema, in which glyceroles and 
unguents have failed, the following formula has been suc- 
cessful : — 

Chlorate of potassium, . . .30 grains. 

Wine of opium, . . . .50 grains. 

Pure water, . . . . .1 quart. 

Applied to the parts by linen compresses covered with 
oiled silk. If there is much inflammation precede this with 



Medical Items. 151 

warm hip-baths and cataplasms sprinkled with powdered 
carbonate of lime. In obstinate pruritus, associated with 
leucorrhcpa, a tablespoonful of a mixture of equal parts of tinc- 
ture of iodine and iodide of potassium, in a quart of warm 
tar-water (tar-water holding the iodine in solution), useil 
daily, night and morning, removes the pruritus and ameli- 
orates the leucorrhoea. In fcietid leucorrhoea, two or three 
tablespoonfuls (in a quart of warm water, morning and 
evening, as an injection) of the following formula will be 
found useful : — 

Chlorate of potassium, . . . 13 parts. 

Wine of opium, . . . . 10 parts. 

Tar-water, . . ... . 300 parts. 

Or, 

White vinegar (or ^viiie), . . 300 parts. 

Tinct. eucalypti, .... 45 parts. 

Acid, salicylic, .... 1 part. 

Salicylate of sodium, ... 20 parts. 

One to five teaspoonfuls in a quart of warm water, as an 
injection, two or three times a day. — {Ohstetric Gazette.) 
Quoted from Canada Medical Record. June, 1884. — J. L, S. 

Iodide of Potassium in Pneumonia. — Thinking that 
pneumonia should be considered not as a local disease with 
general symptoms, but as a local manifestation of a general 
disease, Schwartz has proposed the administration of iodide of 
potassium in doses of gr. vj every two hours, with the applica- 
tion of an ice-bag over the pneumonic focus. Iodide of 
potassium acts against the causal agent of the pneumonic 
process ; and, when given at the commencement of the disease, 
arrests its effects, causing quick and complete recovery. All 
of the cases thus treated by Schwartz were cured, and in 
one-tenth of the cases recovery took place on the second day. 
Riebe obtained equally good results. Dr. Gualdi (Boll, delta 
R. Acad. Med. di Roma) has employed this method of treat- 
ment in thirty-nine cases, and with excellent results. In all 
of the cases he noticed that in about two days the sputa lost 
their pneumonic characteristics, changing from the viscid and 
tenacious to the serous and fluid state ; the fever disappeared, 
and dj'spnciea ceased, whilst the physical state of the lung 
had not changed, and in some cases was worse ; and it was 
also noticed that the appetite of the convalescents was such 
that the amount of food had to be decreased. The mortality 
was six in 1 00, but two of the fatal cases could not strictly be 



152 



Med tea I IteDm. 



included, as they became wildly delirious early in the disease, 
and only took gr. xxx of the iodide. It is noteworthy that, 
under this treatment, whilst the fever and dyspnoea disappear, 
the lung remains in the same state. This seems to justify 
the opinion of Jiirgensen that the dyspnoea is dependent upon 
the fever, and not upon the changes in the state of the lung. 
Dr. Gualdi draws the following conclusions as to this method 
of treatment : (1) the method of Schwartz gives excellent 
results in pneumonia ; (2) these results are better with chil- 
dren than with adults ; (8) this treatment should be 
commenced at the beginning of the disease, as the result is 
then immediate and perfect ; (4) the advantages are seen in 
the eff'ects upon the fever and dyspnoea, not upon the local 
lesions ; (5) the action of the ice is secondary in the sense 
that it bears on the effects and not on the cause of the disease. 
It is useful in the stage of congestion, but injurious at a later 
period, when the contents of the alveoli are coagulated and 
the lung indurated. {Bull. Gen. de Therap., loth August, 
1884.) — The Practitioner. January, 1885. 



Pulmonary Syphilis. — Professor de Renzi of Naples for- 
mulates the following conclusions on this subject : — 

1. Syphilis of the lung may be hereditary or acquired. The 
latter, which he has most frequently seen, is not so rare as is 
generally supposed. 

2. The development of pulmonary syphilis is favoured by 
the following conditions :— Debility of the patient; acute 
catarrh of the respiratory passages, larynx, trachea, or 
bronchi ; chronic catarrh of the same parts. Catarrh of 
the respiratory passages may, in a syphilitic person, deter- 
mine the pulmonary localisation of the disease, even when 
the individual enjoys a flourishing and robust constitution. 

3. Pulmonary syphilis presents no phenomena peculiar to 
itself. As regards both symptoms and progress, there is 
nothing to distinguish it from tubercular disease of the lung. 

4. To distinguish the two maladies, there are certain signs 
of great diagnostic importance : — - 

a. Absence of the tubercular bacillus from the sputa. 

h. Efficacy of anti-syphilitic treatment. When the case is 
one of syphilis there is rapid amelioration and even cure, but 
want of success must not lead to the conclusion that the case 
is therefore tubercular. This therapeutic criterion is in 
general doul)tful when the iodide is employed; it is certain 
when mercury is administered, and when it rapidly produces 
an effect. 



Medical Items. 153 

c. Existence of other syphilitic lesions, especially syphilitic 
ulcerations of the larynx. 

d. History of syphilis years before. 

5. Iodine and the iodide of potassium may be employed, 
I'ven in doubtful cases, but mercury has a more certain effect 
on syphilis, and should have the preference. — La France 
Medicale. 8th Dec, 1883.— G. S. M. 



The Effects of Bromoform, Bromethyl, and Brom- 
ethylene. — Bonome and Mazza, from a series of physiological 
experiments recently conducted in the laboratory of Professor 
P. Albertoni, in the university at Genoa, obtained the following 
i-esults : (1) Bromoform is a general anaesthetic. Dogs and 
guinea-pigs almost always show the same symptoms of anaes- 
thesia and muscular relaxation, following inhalation, that the 
human subject does. In five experiments upon men, three 
were well narcotised, the effect lasting for a whole hour ; in 
two (probabl}- on account of the use of a defective preparation 
containing free bromine) there was no narcosis, but, on the 
contrary, irritation of the conjunctivae, a flow of tears, burning 
in the eyes, &c. The narcotic action they believe to be a little 
slower in appearing than when chloroform or ether is used, but 
the success is apparently the same as with both of these valu- 
able anaesthetics. (2) The narcosis obtained from the inhalation 
of bromoform is free from the stage of exaltation which we are 
called upon to witness during chloroform administration. On 
this account preference should be given this agent in case the 
patient is subject to epilepsy or alcoholism: Billroth and Nuss- 
baum have each directed attention to the danger of exciting 
attacks in epileptics by the use of chloroform. This does not 
occur during the use of bromoform, which allays the irritability 
of the cerebral cortex. (3) Bromoform does not disturb the 
respiratory function, but after prolonged narcosis there is a 
slight reduction of the blood-pressure. The respiratory fluctua- 
tions of the blood-pressure in the course of the narcosis are 
very regular ; the pulse remains strong. In none of the dogs 
which inhaled it did the bromoform cause sudden arrest of the 
heart's action, such as is seen during the use of chloroform. 
(4) During the bromoform narcosis, while it was noticed in 
dogs that there was decided mydriasis, in man there occurred 
only trifling alterations of the pupil ; there was neither nausea 
nor vomiting. The quantity of bromoform required to produce 
complete narcosis is less than that of chloroform as it is com- 
monly used. (5) In the flrst few hours after narcosis, it was 



154 Medical Items. 

noticed that there was a sinking of the temperature exactly as 
after chloroform ; but the patient appeared to recover sooner 
from its effects. (6) Given by the mouth, bromoform also acts 
as a hypnotic and anaesthetic. (7) Moreover, bromoform pre- 
vents putrefaction in organic substances (urine and meat) : 
bacteria are not developed in the presence of bromoform. (8) 
Injected under the skin, bromoform is fatal when given in a 
dose of 0"15 gm. for every 100 gm. of the bodily weight. 
Ethyl bromide produces narcosis more quickly than chloroform 
or bromoform, but is more easily eliminated from the system, 
and, on this account, its effects are more temporary. It is to be 
recommended for short operations. It is less active than 
bromoform, and becomes poisonous at a point of 0*17 gm. for 
each 100 gm. of the bodily weight. Whilst the narcosis re- 
duces the blood-pressure (20-30 mm.) at first, it rapidly 
increases again after the termination of the narcosis, when the 
respiration also is accelerated. Bromide of ethyl also reduces 
the irritability of the cerebral cortex, and likewise hinders the 
development of bacteria in organic infusions. Ethylene hrowiidc 
does not produce complete narcosis upon inhalation, but, when 
pushed, causes fatal results by abolishing the cardiac activity. 
(Centralblatt filr Ghirurgie, 36, 1884.) — The Practitioner. 
January, 1885. 



Corrosive Sublimate in Midwifery. — Prof. G. Leopold 
has published his experience of the use of corrosive sublimate as 
an antiseptic in the Maternity Hospital of Dresden. He thinks 
1 : 1,000 is too strong for common use. For washing out the 
vagina in ordinary cases, he uses 1 : 4,000 ; where there has 
been operative interference within the uterus, he washes out 
the cavity with a 1 : 2,000 solution. The 1 : 1,000 solution is 
used only for disinfecting hands and instruments. Every 
woman, after being received into the hospital, gets a vaginal 
injection of 1 : 4,000, and this is not repeated unless in 
operative cases, or those in which the discharge becomes 
foetid, and in such they are used three or four times a day. 
The result of this treatment is, that of six hundred women 
confined between May and October, not one died of puerperal 
disease. Nine suifered more or less from fever, and in four 
of these cases the uterus had to be washed out with a five 
per cent solution of carbolic acid. All the nine recovered. 
The author strongly commends corrosive sublimate, and 
especially the common use of very weak solutions. — Centralhl. 
filr Gynceh. 15th November, 1884. — W. L. R. 



Medical Items. 155 

Phosphorus Poisoning, with Rapid Death. — By Prof. 

Von Masclika, Prag.— (ir/^H. Med. Wochenschrift. 20-21, 84.) 
The course of phosphorous poisoning lasts as a rule 3 to 7 
days, and the changes which take place in the body during 
that time are so characteristic — icterus, fatty degeneration of 
the heart, liver, kidneys, and vessel walls, ecchynioses of the 
mucous membranes, &c. — that the diagnosis can be rendered 
certain by the post-mortem. Cases occasionally happen, how- 
ever, in which death occurs very rapidly after 8-9 or 12 
hours, and then the appearances after death are naturally more 
negative ; indeed, the cloudy swelling of the mucous mem- 
brane or the fatty degeneration of organs may be only very 
slightly or not at all present. Maschka describes three cases 
in which death took place from 7 to 8 hours after the taking 
of the poison, and as the result of paralysis of the heart. The 
body cavities smelt of phosphorus, in one of them the con- 
tents of the rectum especially. In all three bodies after 
distillation in Mitscherlich's apparatus the phosphorus was 
recognised by phosphorescence. Also Scherer's reaction 
succeeded. A strip of paper moistened with nitrate of silver, 
which was hung in a vessel containing a portion of the body, 
was coloured black in a short time, while, as a test experiment, 
a strip of paper moistened with lead solution did not change 
its colour. In spite of the short course of the disease in the 
kidneys a slight, and in the liver a more widespread, fatty 
degeneration was also present. — Deutsche Medizinal Zeitung. 
4th August, 1884. No. 62, p. 111.— J. L. S. 

Acker on the Transmissibihty of Tubercle by Vac- 
cination. — Dr. Joseph Acker {Centralbhitt fur AUgeni. 
Gesuiidheitspflege) reviews the question of the transmissi- 
bihty of tubercle by means of vaccination. 

The notion of the communicability of phthisis is not new. 
In the last century phthisis and scrofulous diseases were 
frequently classed with venereal afi'ections and itch ; but 
though the physicians of the early part of the present century 
treated the possibility of the transmission of tubercle through 
vaccination as in the highest degree improbable, it must be con- 
fessed that Koch's discovery of the tubercle-bacillus rendered 
a re-investigation of the whole subject imperative ; although 
hitherto there has not been a tittle of evidence in favour of 
any increase of consumption or scrofula in consequence of 
vaccination. 

The experience of Willan, Woodville, Alderson, Perroud, 
Brevard, and Tyndall, ajul, in a still liigher degree, of Alford 



156 Medical Items. 

and Thiriar, showed that, when vaccine lymph was taken 
from persons ah-eady infected with small-pox, it was incapable 
of connnunicating the latter ; and that, even when the charac- 
teristic pustules of variola and vaccinia were developed side 
by side, each was capable of conveying its own virus only ; 
though it must be admitted that the cases of small-pox and of 
tubercle are not strictly parallel. 

More to the point is that of syphilis ; but even here it has 
been found that the clear lymph obtained between the fifth 
and seventh days after vaccination could be used without ill 
results, while the purulent matter of the second week was 
highly infectious. 

The superiority of the lymph taken from the third to the 
sixth days over that of the seventh, eighth, and ninth days, 
when micrococci of all kinds and leucocytes make their 
appearance, has been practically ascertained ; and the sugges- 
tion of Koch that these other micro-organisms by their rapid 
growth, or perhaps by some product of their development, 
overpower those of the original vaccine, affords at least a 
probable explanation. 

Lothar Meyer examined the lymph from eighteen phthisical 
persons for tubercle-bacilli without success ; but Wolff having 
thrown some doubt on the trustworthiness of Meyer's observa- 
tions. Dr. Acker, at the suggestion of Dr. Wolfberg, of the 
Imperial Board of Health, undertook a series of the most 
carefully conducted experiments. Eighty-seven phthisical 
persons, in the sputa of most of whom tubercle-bacilli were 
present in large numbers, were vaccinated under antiseptic 
precautions, their skins being carefully washed with soap and 
alcohol, and the parts kept covered with antiseptic cotton, 
except during the moments while the lymph was withdrawn 
by previously sterilised needles. Lymph was taken day by day 
so long as any was to be had, and 214 preparations were made, 
the most approved methods of mounting and staining being- 
employed. In no single instance could a tubercle-bacillus be 
discovered. Weigert, from the connection between venous 
and acute miliary tuberculosis, had come to the conclusion 
that the acute miliary form of the disease was due to the 
dissemination of the bacilli through the venous circulation ; 
and, as Ponfick has shown, it may also originate in tubercle 
of the thoracic duct ; whereas, in the more chronic and local- 
ised forms the bacilli are at least originally confined to certain 
glands, and thus do not find their way so easily into the 
general circulation. Prior, Gessler, and Wechselbaum invari- 
ably found bacilli in the blood of acute miliary cases, but not 



Medical Itertis. 157 

in that ot" chronic phthisis, nor in the urine and milk unless 
the kidneys and mammary glands were already invaded. 

On the suggestion of Prof. Bollinger, Dr. Schmidt under- 
took another series of experiments, with a view to determine 
the possihility of inoculating tubercle into the subcutaneous 
tissues of rabbits and guinea-pigs, animals which are, as is 
well known, extremely susceptible of artificial tubcrculisation 
by inoculation into the anterior chamber of the eye or into 
the pleural and peritoneal cavities. Dr. Acker repeated 
Schmidt's experiments with the same result — that in not a 
single instance did he succeed in infecting these animals by 
subcutaneous injection of tubercle-bacilli, although others 
inoculated at the same time and with the same materials, into 
the eyes or serous cavities, succumbed speedily and certainly. 

He therefore comes to the conclusion that it is only in cases 
of acute miliary tuberculosis, and when blood is allowed to 
mix with the lymph, that the vaccine vesicle can by any 
possibility contain tubercle-bacilli ; and that, even should such 
lymph be used, which it could not be without inconceivable 
negligence or perversity, the skin presents so unfavourable a 
soil for the bacillus that infection would be in the last deo'ree 
improbable, though at the same time he would advise the use 
of lymph taken not later than the seventh day, as affording 
the greatest possible safeguard against infection of any kind 
whatever. — The London Medical Record. 15th January, 1885. 

Dissemination of Bacteria on Coins. — " That the ' love 
of money is the root of all evil ' seems to have received con- 
firmation in a novel sense from the obse-rvations of Professor 
Reinsch at Erlangen (Allg. Med. Centr. Z., 31, 1884), who, on 
examining a number of coins, found, to his astonishment, that 
all coins which showed some encrustation, little sediments, 
vtc, on their surface, contained living bacteria. Reinsch then 
collected coins of all nationalities, and made the same ob- 
servations in all coins that had been in circulation for a 
number of years. When the adherent dirt particles are 
removed with a perfectly clean (aseptic) knife, and dissolved 
in distilled water, a sufficiently powerful microscope will at 
once reveal the bacteria. The dirt sticking to coins seems to 
offer to these microzymes a soil specially fertile and favour- 
able to their development." — Bodon Med. and Surg. Journ. 
28th August, 1884.— D. M'P. 

Endermoses or Internal Herpetic Affections. — Under 
tliis title Di'. Noel Gueneau de Mussy describes two cases 



158 Medical Items. 

with all the symptoms of cancer of the stomach, but which 
ended in recovery, coincidently with outbreaks of skin 
disease. In La France Medicale for 1879 he reported his 
first case of this nature, that of a woman in whom a chronic 
urticaria gave place to all the symptoms of gastric cancer, 
including vomiting of blood, black vomit, excessive emacia- 
tion, cachectic appearance, &c. This woman recovered simul- 
taneously with the return of the urticaria to its usual site. 
In his present paper he records two somewhat similar cases. 
The first was a woman, 71 years of age, of an arthritic family, 
and herself the subject of neuralgias, and of a delicate stomach. 
Some time after an attack of enteric fever in 1862, she was 
seized with dyspepsia and gastralgia, accompanied by marked 
emaciation and a yellow colour of the skin. This aftection 
had persisted obstinately for several months when she came 
under his care. Believing it to be of an arthritic nature, he 
treated her with small doses of alkalies and a careful regimen, 
with the result that recovery shortly took place, at the same 
time that an eczematous eruption broke out in the hypogas- 
trium. Under the use of arsenic and baths she recovered. 
In 1872 she sustained a fracture of the left arm, and the 
shock induced an eczematous explosion on the chest and upper 
limbs, which tormented her for a long time. In 1878 she had 
a very severe attack of diarrhoea, with violent pain in the 
stomach, black vomit, and melsena, which left her very feeble 
and much emaciated. Since November 1879 attacks of gas- 
tralgia and dyspepsia recurred, more painful than ever ; she 
suffered from vomiting, loathing of food, fainting, great 
emaciation, with yellow skin ; she also had attacks of acute 
pain in the course of the sciatic nerves. She was extremely 
depressed, especially as she remembered that her mother had 
died of a cancer of the stomach at about the same age. 
Various methods of treatment having proved ineffectual, Drs. 
Potain and Gueneau de Mussy both feared that they had to 
deal with a case of cancer, a diagnosis favoured by the age of 
the patient, the family history, the obstinacy of the vomiting, 
which was occasionally black, the jaundice, and the emacia- 
tion ; but there was neither tumour nor inci'eased resistance 
made out in the abdomen. 

Being unwilling to accept this diagnosis, and considering 
that the patient's history was in accord with that of those 
herpetic affections which simulate visceral diseases, he deter- 
mined once more to try counter irritants on the surface, and 
to alleviate the pain of these he applied a belladonna plaster 
to the epigastric region. From the date of this application. 



Medical Items. 159 

and siiuultaneously with a very abundant eczematous erup- 
tion on tlie breasts and on the left side, the vomiting ceased 
and has never recurred ; the other symptoms gradually dis- 
appeared, and now for four and a half years the patient 
has been in good health, except that the eczema persists, and 
he declines to do anything to cure it. He suggests that the 
appearance of the eczema may be explained by the patient 
being one of those with the peculiar idiosyncrasy which shows 
itself in immediate development of eczema after the applica- 
tion of belladonna or opium to the skin. He cannot attribute 
the recovery to the revulsives used, because they had previ- 
ously been employed in vain. But the whole history of the 
case leads him to the conclusion tha^ it is a veritable case of 
metastasis, in the language of modern medicine. 

The second case recorded is that of a man, 71 years of age, 
whose symptoms were complete anorexia, constant nausea, 
black cottee-grounds vomit, violent gastralgia, great emacia- 
tion, with cachexia, and a sense of pseudo-resistance, with 
tenderness in the epigastric region. These symptoms came on 
after an attack of eczema of the abdominal wall ; and there 
was a marked periodicity about the pain, nocturnal exacerba- 
tions, and changes due to the season of the year. These latter 
facts inclined to the diagnosis of an arthritic endermosis. 
Quinine was tried without effect ; but the patient recovered 
perfectly after a long course of treatment by hypodermic 
injections of morphia and a carefully regulated (milk) diet. 
Of course, the symptoms may be explained by a gastric ulcer ; 
but even if that were the cause in this case, l)r. de Mussy 
suggests that in this, as in other cases, the. origin of the ulcera- 
tion may be a herpetic affection of the mucous membrane of 
the stomach, just as it is sometimes in ulcer of the uterus. 

These cases may be read with interest along with Dr. 
Clifford Allbutt's celebrated lectures on Abdominal Neuroses. 
—La France Medicale. 29th Ma.rch, 1884.— G. S. M. 

A New Method of Reducing the Body Temperature.— 
A new method of reducing the temperature of the body has 
lieen proposed by M. Preyer, but as yet it has only been 
experimentally tried upon the lower animals. The idea under- 
lying M. Preyer's experiment is, that the reduction of tempera- 
ture produced by the evaporation of finely divided liquids 
from the surface of the body, as in diaphoresis, i.s much more 
intense than that which is caused by the direct application of 
cold. He has attempted to produce such a result by means of 
the spray, and has subjected the surface of the body in a 



160 Books, Sc, Received. 

number of animals to the action of water in an exceedingly 
minute state of division. With water of the temperature of 
about o C, an action, lasting from five to ten minutes, produced 
a fall of heat in the rectum of about 1° C, and this reduction 
continued to become more and more marked as the process 
lasted. M. Preyer considers this mode of reducing the animal 
heat to be at once certain, easily put into practice, and devoid 
of danger, and he is anxious to have it tried in a clinical 
manner. — {BerHner Klin. Wochenschrift, 1884, bd. 23.) Gazette 
Medicale de Paris. 28th June, 1884.— J. Y. M. 

Iodoform Suppositories for Piles. — -The following formula 

for suppositories for haemorrhoids is from the Zeitschrift fur 

Therapie : — 

R. Iodoform, ..... 4 parts. 

Balsam of Peru, .... 8 parts. 

Cacao butter, I r. , /• . 

,,7-, ., ' > oi each, . , . b parts. 

White wax, j ' ^ 

Calcined magnesia, .... 4 parts. 

Mix. To make twelve suppositories. One to be introduced 

after each iiiool.— Canada Medical Record. June, 1884. — 

J. L. S. 



Books, Pamphlets, Cfc, Received. 

Practical Pathology : a Manual for Students and Practitioners. 

By G. Sims Woodhead, M.D. With 162 coloured plates. 

Second edition. Edinburgh : Young J. Pentland. 1885. 
The Story of a Great Delusion, in a Series of Matter-of-fact Chapters. 

By Wm. White. London : E. W. Allen. 1885. 
An Introduction to the Study of the Diseases of the Nervous Sys- 
tem. By Thos. Grainger Stewart, M.D. Edinburgh : Bell &: 

Bradfute. 1884. 
Forty-five Years of Registration Statistics, proving Vaccination to 

be both Useless and Dangerous. In two parts. By Alfred E,. 

Wallace, LL.D. London : E. W. Allen. 1885. 
Specielle Physiologie des Embryo, Untersuchungen ueber die Lebens- 

erscheinungen vor der Geburt. Von W. Preyer, Jena. Mit 

9 Lithographirten Tafeln und Holzschnitten im Text. Leipzig : 

Th. Grieben's Verlag. 1885. 
The Student's Guide to Diseases of Children. By Jas. Frederick 

Goodhart, M.D. London: J. & A. Churchill. 1885. 
The Care of Infants. By Sophia Jex-Blake, M.D. London : Mac- 

millan «t. Co. 1884. 
The Year-Book of Treatment for 1884. London, Paris, and New 

York. Cassell «fe Co., Limited. 



THE 



GLASGOW MEDICAL JOURNAL. 



No. III. Marcu, 1885. 



ORIGINAL ARTICLES. 



ON THE TREATMENT OF DISEASES OF THE 

STOMACH. 

By dr. M'CALL ANDERSON, 
Professor of Clinical Medicine in the University of (ilasgow. 

(In opening a discussion on the subject at the Southern Medical Societyy 
22nd January^ 1885.) 

At a former meeting of the Society I made a feAv remarks 
on the diagnosis of diseases of tlie stomach, and to-night, 
according to promise, I propose to inaugurate a discussion on 
the treatment of this class of afl'ections. 

The subject is, however, so vast as to render it necessary for 
me to attempt nothing more than a mere outhne, the details of 
which may, I trust, be filled in by subsequent speakers. 

In the first rank must be placed diet and regimen, as many 
disorders can be cured by attention to them alone, while few- 
can be treated successfully without them. 

As an instance of a disease in which they are indispensable, 
let us take the case of ulceration of the stomach. In this 
affection absolute rest in bed is generally indicated, although I 
am by no means prepared to deny that many can, and do, 
recover without it. Here the diet must be of the simplest 
kind, given in small quantities, and at short intervals ; and a 
good rule for our guidance is, that anythinfj ivhich causes paioi 
or sickness — and this remark applies almost universally to all 
affections in which these symptoms are present — is injurious. 
Milk, in combination with lime, Vichy, or seltzer water, and well 
iced, is usually the best ; or if this does not agree, butter milk 
No. .S. M Vol. XXTII. 



162 J) II. M'Oall Anderson — On the Treatment of 

or koumiss, or peptonized farinaceous food (such as that pre- 
pared by Savory & Moore), or what is known in commerce as 
■' Solution of Meat,"* may be tried ; the quantity administered 
at a time being reduced to the point at which it occasions no 
discomfort. Even a teaspoonful may be all that can be borne 
at once, and it is much better to give a very small quantity 
which is retained than a larger amount which disagrees. In 
extreme cases, the best practice by far is for a time to suspend 
the administration of food by the mouth altogether, and to 
feed the patient |9ei' rectum, allowing him, however, to slake 
his thirst by sucking a small piece of ice occasionally. The 
enemata, which I have latterly been in the habit of using, are 
Savory & Moore's " nutritive enema " and " Carnrick's beef 
peptonoids." Leube's meat-pancreatic clysters — a solution of 
meat treated with pancreatine — are also worthy of trial. But 
it must never be forgotten that feeding per rectum is only a 
temporary expedient, with the view of giving perfect rest to 
the affected organ, because the co-operation o£ all parts of the 
digestive tract is required ; Voit and Bauer having shown that 
the rectum is only capable of absorbing about a quarter of 
the albumen necessary for the maintenance of life with the 
addition of fat or hydro-carbons. And yet, in the case of an 
eminent citizen — well known by reputation at least to all of 
you — whom I saw several times in consultation, life was 
maintained for a whole month by the use of nutritive enemata 
alone, not even a drop of water having passed his lips during 
the whole of that time. 

Dr. Debove-f- does not approve of milk diet, owing to its 
tendency to dilate the stomach. He prescribes three meals 
daily, each composed of 25 grammes of meat powder, mixed 
with 1 of burned magnesia, 2 of prepared chalk, and 1 of 
saccharated lime; and a quarter of an hour after each meal 
he administers 4 grammes of bicarbonate of soda. The gastric 
juice is thus neutralised, and no peptones are formed in the 
stomach. On the other hand, many are in favour of a method 
of treatment, whose principal exponent is Professor Ziemssen, 
and which consists in the administration every morning of an 
alkaline aperient whose basis is Glauber's salt. For this pur- 
pose he gives Carlsbad water, or the natural, or — ^best of all, 
because most aperient — the artificial Carlsbad salts dissolved in 
water. "I make my patients," he says, "take every morning, 
fastinor, a solution of from 8 to 16 grammes, or 2 to 4 

* Leulie sjiecially recommends the preparation of the Court Apothecary, 
Dr. Minis, in Jena. 

t London Medical Record, 15th Oct., 1884. P. 442. 



Diseases of the Stomach. 1G8 

drachms (one or two teaspoonfuls heaped up) of the salt 
to a pound (one pint) of water, which has been poured on 
when boilino^, and then the whole cooled down to about 44" E.. 
A quarter of a pint is taken every ten minutes. Two or three 
motions are necessary ; if the bowels are moved only once, or 
not at all, an enema should be used, and on the followino- morn- 
iui^ the quantity of the salt should be increased by onedialf, or 
doubled, the quantity of water remaining the same. Subse- 
quently, as a general rule, less concentrated solutions are 
sufficient, and then the patient may return to a teaspoonful of 
the salt to a pint of water. In cases where the gastric catarrh 
is very intense, and the pyrosis particularly obstinate, it will 
be found advantageous to administer, every evening during 
the first week, another bottle of an acidulous soda water 
(Giesshiibel, Bilin, or Vichy.) * " The carbonate of soda, the 
chloride of sodium, and the Glauber's salts neutralise the acids 
and check the fermentation. They therefore suppress the 
corrosive action upon the tioor of the ulcer, and the reflex 
contractions of the pyloric muscular fibres, and by their 
strongly excitant action upon the peristaltic miovements of the 
stomach they cause the fermenting liquids to be rapidly dis- 
charged into the bowel. It is evident that if the stomach is 
thoroughly emptied at least once a day, its contents are much 
sooner rendered temporarily alkaline, or neutral, and their 
tendency to fermentation restricted. "-f- 

In many cases of ulceration sedatives, such as small doses of 
morphia with bismuth and hydrocyanic acid, are valuable, but 
constipation is apt to be induced or aggravated by such medi- 
cation ; and then they may be combined with the use of the 
alkaline aperient above mentioned, or resort may be had to 
the black oxide of manganese — a gastric sedative not so well 
known, which was introduced by the late Dr. Leared — and 
which, in doses of 10 grains, has proved most useful in my 
hands for this and similar conditions. In chronic cases, small 
doses of arsenic — from one to two minims of Fowler's solution 
three or four times a day — often yield the best results. This 
method of treatment is much employed by our American con- 
freres, and an interesting paper on the subject has recently 
been published by Dr. John Strachan, of Belfast. :): 

In acute catarrh of the stomach, even greater care is required 

* Clinical Lectures on Subjects connected with Medicine, Surgery, and 
Obstetrics, by varioiLS German authors. London : New Sydenham Society, 
1876. P. 68. 

t Op. cit., p. 6"). 

I Brit. Med. Jour., 21st June, 1884. P. 1-202. 



164 Dr. M'Call Anderson — On the Treatment of 

as to food than in the case of ulceration. Indeed, on the prin- 
ciple of keeping an inflamed organ at rest, it is often the 
wisest course to abstain altogether for two or three daj^'s from 
the administration of food by the mouth, although ice may 
usually be sucked with comfort and advantage. Hot appli- 
cations to the epigastric region often afford some relief, while 
calomel is one of our sheet-anchors, especially for those in 
whom it acts as a gastric sedative, and checks vomitino- ; it 
may be given in a dose of 5 grains, which may be repeated in 
a day or two if need be, or in smaller doses at shorter intervals. 
In addition to this other gastric sedatives, such as those 
already mentioned, may be used, but none are so likely to 
prove beneficial as the subcutaneous injection of morphia. If 
there is great exhaustion, a little well-iced champagne may be 
tried from time to time, and as the symptoms subside, the 
utmost caution must be observed in improving the dietary. 

It is often difficult to say whether we have to deal with 
dyspepsia or with chronic catarrh of the stomach (inflammatory 
dyspepsia as it is sometimes called.) We may, however, 
suspect the existence of the latter if there is slight fever at 
night with some loss of flesh, if the tongue is coated and red 
at the tip and edges, or red, smooth, and glazed, or raw looking ; 
if thirst is present, if the uneasiness after food ever amounts 
to pain, if there is tenderness in the epigastric region, if there 
is nausea or vomiting, if mucus is vomited in the mornings, and 
if the urine is high coloured and deposits lithates. Having 
satisfied ourselves that we have to deal with chronic catarrh, 
our first aim in treatment is to remove the causes — such as 
irregularities of diet and regimen, constipation, the excessive 
use of stimulants, gout, disease of the kidneys, obstructive 
disease of the liver, lungs, or heart — which we must attack on 
the same principles as we would do if they occurred inde- 
pendently of stomach catarrh. This having been done, and 
the symptoms persisting, we may resort to the use of occasional 
doses of calomel and of saline purgatives — such as Friedrichs- 
halle, Hunyadi Janos, Piillna, &;c., or a visit to one of the more 
celebrated spas — such as Homburg, Kissingen, Carlsbad, or 
Wiesbaden, may be recommended. When there is evidence of 
fermentation in the stomach — flatulence, acid eructations, &c. 
— permanganate of potash is specially to be commended, and 
often speedily gives relief. 

In the later stages the saline treatment may be combined 
with tonics — the sulphate of magnesia mixture in combination 
with sulphuric acid, strychnia, and calumba for example. The 
diet must all along be most carefully regulated, consisting of 



Diseases of the Stomach. 165 

milk, beet'-tca, and farinaceous food, wliile, in the slighter cases, 
fish, poultry, and game may also be allowed. The meals should 
be small, and not too numerous ; and as a rule, all stimulants 
should be strictly forbidden. During convalescence, tonics 
may be cautiously administered — being selected in accordance 
with the surroundings of each case. 

Arsenical treatment has already been alluded to as being 
sometimes useful in cases of ulceration, but there is another 
class of affections in which it, as well as other anti-neuralgic 
remedies, is sometimes of the utmost value — viz., " neuroses of 
the stomach." These usually give evidence of their presence 
by the occurrence of pain of a neuralgic character or of vomit- 
ing. Such cases are very apt to be mistaken for ulceration 
on the one hand, and dyspepsia on the other ; and we may 
frequently aid our diagnosis, as well as contribute to their 
successful treatment, by means of diet, for the symptoms are 
sometimes relieved by giving nourishing food — even solid, hot, 
and stimulating food — and by administering stimulants, while 
those of the above mentioned disorders are pretty sure to 1)e 
aggravated thereby. 

In other cases the stomach pain is but a sjanptom of 
chlorosis, and its true nature may be suspected if there is an 
absence of other symptoms of stomach disorder on the one 
hand, and the presence of waxy pallor of the surface and other 
symptoms of chlorosis on the other ; but care must be taken 
to excludes ulceration, vs'hich is by no means an uncommon 
complication in chlorotic subjects. In this class of cases iron 
in full doses constitutes our sheet-anchor, and nothing in my 
experience answers better than a prolonged course of Blaud's 
pills. 

Nor must we forget that these neurotic symptoms fre- 
quently result from irritation of the spine, so much so, that I 
make it a rule in all cases of doubt to examine the spinal 
region, even when the patient makes no complaint of back- 
ache, to ascertain whether there is any spot which is tender 
on pressure ; and I have been surprised to find how often 
there is tenderness in the dorsal region which had never 
before been suspected. Such tenderness is all the more likely 
to be present if the gastric are accompanied by other symp- 
toms, such as a hard barking cough, or localised pain beneath 
the left breast. When the mischief lies in the spine it is 
needless to attack the stomach, but leeches, and counter-irrita- 
tion by means of fiy-blisters over the tender parts, along with 
rest, tonics, and careful attention to the general health, consti- 
tute our sovereign remedies. As an illustration of this, let 



1 66 Dr. M'Call Andeeson — On the Treatment of 

me recall the case of a weakly young woman who was under 
my care in June 1879, and who came complaining of per- 
sistent vomiting of several months' duration. The vomiting 
was easy and painless, and there was no preceding nausea nor 
any sensation of pain while the food lay in the stomach ; it 
was accompanied by a hard, dry cough. The vomited matters 
consisted of undigested food, mixed with green streaks and 
patches, and blood was never observed to be present. The 
regurgitation of the food went on getting worse, occurring 
after every kind of food, and at gradually decreasing intervals 
after meals, sometimes even taking place during the act of 
eating. All kinds of stomach remedies, including the applica- 
tion of a fly-blister to the epigastrium, had been tried ineffec- 
tually, and when I saw her she was not only in a state of the 
greatest debility, but more emaciated than almost any patient 
I have ever seen. On examination of the spine, distinct ten- 
derness was discovered for a distance of about 2 or 3 inches 
at the junction of the middle and lower dorsal regions. A fiy- 
blister was applied over the tender part, and after it rose the 
vomiting entirely ceased, except on one occasion, after taking 
some purgative medicine. From that day onwards she never 
looked behind her, and made a rapid and excellent recovery. 

Again, as is well known, irritability of the stomach, in a 
very tractable form, may set in during the first half of preg- 
nancy. It may sometimes be removed by careful attention to 
diet and regimen, and by the administration of gastric seda- 
tives such as those already mentioned, or by the use of the 
oxalate of cerium, a favourite remedy with the late Sir Jas. 
Simpson. But, as has been clearly stated by Dr. Graily 
Hewitt, in an excellent paper read at a recent meeting of the 
Obstetrical Society of London, * it is in many cases the result 
of interference with the normal expansion and growth of the 
gravid uterus — there being two factors, both of which may be 
conjoined in a given case, capable of producing this — viz., 
(1) incarceration with flexion or version; and (2) hardness 
and rigidity of the os and cervix, the first being much the 
more important of the two. The second factor is likely to be 
removed, and with it the vomiting, by Dr. Copeman's plan of 
dilating the internal os ; while the first is obviated by raising 
the uterus from its displaced position, and if this can be done, 
the vomiting almost invariably ceases. In the last resort we 
must relieve the condition by the induction of premature 
labour, which should be done before the strength of the 
patient is reduced to too low an ebb. 

* Brit. Med. Joum. 22nd November 1884; p. 1019. 



Diseases of the Stomach. 167 

Of the treatment of that li3'ch-a-hcacle(I monster dyspepsia, 
time will only permit of my giving one or two illustrations. 
Let us take the case of a full-blooded man of sedentary habits, 
who indulges in the pleasures of the table, and whose bowels 
are habitually costive. He has bad teeth or eats his food 
very quickly ; he dines in town, making for the nearest 
restaurant and snatching a hasty meal of very miscellaneous 
and often badly cooked food. He has frequently headaches, 
or a feeling of " swimming in the head," which may be tht; 
immediate cause of his seeking advice. We find that his 
tongue is habitually coated, that his appetite is defective, that 
he has a craving for food, and after a meal he has " a load at 
his stomach," or complains of a feeling of distension, from 
which he finds relief by loosening his clothing. At times, too, 
he may suffer from uneasiness in the hepatic region or in 
the shoulder, and his liver may even be slightly tender oji 
pressure. 

I have taken as an illustration a typical case, such as we 
often meet with in business circles, and which cannot readily 
be mistaken, but minor forms of the same condition are very 
apt to be overlooked, especially if our advice is sought for 
some ailment indirectly produced or aggravated by the dys- 
pepsia such as asthma, or eczema, or gravel. 

In such cases the bowels must be carefully regulated, and 
occasional doses of antibilious medicine — than which nothin<>- 
is better than calomel — are indicated, or a course of Friedrichs- 
halle or Hunyadi Janos, or of the mineral waters of Harro- 
gate, Homburg, or Marienbad. 

This treatment is, however, only of temporary service, 
unless at the same time we remove the causes by making a 
complete change in the diet and regimen. 

Our patient must be instructed to take plenty of exercise in 
the open air, to pay a visit to his dentist if need be, to have 
his meals with regularity, to eat slowly and in great moder- 
ation, to chew his food thoroughly, even soft food being well 
mixed with the saliva before it is swallowed — in a word, he 
must be instructed to do as much as possible in the way of 
division and digestion of his food in the mouth, so as to throw 
less work upon the lower portion of the digestive apparatus. 

He should dine off two or three dishes, and should, for the 
most part, avoid many articles of diet in every day use such 
as tea, coffee, spices, and stimulants, oatmeal, cheese, pastry, 
soups containing vegetables (such as hotch-potch), potatoes, 
raw vegetables (such as salads), and unripe fruits, fresh bread- 
stuffs of every kind (taking toast, pulled bread, rusks, or plain 



168 Dr. M'Call Anderson — On the Treatment of 

biscuits instead) — sweet things, unless of the simplest kind 
(such as rice pudding or stewed apples). Butcher's meat 
should be partaken of in small quantity, veal and pork being 
eschewed — raw meat is much harder of digestion than cooked, 
boiled than roast, old than young, and fat than lean. 

These rules, as to diet and regimen, must of course be 
modified in character and in stringency so as to meet the 
requirements of different cases, and it is surprising what a 
change for the better is often produced even in a couple of 
weeks. All the above mentioned symptoms may have 
vanished ; the irritability of temper and mental and physical 
hebetude which so frequently accompany them, disappear, 
and the disorders indirectly associated with them cease to be 
troublesome. 

A very different form of dyspepsia is one which, from a 
clinical point of view, may be described as weak digestion (one 
variety of which is the so-called atonic dyspepsia), and which 
is apt to be acquired by long continued abuse of the organs of 
digestion, although it may occur independently of such causes, 
being, so to speak, natural to the individual. 

The more such persons are in the open air the better, 
although care must be taken in the case of those who. are 
weakly that exercise is short of fatigue, and intervals of com- 
plete relaxation from work and worry, with change of air and 
scene, are frequently beneficial, while a course of mineral 
waters at one or other of the more noted spas — such as Hom- 
burg, Carlsbad, or Spa — which must be selected in accord- 
ance with the surroundings of each case, may prove of much 
service. 

The diet must be regulated with the greatest care, the food 
being nourishing, but light and easy of digestion. The meals 
should be frequent but small, fluids being taken only at the 
end of each, and in many cases, with the principal ones, a 
dessertspoonful of whisky in potash water may be prescribed 
with advantage. 

Tonics are frequently beneficial — especially vegetable bitters, 
strychnia, and arsenic — in combination with acids or alkalies, 
but they must be skilfully selected, for their action in different 
persons is very capricious and uncertain. It is in this class of 
cases 'par excellence that artificial aids to digestion are indicated, 
which consist chiefly in the use of pepsine in some shape 
or other, or of acids. A fresh extract of the former may be 
readily made according to v. Wittich's method with glycerine 
as follows. The mucous membrane of a fresh pig's stomach is 
minced, thoroughly washed, and treated with strong alcohol. 



Diseases of tlie Stomach. 160 

which does not affect the pepsine, but lixiviates the salts and 
precipitates a portion of albumen — 500 ccm. of glycerine are 
then added ; in 24 hours the extract is filtered and ready for 
use, the dose being 5 i or more.* For those who are practising 
in country districts, or where expense is an object, this pre- 
paration is specially worthy of trial. For my own part, I am 
in the habit of prescribing Benger's liquor pepticus ; but there 
are other preparations, such as Liebreich's pepsin-essenz, which 
maj' perhaps be preferred by some of my hearers. 

In the majority of cases, however, it is the hydrochloric 
acid of the gastric juice and not the pepsine which is deficient, 
and which is therefore much more frequently required, the 
dose being 8 to 10 minims of the diluted acid in a glass of 
water after each meal. The old established practice of giving 
acid mixtures in cases of fev^er^-during which the activity of 
the gastric juice is impaired — is partly due to this circum- 
stance. It must never be forgotten that hydrochloric acid may 
be indicated even when the gastric juice is very acid — as the 
result, for example, of acetic or butyric acid fermentation; for it 
takes a much greater degree of acidity to effect healthy diges- 
tion with them than with hydrochloric acid, the normal acid 
of the gastric juice. In order to ascertain whether it is the 
pepsine or the hydrochloric acid of the gastric juice which is 
defective. Professor Leube adopts the following plan in some 
cases — " I let the patient take about 25 grammes of Carlsbad 
salt on an empty stomach, so as to cause anything which may 
remain in it to pass downwards ; then about noon some plain 
cold roast veal, with or without bread. In from one to two 
hours afterwards, I take out a portion of the contents of the 
stomach with the stomach sound, and convince iTiyself concern- 
ing its smell and reaction, as well as how far the process of 
solution has advanced in the pieces of roast meat. I next put 
into three bottles equal quantities (about 50 cubic centi- 
metres) of the filtered contents of the stomach, and hang in 
each of them a bundle of boiled fibrin of about equal volume. 
Into one of these bottles I put nothing further, into the second 
two drops of hydrochloric acid, and into the third two drops 
of a neutral solution of pepsine. All three bottles are then 
placed in a large vessel of water, the temperature of which is 
kept at 95°-104<° F. The digestion wdiich takes place in the 
last two bottles will show whether one or other of the 
additions effects a more rapid solution of the fibrin than 

* Lectures on Digestion. By Dr. C. A. Ewald. Translated by R. Sanndby, 
M.D. WiUiams & Norgate. 1880. 



170 Dr. M'Call Anderson — On the Treatment of 

occurs in the first bottle, or whether they remain without 
import."* 

It is to be feared, however, that in this country at least, 
most patients would object to such a procedure ; and we must, 
therefore, be contented with trying the hydrochloric acid if 
the pepsine fails, or vice versa. 

There are two or three other aids to digestion from which I 
have occasionally derived benefit — such as lactopeptine and 
ingluvin,-!" while Benger's liquor pancreaticus (which should be 
given in doses of oi in a glass of water two or three hours after 
food — i. e., when it is leaving the stomach), is specially indicated 
in cases of failure to absorb fats ; but on the whole we are 
more likely to do good to our patients suftering from weak diges- 
tion by the administration of hydrochloric acid, or of liquor 
pepticus than of the above mentioned preparations. 

While there may be doubt as to the propriety of drawing oft' 
the contents of the stomach with the view of ascertainino' whether 
the gastric juice is deficient in acid or in pepsine, there can be 
no question of the necessity of washing it out in cases of dila- 
tation. For this purpose various solutions may be used — such 
as Vichy water, or lukewarm water containing 10 grains of 
pure carbolic acid, or 10 minims of creasote, or a drachm of 
hyposulphite of soda to the pint. But in addition to the daily 
use of the stomach tube, the diet must be carefully regulated 
so as to keep the organ as empty as possible consistent with 
fair nutrition of the system. The food should, therefore, be 
concentrated, given in small quantity and at short intervals ; 
and it may be supplemented, if necessary, by the use of nutrient 
enemata. In order further to favour contraction of the dis- 
tended viscus, an abdominal support may be worn, or Faradisa- 
tion resorted to (one of the sponges being applied over the 
epigastric region), and tonics, especially strychnia and nux 
vomica, are indicated. 

It remains for me to refer to the question of operative 
interference in cases of obstruction at the pyloric orifice of the 
stomach, such as results from fibroid or cancerous disease, or 
from the cicatrization of ulcers — a subject which has been 
carefully considered by Dr. L. Rydygier in Volkmann's 
Sammlung Klinischer Vortrdge,\ to whom I am largely 
indebted for the following facts : — Merrem was the first (in 

* German Clinical Lectures. Second Series. London : New Syd. See, 
1878. P. 489. 

t The medium dose of the former is ^ i, and of the latter gr. x, adminis- 
tered after food. 

X Leipzig : Breitkopf & Hartel. 1882. No. 220. 



Diseases of the Stoniacli. 171 

1810) — and later Gussenbauer and v. Winiwarter — to prove 
that resection of the pylorus was quite a feasible operation in 
the case of the lower animals. But for all that it seems never 
to have been attempted in the human subject until 1879, when 
P^an of Paris, at the urgent request of a patient, cut out a 
carcinomatous pylorus. Death, however, ensued hve days 
thereafter. On the third occasion upon which the attempt 
was made, on account of a similiar condition, in 1881, the 
operator being Billroth, the patient made a good recovery, but 
• lied five months afterwards, owing to a relapse. Altogether, 
from April 1879, till May 1882, the operation seems to have 
been performed 28 times. Of these operations, only 5 were 
successful, including the one already mentioned. The remain- 
ing 4, when last under observation 6, 7, 7, and 12 months 
respecti\ ely after operation, continvied well : 3 of these 
were cases of cancerous disease, and one of contraction of the 
pylorus, consequent upon ulceration ; and in this case, when 
last reported upon, the patient was in the fifth month of 
pregnancy. 

It must be admitted, therefore, that the results hitherto have 
not been brilliant ; and yet, when we remember that the 
disease from which most of the patients suffered was certain 
otherwise to terminate fatally, it is some consolation to knoM' 
that even a small proportion of them were restored to health 
by operative interference ; and there is little reason to doubt 
that — just as in the case of ovariotomy^ — when the rules foi" 
carrying out the operation are more thoroughly understood. 
and further experience has been accumulated, the death-rate 
will be materially lowered. The operation- is specially to be 
recommended when there is reason to believe that the obstruc- 
tion is not of a malignant nature, or if malignant, that the 
cancer of the pylorus has not seriously encroached upon the 
pancreas or other structures in the vicinity; and it is probable 
that earlier resort to the knife, and before exhaustion is 
extreme, may lead to greater success. 

I cannot conclude without referring for a moment to the 
operation devised by Dr. Loreta, of Bologna, for cases of non- 
malignant contraction of the pyloric and cardiac orifices. 
This consists in opening the abdomen, and making an incision 
into the stomach, through which the index finger of the right 
hand is introduced, and with which the orifice is forcibly 
dilated. The cardiac orifice cannot be reached with the 
finger, so that a metallic dilator is used instead. In a 
letter from Dr. Pedrazzoli,* we are told that up to 15th 
* 4th August, 1883, p. 212. 



172 Dr. Munro — The Sclentijic Basis of Medicine. 

•Juh% 1883, Dr. Loreta has in this way forcibly dilated 
the pylorus four times, and the cardiac orifice once. All of 
these operations were successful, although one patient is said 
to have died 36 hours after the operation "from causes 
entirely independent of the operation," and the evidence is in 
favour of the permanency of the cures. We may, therefore, 
look forward with confidence to the results of subsequent 
attempts in the same direction. 

In cases of malignant obstruction at the cardiac orifice, we 
may sometimes prolong life by the formation of a fistula, or 
by introducing food with the aid of a narrow gum elastic tube. 

I need not dwell upon the treatment of cancerous disease of 
the stomach other than by operative interference, as I have 
already taken up too much of j^our time, more especially as all 
our measures must be of .a palliative nature; and for the relief 
of special symptoms, the management of which has been 
sufficiently indicated in the course of my remarks. 



THE SCIENTIFIC BASIS OF MEDICINE.* 

By ROBERT MUNRO, M.A., M.D. 

Gentlejiex, — -When Christianity became amalgamated with 
the pagan ceremonies and superstitions of the Roman Empire, 
about the beginning of the 4th century, there gradually arose 
a system of religious despotism which ultimately absorbed 
into itself not only all spiritual power, but the entire control 
of the moral, intellectual, and political life of Europe. To 
such an extent was this ecclesiastical tyranny carried that the 
mere denial of a cosmical theory — which represented the earth 
as a fixed plain in the centre of the universe, having its physi- 
cal laws and phenomena directly dependent on God, but liable 
to suspension or interference by various supernatural agencies 
— was considered a sufficiently dangerous heresy to merit the 
punishment of death. During the prevalence of this Stygian 
fog the most deadly plagues and epidemics, which then fre- 
quently swept over Europe, were considered to be special 
visitations from an oflended Deity, which could only be 

* Being Inaugural Address as President of the Glasgow and West of 
Scotland Branch of the British Medical Association, read at the Annual 
Meeting in Glasgow, 31st Janurary, 1885. 



Dr. Munro — The Scientific Basis of Medicine. 1 73 

removed by the prayers and general liumiliation of the 
afflicted comLuunities. Evil spirits and witclies were believed 
to have the power of inflicting on poor humanity a variety of 
diseases, and for this crime alone many thousands of unfortu- 
nate beings, chiefly decrepit old women, were unmercifully 
hanged or committed to the flames. As mediator between 
heaven and earth, the church advocated the efficacy of 
miracles and holy relics in the treatment of diseases, and 
discouraged medical art as an interference Avith the profits of 
shrines and sanctuaries. As an instance of the abject super- 
stition of these times, it is related that when Halley's comet 
appeared in 1456, the people were struck with so nmch terror 
that the church bells of all Europe were set. to ring in order 
to scare it away, because its immense tail, which extended 
over a third of the heavens, was supposed to " shake down 
diseases, pestilence, and war upon the earth." 

When we consider that the healing art, in addition to the 
conjectural and problematical nature of its inherent elements, 
had to contend against a priestcraft which long sought to 
monopolise its practice as a privilege of Divine inspiration, 
we need not be astonished that it was longer than many of 
the collateral sciences in emerging from the shackles imposed 
upon all truth by institutions founded on such ignorance, 
prejudice, and superstition, as characterised the Middle Ages. 
The primary object of the Reformation was to remove the 
rites and ceremonies of pagan superstition from Christianity, 
but this struggle, though it gave the first great stimulus and 
comparative securit}' to scientific investigations, did not extin- 
guish religious intolerance towards discoveries that were sup- 
posed to be contrary to the verbal interpretation of the sacred 
writings. Hence we find that diseases continued to be prayed 
for as formerly, and as for actual treatment, more reliance 
was put in miracles, charms, &c., than in medical skill or sani- 
tary measures. The witch mania was by no means abated, so 
the poor witches were tried, condemned, and burnt, not only 
for the infliction of diseases, but for their actual removal, 
which was said to be done by illegal remedies. One of the 
recorded pleadings by Sir George M'Kenzie, between the 
year 1661 and 1672, is for a woman named Ma^via, who was 
accused of witchcraft. The indictment against this poor per- 
son is made up of the following three charges: — '"'(l.) That 
she did lay on a disease upon A B b}^ using a charm. (2.) 
That she took it off by another. (3.) That it is deponed by 
two penitent witches that she and they did flee as doves to 



174 Dr. Muxro — The Scientific Basis of Medicine. 

the meeting place of witches." * Not longer ago than the 
year 1697, on the evidence of Christina Shaw, a girl of 11 
years of age, who, it appears, was subject to hysterical con- 
vulsions, and was said " to put out of her niovbth quantities of 
egg-shells, orange-peels, feathers of wild and bones of tame 
fowl, hair of various colours, hot coal cinders, straws, crooked 
pins, &c." no less than 7 persons were condemned and com- 
mitted to the flames on the Green at Paisley for having been 
" the authors of these malefices from which the said Christina 
Shaw suftered." -I* 

Some notion of the opinions prevailing in Scotland, at a 
much earlier period, regarding diseases may be formed from 
the prominence given to the miraculous power of healing 
ascribed to St. Columba by his biographer, Adamnan. In the 
final chapter of his second book — a l)ook entirely devoted to 
a record of the saint's miracles — -Adamnan gives an account of 
his own knowledge and experience of the plagvx, which is of 
singular interest, both on account of the authenticity of its 
date (the close of the 7th century) and the literary ability 
of the author. The chapter is as follows — 

" Concerning the Plague. — What we are about to, relate 
concerning the plague, which in our own time twice visited 
the greater part of the world, deserves, I think, to be reckoned 
among not the least of the miracles of St. Columba. For, 
not to mention the other and greater countries of Europe, 
including Italy, the Roman States, and the Cisalpine provinces 
of Gaul, with the States of Spain also, which lie beyond the 
Pyrenees, these islands of the sea, Scotia (Ireland) and Britain, 
have twice been ravaged by a dreadful pestilence throughout 
their whole extent, except aiiiong the two tribes, the Picts 
and Scots of Britain, who are separated from each other by 
the Dorsal mountains of Britain. And although neither of 
these nations was free from those grievous crimes which 
generalh' provoke the anger of the Eternal Judge, yet l)oth 
have been hitherto patiently borne with and mercifully spared. 
Now, to what other person can this favour granted them by 
God be attributed unless to St. Columba, whose monasteries 
lie within the territories of both these people, and have 
been regarded by both with the greatest respect up to the 
present time I But what I am now to say cannot, I think, 
be heard without a sigh — that there are many very stupid 
people in both countries who, in their ignorance that they owe 

* Phadings of some Remarkahle Cases before the Supreme Courts of Scot- 
land. By Sir George M'Kenzie, 1661-1672. 
+ Arnot, Celebrated Criminal Trials^ p. 362. 



Dr. Muxro — The Scipiitific Bums of Medicine. 175 

their exemption from the plague to the prayers of the saint, 
ungratefully and wickedly abuse the patience and the good- 
ness of God. But I often return my most grateful thanks to 
God for having, tli rough the intercessioii of our holy patron, 
preserved me and those in our islands from the ravages of the 
pestilence ; and that in Saxonia also, when I went to visit my 
friend King Aldfrid, when the plague was raging and laying- 
waste many of his villages, yet both in its first attack, imme- 
diately after the war of Ecfridus, and in its second, two years 
subsequently, the Lord mercifully saved me from danger, though 
I was living and moving about in the very midst of the plague. 
The Divine mercy was also extended to my companions, not 
one of whom died of the plague, or was attacked with any 
other disease."* 

No symptoni is here mentioned which would enable us to 
form any conjecture as to the nature of this plague, but, in 
chap, iv, there is a description of St. Columba's prophecy 
regarding a dense rainy cloud which he predicts " will dis- 
charge in the evening a pestilential rain which will raise large 
and putrid ulcers on the bodies of men and the udders of cows ; 
so that men and cattle shall sicken and die, worn out with that 
poisonous complaint." The cure of this pestilence was effected 
by sprinkling man and lieast with water in which some bread 
" blessed by the invocation of the name of God " had been 
previously dipped. 

To this widespread belief in the supernatural origin and 
cure of diseases, I have to note one or two other causes 
which fostered the medical absurdities of -the Middle Ages. 
A firm belief in the existence of the philosophers' stone, which, 
if discovered, would enable the happy finder to convert the 
baser metals into their equivalent in gold, and an elexir vitct, 
which was supposed to prolong life almost ad infmitvim, 
misled many of the philosophers of the period, and tinged all 
their speculations. The search for these valuable secrets of 
Nature appears to have been the special province of alchemy. 
While prosecuting their investigations, the alchemists found, 
however, that funds for supplying the ordinary necessaries of 
life were requisite ; hence they combined with their pretended 
science the more lucrative profession of working miracles, and 
curing all sorts of maladies by touch, charms, talismans, &c. 
But to describe the motley crew of quacks, empirics, and char- 
latans, who practised the art of healing, and claimed a share 
in the noble work of relieving suffering humanity, would lead 
me awav from the object of my address. Besides astrolocrers, 
* Historians of tScotland^ vol. vi, book ii, chap, xlvii, page 77. 



176 Dr. Munro — The Scientific Basis of Medicine. 

necromancers, sorcerers, dealers in charms, amulets, and 
philters, touchers for the evil, compounders of sympathetic 
powders, mongers of secret remedies and all sorts of panaceas, 
we would have to wade through the exploded opinions of a 
variety of medical sects, such as chemical and mathematical 
physicians, animal magnetisers, homoeopathists, allopathists, 
&c., some of whose theories have become merged into the 
medical speculations of our own time. 

The commercial spirit of enterprise aroused in consequence 
of the discovery of America, and the revival of Greek learn- 
ing in the West during the latter part of the loth century, 
paved the way for the intellectual freedom of Europe. Though 
the introduction of the works of Hippocrates and Galen, as 
well as the Latin works of Celsus, had no immediate effect on 
the practice of medicine, it cannot be doubted that they 
were instrumental in sowing seeds which have continued to 
germinate to the present time. The separation of chtanistry 
from alchemj', and the study of human anatomy, which may 
be said to have been fairly established in the 16th century, 
speedily led to the important anatomical and physiological 
investigations which culminated in the discovery of the circu- 
lation of the blood by Harvey, and the lymphatic vessels by 
Aselli, early in the following century. Henceforth medicine 
was placed on a more rational foundation, and its subsequent 
history is but a record of a long series of discoveries in 
anatomy, chemistry, and physiology, and kindred sciences, 
which have greatly advanced the claim of medicine to be 
considered a scientific art. 

It will be thus seen that the medical science of the present 
day is the offspring of a heterogeneous mass of ancient medi- 
cal opinions, engrafted on the blind empiricism and superstition 
prevalent among the western nations of Europe during the 
dark ages. It is true that other sciences, such as chemistry, 
astronomy, geology, anthropology, &c., can boast of no better 
pedigree. But these all have this grand feature in common — 
viz., that a clean sweep has been made of all principles and 
doofmas which were found not to be in accordance with 
known truths. And this purging process still continues in 
force. At the present time astronomy has rejected every 
single clause of the Mosaic cosmogony, which was so long- 
enforced by theological intolerance. Under the new and 
improved methods of investigation, and extended clinical ob- 
servation now adopted in medical researches, a similar process 
is going on in the practice of medicine ; and already many 
erroneous doctrines have been exploded. As for the super- 



Dii. .MuNRO — The Sclent ifir Basis of Medicine. 177 

natural element, it is no longer reckoned a factor either 
in the cause or treatment of disease. 

Before gix'ing expression in categorical language to the 
facts and principles which, in my opinion, constitute the 
scientific basis of medicine, I have to remind you that the 
science which investigates the laws and phenomena of disease 
may be a totally different thing from the art which professes 
to cure it. Thus, for example, the pathogenic causes of 
Bright's disease of the kidneys, and the morbid changes 
gradually induced in the uriniferous ducts, may be clearly 
ascertained, and yet nothing ma}* be known of the means of 
stopping these changes, or restoring the altered renal structures 
to their normal condition. The same may be said «/oriiori 
of the sciences by which the laws of health and the normal 
functions of tlie body are determined. Hence, one may be 
intimately acquainted with the anatomical and microscopical 
structures of the body, and he may thoroughly understand the 
principles of hum.an physiology, as well as the chemical and 
physiological action of drugs ; or he may be conversant with 
the laws and natural history of a disease — its origin, effects, 
and probable termination, and yet have no knowledge of the 
art of curing it. A man full of such wisdom may be absolutely 
powerless in averting a fatal issue or relieving suffering. It 
does not, however, follow from this that these attainments are 
not essential as a preliminary step in acquiring a knowledge 
of the art of healing. On the contrary, as I shall afterwards 
more fully explain, I believe that no truly scientific system of 
medicine can exist that is not founded upon, and directly 
dependent on, the extent and correctness of the facts derived 
from such investigations. A difference of opinion on this very 
point gave rise at an eai'ly period in the history of medicine 
to two distinct medical schools or sects called Rdtiomdisfs and 
Empirics. This division first assumed prominence among the 
professors of medical art in the famous school of Alexandria, 
which was established by the nnmificence of the Ptolemies, 
about 300 years before the Christian era. The adherents of 
the former (known also as I)(;gmatists) asserted that before 
diseases could be correctly treated it was essential to be 
acquainted with the nature and functions of the healthy bodj', 
the action of drugs upon it, and the morbid changes induced 
ill the affected parts. Hence, they insisted on the necessity of 
iiKiking dissections of the human body, and prosecuting by 
• •very possible means the study of physiology, pathology, and 
therapeutics. Meanwhile, until such accurate knowledge 
could be attained, they disparaged the use of active remedies and 

\o. a ' N Vol. XXIII. 



178 Br. Munro — The Scientific Basis of Medicine. 

blood-letting, and trusted more to the regulation of diet, hgyiene, 
and the vis '}nedicatrix natune. On the other hand, their 
opponents, the Empirics, ridiculed the acquisition of such 
minute knowledge as fanciful or impossible to be attained, and, 
even if possible, contended that it was of little use, and relied 
on experience as the sole guide in the treatment of disease. 
The disciples of these two rival schools, who enlisted apparently 
in about equal numbers all the physicians of that period, con- 
tinued for a century or two to be the chief exponents of 
medical teaching, but, with the fall of the spendid museum at 
Alexandria, and the decline of Greek philosophy in general, 
their doctrines ultimately gave place to the sacred shrines 
and miracle cures of the subsequent dark ages. But the 14 
centuries of Stygian darkness, which so long warped the 
intellectual aspirations of Europe, and prevented these early 
germs from bearing fruit, have now come to an end, and it is 
no small privilege to be able, in the full zenith of an 
enlightened era, to resume these discussions without encounter- 
ing any persecution. In looking at medical science from two 
such widely separated chronological standpoints, it is singular 
to find how little the curative art has advanced beyond the 
point where the Alexandrian physicians left it. Rationalism 
and Empiricism are still the chief rival theories in medicine ; 
and the description which Celsus gives of their respective 
doctrines, some 1800 years ago, is as applicable now as it was 
then. No doubt the numerous experimental researches 
conducted on the lower animals, and the strict attention now 
given to clinical observations, and the collective investi- 
gations of facts bearing on the natural history of disease, 
together with many other greatly extended and exact 
methods of diagnosis, have increased our knowledge of 
physiological and pathological processes, and opened up specu- 
lations regarding the nature of epidemic diseases which 
were entirely unknown to our Alexandrian confreres. But, 
notwithstanding all this, if we exclude the province of 
surgery, we have not got beyond the preparator}^ stage of 
collecting materials and data towards a science which yet 
remains to be constructed on truly scientific principles. 

All organised living bodies are subject to the laws of matter, 
and so long as their structure and functions remain unim- 
paired they are said to live in a state of health. Health may 
be thus appropriately compared to the resultant of a compound 
parallelogram of forces, where the sides of the parallelogram 
are represented by the multifarious animal and physical 
influences which regulate the phenomenal activity of the indi- 



Dr. Munro — The Scientijic Basis of Medicine. 17!) 

vidual (luring its life period. From this point of view the 
orit^niial character of the body is already determined at birth 
by the mysterious laws of heredity ; and the molecular forces 
thus acquired are as real factors in its subse(|uent changes as 
those that come into pla}' after birth. But this normal condition 
of the living organi-sm is liable to be disturbed by a variety 
of causes, due to fluctuations in its environments, or some 
changes in the conditions of its existence, and when these 
deviations, either in structure or functions, exceed certain 
limits, the individual is said to be in a state of disease. The 
term disease is therefore a generic one, representing the aggre- 
gate of all those deviations from the normal type which tend 
to mar the enjoyments of life or Ijring the organism to a pre- 
mature end. 

At the head of animated creation, both as regards differen- 
tiation of structure and specialisation of function, stands the 
human being. He is the terminal link of the long chain with 
which evolution has bound together all the countless and varied 
organisms on the globe, from the simplest cell or protoplasm 
upwards. The primary" conditions of his existence are pure 
atmospheric air within certain limits of temperature, a regular 
supply of appropriate food, and a healthy activity of the entire 
metabolic phenomena of his body. The regulation of the 
details of many of these conditions is under his own control. 
This is notably true with regard to food, which entails on him 
a constant watchfulness and scramble for the means of daily 
existence. Though man, owing to his great mental develop- 
ment, has been enabled to modify the primitive struggle for 
existence imposed upon him by nature in several important 
respects — such as by increasing the productiveness of the 
earth and acquiring the means of transporting food from all 
parts of the world — yet these advantages are not always 
attained without corresponding drawbacks. Indeed, it not 
unfrequently happens that disease, sickness, and increased 
mortality advance pfcri jmssu with the so-called blessings of 
civili.sation. It is the progressiveness of this civilisation, with 
its ever widening organisations, that gives scope to the profes- 
sion of medicine. 

A cursory glance at the mechanism of the hinnan fabric, 
and the nature of its environments, will be sufficient to 
disclose the leading sources of disease. The atmosphere 
may contain a great vai'iety of impurities, such as noxious 
gases, particles of inorganic matter, pollen and spores of 
plants, germs of disease, &c., which will either irritate the 
organ of breathing or prevent it from performing its excre- 



180 Dr. Ml^nro — The Scieidijic Basis of Medici nc 

toiy function, and so cause secondary disturbances in the 
tissues. Other chano-es in the surroundin^r media, due to 
variations in heat, light, electricity, atmospheric pressure, &c., 
may also cause various constitutional disturbances. Hence, 
to the variableness of the constitution of the atmosphere and 
its suspended impurities may be traced many of the diseases 
which afflict humanity. Again, this globe affords the oppor- 
tunity of existence to thousands of other creatures besides 
man. These appear to be pei'petually at war, not only with 
man but amon«- themselves. In short, the entire organic 
world is a sort of Donnybrook fair, with consta.nt struggles 
and free tights all round, each creature defendino- or attackino- 
according to its own special methods and weapons. Over the 
larger animals man has now got the mastery, and, conse- 
(juently, he has been dubbed lord of the creation ; but in his 
struggles against the smaller ones he often falls a victim. 
These micro-organisms live on his body as parasites, or find 
their way in a variety of ways into his blood and tissues, 
where they create terrible havoc. A third source of disease 
is the food. This may contain organic germs of disease, or it 
may be deleterious, deficient in some nutritive qualities, or in 
excess as regards others, all of which eventualities are sure to 
be followed by consequences more or less injurious to the 
o-eneral life and wellbeino; of the oro^anism. Moreover, from 
the extreme delicacy and complexity of the chemico-vital 
processes and their interdependence on each other, the phe- 
nomenal forces of the body are liable to many derangements, 
all of which are intensified owing to their partial subjection to 
mental emotions and other obscure nervous causes. Nor 
must we forget to note that the body is subject to physical 
laws and their occasional violent results. Thus, we might 
classify diseases according to the immediate sources from 
which they are derived. Such a classification, though per- 
haps more philosophical than practical, suffices for my present 
purpose, inasmuch as it shows the extensive knowledge and 
wide range of subjects with which the physician must be 
familiar before he is in a position to apply any curative 
measures whatever. Not only must he know the structure 
and entire mechanism of the human body, the normal action 
of its organs, and the pathological changes induced in the 
state of disease, but he must seek for the primary causes of 
morbid conditions. Sometimes attention is directed to the 
external surroundings of the sufferer, and sometimes to errors 
of diet or obscure disturbances of mental origin. At other 
times he has to grapple with the effects of a colony of one or 



Dii. MuNRo — The Scu'nti/ic Ba.sls of Medicine. ISl 

other of those parasitic germs which find in huinan blood and 
tissues the special conditions of their existence. In fact, it 
would be difficult to name a science from wliich the physician 
has not occasionally to cull information. Having ascertained 
the exact patliological condition of the patient, and the precise 
physical or organic circumstances which induced it, or, in 
other words, the cause of the disease, the next problem to be 
considered is the treatment. I specially mention fJie cause, 
as its determination often plays a very important part 
in the further proceedings. Thus, it makes a material 
diti'erence in the treatment of mortification, say of the 
foot, whether it is due to frostbite, embolism, or ather- 
omatous degeneration of the arterial vessels. Again, the 
treatment of chronic bronchitis, so common among colliers, 
Sheffield knife-grinders, &c., by expectorants, or indeed by 
any other remedial agents, would be of little avail so long- 
as the patient continued his employment. Hence, the first 
thing to be done is to remove the cause of the disease ; and this 
is of much importance in cases where the cause is in constant 
operation, as among children living in close and confined rooms 
wliere the vitiated atmosphere poisons the system, as it were, 
in houKeopathic doses. When the cause is a definite act, as 
fracture of an extremity by sudden violence, or temporary 
exposure to extreme cold, resulting in local mortification, we 
may have treatment alone to consider — the primary causes, i. e., 
the violent strain and low temperature being already removed. 
In such cases it is most instructive to watch the marvellous 
powers of nature in restoring the contiguity of the broken 
bones, throwing ofi'dead matter, and forming a new protective 
covering. Any outside interference must be exactly on the lines 
indicated by nature herself. The ends of the fractured bones 
may, however, be more evenly adjusted, and the morbid parts 
may be removed quicker by the knife of the surgeon tlian l:>y the 
unaided ettbrts of nature. The healing action of a wound may 
also be quickened and assisted by various applications, and 
the absorption of pathogenic organisms, and other secondary 
efifects on the system, may be entirely averted. But, besides 
such aid as can be given by surgical and mechanical appliances, 
there remains to l»e mentioned the power claimed by medical 
art in curing or modifying diseases by the administration of 
drugs, and so-called specific reme<lies. It would thus appear 
that all the objects contemplated by the medical ai-t, in its 
widest application, may be summed up under the following- 
three heads: — (1) Prevention of disease; (2) Removal of its 
primary causes ; and (8) The administration of substances, sup- 



182 Dr. Munro — The Scientific Basis of Medicine. 

posed to act beneficially on the pathological conditions of the 
disease. 

The unfortunate misconception of the nature and treatment 
of disease which followed the spread of Christianity in Western 
Europe, and so long retarded the development of rational 
medicine in mediaeval times, led to a similar retrogression in 
sanitary matters. Notwithstanding the strict injunctions given 
in the Mosaic code of laws regarding personal cleanliness, 
healthy dwellings, and indeed everything bearing on the well- 
being of the Jewish nation ; but especially the importance 
attached to isolation from the camp of all persons suffering 
from contagious disorders, it does not appear that the possible 
prevention of disease by similar measures \^ as ever even enter- 
tained by either statesmen, ecclesiastical dignitaries, or the 
professors of medical art, until comparatively modern times. 
And this neglect is more remarkable when we consider that 
these sanitary laws were part of the religious duties of the 
Jew\s, and that the entire teaching of the Pentateuch became 
incorporated with the doctrines of Christianity, many of which 
became infallible dogmas, and were enforced with the utmost 
rigour. That the Greeks, Romans, and other nations of 
antiquity, as they advanced towards civilisation, were much 
influenced by hygienic laws, is manifest from the structure of 
their houses, the number of public baths, the drainage schemes, 
vast aqueducts, and other sanitary arrangements which they 
possessed. But this knowledge, as well as that embodied in 
pagan medical literature, became a dead letter, and had no 
effect on the social organisations of Western Europe for many 
centuries. 

When, therefore, one of those terrible epidemics of which we 
read in the Middle Ages arose, the misguided people had no 
idea of its causal connection with their prolonged and total 
disregard of the laws of sanitation. Instead of cleaning and 
ventilating their houses, which writers of the period describe 
as filthy beyond measure, and adopting the truly scientific prin- 
ciples of disinfection inculcated on the Israelites by their great 
Lawgiver — such as the cremation of all putrescible matters and 
articles of clothing which were likely to convey and dissemi- 
nate contagious diseases, and the free use of water and fresh 
air — they fled, terror stricken, to shrines and sanctuaries, or 
otherwise performed such penances as were prescribed by an 
ignorant priestcraft. When, at length, statesmen became alive 
to the fact that the poor, living in unventilated and undrained 
hovels in the midst of accumulated organic debris, suffered 
severely from an epidemic, while the better classes were com- 



Dr. ^Iuxro — The Scientific Basis of Medicine. 183 

parativ^ely safe, many important measures were undertaken 
tor the improvement of public health. With improved dwell- 
ings and social cleanliness, the local causes which fostered the 
plague, sweating sickness, and other diseases, are gone ; and 
hence the community no longer dreads the return of these 
scourges. Under a proper system of drainage, ague has entirely" 
disappeared from the country. Typhus fever, small-pox, 
scurvy, Szc, though not completely eradicated, are greatly 
mitigated in severity. On the other hand, scarlet fever, 
measles, typhoid fever, and cholera still baffle us ; but, con- 
sidering the promising prospects of sanitary science opened up 
by the experimental researches of Pasteur and Koch, we need 
not despair that, eventually, they also will succumb to the 
ingenuity of man. The immense benefit conferred on mankind 
by the sanitary improvements of this century may be esti- 
mated from the fact that the average death-rate in Britain at 
the present time is only about half of what it was in the 
middle of the IGth century. But, notwithstanding the im- 
proved social and domestic habits of the people, who are 
undoubtedly better housed, clothed, and fed than formerly', 
and the many legislative enactments now in force, by means 
of which distress and poverty are instantly relieved, I hold 
that preventive medicine has not yet received the attention 
from the State which it merits. Much has been done, but still 
more remains to be done before the Augean stables are cleared 
out. 

Among the many achievements of preventive medicine there 
is none, since the day when Edward Jenner gave experimental 
proof of the protective power of vaccination against small-pox, 
that hcxs attracted more attention than the l)iological investi- 
gations now enthusiastically pursued in every efficient labora- 
tory in the civilised world, which appear to support, if not 
demonstrate, a causal connection between micro-organisms and 
epidemic diseases. The general outcome of these investigations, 
so far as their medical aspect is concerned, is the discovery of 
a method of separating the pathogenic organisms from the 
blood and tissues of a diseased animal and, by means of a 
series of artificial cultivations, converting them into a modified 
vaccine, which, when inoculated upon healthy animals, pro- 
duces certain harmless symptoms, somewhat analogous to the 
original disease, but (and this is the important part to humanity) 
still retaining tlie power of rendering individuals so treated 
unsusceptiljle to the natural disease. It is curious to note the 
complete parallelism there is between these two great dis- 
coveries ; and this is more remarkable when we bring to 



18-* Dr. Airman — Mcceut Eij'ulenuc of Measles hi Guernsey. 

recollection Jenner's belief in the identity of the virus of small- 
pox and cow-pox — in other words, he believed that it is the 
same oro-anic substance that produces cow-pox in the cow and 
small-pox in man. Experiments have now proved that if a 
cow is vaccinated with a portion of the matured pustules of 
small-pox the result will be cow-pox. Hence we conclude 
that the pathogenic organisms ai'e merely deprived of their 
virulent properties during their transitory habitation in the 
blood and tissues of this animal. The difference, therefore, 
betw^een Jenner and the modern experimenters is simply this, 
that, instead of the bovine influence which the former took 
advantao-e of to mitigate the virulence of the disease, and so 
permit of the altered virus being used as a prophjdactic 
ao-ainst the natural disease, the latter substitute a new method 
— viz., that of isolated cultivation, which is found to produce a 

similar result. 

(To be concluded.) 



NOTES ON A RECENT EPIDEMIC OF MEASLES IN 

GUERNSEY. 

By J. AIKMAN, M.D. 

During the last quarter of the year 1884 the island of 
Guernsey was visited by a sharp epidemic of measles. In 
many, perhaps in most communities, the event would scarcely 
have called for any special record. But Guernsey has been so 
peculiarly free from serious epidemics of any kind for the past 
thirty-hve years that this blot upon its fair fame seems to 
merit comment. Slight epidemics of simple measles do 
occasionally show themselves ; sporadic cases of scarlet fever 
crop up now and then and spread in a feeble way within a 
limited circle ; even on one or two occasions a case of small- 
pox has been imported, but the disease has soon died out. So 
attenuated does infectious virus rapidly become that it is very 
unusual for even Ijdng-in women to be endangered by it. 

Why, then, should measles have become virulently epidemic? 
In reply to this question it must be granted that measles of 
an epidemic type has been extensively prevalent during the 
last half of 1884. 

I am indebted to Dr. Le Page, the senior parish surgeon, for 



Dr. Airman — Recent Epidemic of Measles in Guernsey. 185 

information that this measles' infection was imported from 
Jersey, and nurtured among- the parish patients of the north 
district until it gathered epidemic force and attacked the more 
well-to-do population. No mode of attack could have been 
hetter calculated to secure a wide dissemination of the disease. 

Dr. Le Page reports that the first cases observed in Guernsey 
were seen by him at the Longshore, on the 22nd September, 
ISS-i. Three cases were seen on that day; and fresh cases, 
numbering 2 or 8 daily, were seen by him in nearly every 
tlioroughfare in the district. " The epidemic was at its height, 
and the rate of spread was greatest, during October, 1884, 
when the cases atten<led by me numbered 106. It then gradu- 
ally decreased to 76 cases in November, and 20 in December; 
and with the close of the year the epidenuc ceased as far as 
the north district was concerned." 

Among these cases seven deaths are reported. One on 
8th October, from catarrhal pneumonia, in a child of 18 
months ; one on 9th October, from acute desquamative 
nephritis, in a child of 5 jesivs ; one on 10th November, 
from capillary bronchitis, at 6 years; one on 14th November, 
from convulsions, at 1 year; and one on 17th November, from 
catarrhal pneumonia, 2 years. Two deaths occui*red during 
convalescence, one from pleurisy and one from croup. 

" Petechise were observed only in two cases. In one of the 
t.'arly cases the rash and catarrhal symptoms were repeated 
within a month of the original eruption." 

This report presents points of contrast with the description 
of the epidemic as seen among the better class population. 
Prominently there is the comparative absence of cases which 
became petechial, which suggests the existence of some local 
cause for the increasing virulence of the epidemic. Equally 
prominently, the fatal cases are not congregated into a short 
space of time, and are manifestly due to complications, such as 
would occur in ])adly fed and badly tended classes, and not to 
epidemic influence. It may, therefore, fairly be said that the 
infection was nurtured in the north district mitil it acquired 
epidemic force. 

It is still a matter of dispute whether epidemic influence 
can gain ascendancy without the aid of insanitary conditions. 
It is, however, not a matter of dispute that it is always of the 
utmost importance to enquire carefully into sanitary con- 
ditions in the presence of an epidemic, and in view of the 
possibility of exposure to further epidemic influence. 

There is no reason why the sanitary condition of Guernsey 
should not be perfect. The situation of its principal town on 



186 Dr. Aikmax — Recent Epidemic of Measles in Guernsey. 

the side of a hill, the free permeation of even its narrowest 
streets by the constant sea breeze from the Channel, and the 
gravel and granite upon which it is built, are natural aids of 
immense importance. In one or two points, liowever, there is 
room for improvement. 

The States of the island have constructed good main sewers, 
only faulty in that they are ventilated at the street level ; but 
the private householders have not, it is to be feared, co-oper- 
ated with them. In many, perhaps in most, cases there is no 
proper disconnection made between the main sewers and the 
house pipes, and in only a few instances are house drains 
ventilated. The local centre of the St. John's Ambulance 
Association have, I believe, given some prominence to this 
subject in recent lectures, and it is to be hoped that the teach- 
ing will not be without good effect. 

The water supply of the town is derived from public and 
private wells. These wells are of different depths, some 
taking rank as deep wells, i. e., over 50 feet, while others are 
not so. They are sunk either in gravel soil or granite, the 
water percolating through the gravel, or running in clefts in 
the granite. The wells in many cases are in close proximity 
to buildings, and are liable to accidental contaminations. 

A proposal is on foot to supply the town with water from 
borings made in selected ground. This project is worthy of 
warm support, for although the fault in the water supply is 
not at jDresent marked by any very disastrous consequences, it 
undoubtedly exists. Even water drawn from wells at some 
distance from the town contains an excessive quantity of 
organic matter. This organic matter is probably, in many 
instances, derived from peat ; and though not poisonous in 
itself, it certainly favours the development of putrefactive 
changes. This property is readily demonstrated in gelatine 
solutions, or more simply by comparing the odour of boiled 
and filtered water with that of unfiltered water, kept for a few 
days in clean stoppered bottles. The organic matter itself, 
when dried and heated, burns with a toasted bread smell, quite 
different from that of sewage pollution. This merits the 
attention of the proposed water company, as arrangements 
should be made for purification. All the waters contain much 
chlorine, and many of them much magnesia. If the circum- 
stances detailed constitute a sanitary fault, they cannot be left 
out of consideration either with regard to the late epidemic of 
measles, or the near approach of cholera to our shores during 
the past autumn. 

There are no data upon which to base any statistics with 



Number 


Cases 


of Cliililren. 


of Measles 


550 


227 


270 


109 


700 


340 


220 


150 


44 


26 


country, 




06, . 


96 




325 



Dr. Airman — Recent Epidonic of Mea^la^ in Guernsey. 187 

regard to the extent of the recent cpideniic. The local papers 
stated it at from .'3,000 to 4,000 cases, and I subtend some 
information such as can be gathered from reports of tlie cases 
known to have occurred in the schools before they were closed 
on 12th November, 1884. St. Stephen's schools were not 
closed at all. 

The figures show the number of children on the books, and 
the number of cases of measles known to have occurred. 



St. John's Scliools, . 

Britisli Schools, 

Central Schools, 

St. Stephen's Schools, 

Militia Arsenal, 

St. Andrew's School, on books 154 (country, 

not closed), average attendance 106, 
In personal practice. 
Dr. Le Page's report of parish work (Sept. 

omitted), 202 

These figures cannot be rigidly added to form a total as, no 
doubt, some of the school cases would appear a second time 
either in the Arsenal, or in the report of JJr. Le Page's, or my 
own cases. The proportion of cases to children in the schools 
may, however, fairly be used, and in the instances of the St. 
Andrew's school and Arsenal, they represent fully the number 
of children attacked. Guernsey has a population of about 
30,000, and gives employment to 14 or 15 medical practitioners. 
The first cases which fell under my notice were among the 
well-to-do population, and I was struck by the fact that I had 
to deal witli a disease which I had not seen since the epidemic 
of measles in Lancashire in 18G9-70. The parents and grand- 
parents of the children told me that they had never seen 
measles in that form before, and were alarmed at its severity. 
But altliough the cases were severe, the mortality among the 
better fed and better cared for population was not great. I 
only lost one case among those which had been as much as 
twenty-four hours under treatment, and that was from con- 
vulsions late in the convalescence. One evening I saw two 
children moribund with pneumonia as a complication, and they 
died that night. Pneumonia was not, in my experience, a com- 
mon complication. The history of typical cases during the 
height of the epidemic differs only in a few points from the usual 
description of epidemic or, as it is sometimes called, malignant 
measles. Sharp .signs of invasion — fever, pains in the limbs, 



188 Dr. Aikman — Recent hJpideinlc of Measles in Guenisey. 

catarrhal signs, and a rather foul tongue, followed by a rash first 
seen on the roof of the mouth, then behind the ears, at the roots 
of the hair, on the forehead, and later on the face, chest, arms, 
and legs. Coincident with the rash upon the chest and arms, 
the couo^h ffave trouble, and as the rash reached the leo;s, 
diarrhoea, profuse, watery, and exhausting, often set in. The 
rash tended to become petechial in some situations, the points 
of selection for ecchymosis being in the order mentioned— 
thighs, upper arm, forearm, lower leg, cheeks, and neck. In 
a few instances the whole rash became petechial. Epistaxis 
was not so general as one might have anticipated, but was not 
uncommon. Hsematuria and pulmonary hsemorrhage I never 
saw. The effusion of blood beneath the skin was in some 
instances considerable, the discoloration lasting late into the 
convalescence. 

The temperature as a rule ran high, 104" Fahr. being not 
uncommonly recorded, while 105' and 106° Fahr. were occa- 
sionally reached. In the latter instances there was much 
swelling of the face, resembling erysipelas. Little activ^e 
delirium, but very intense headache was noted, and in a few 
cases faceache concentrated along the gunjs. Desquamation 
was frequent. All the symptoms, except diarrhtea, were 
usually relieved with the decline of the rash, but frequently 
great lassitude I'emained. In some few instances, where 
ecchymosis was abundant, the troublesome cough was pro- 
longed into convalescence. No serious consequences seemed 
to follow, and even when expectoration did take place it was 
not more than muco-purulent, and never sanguineous nor even 
lymph-like. 

Diarrhoea was sometimes alarming, but I know of no fatal 
case. When it occurred late in the disease, symptoms of 
collapse soon showed themselves ; but beyond the evidences of 
intestinal desquamation, which were frequently seen in the 
stools, I recognised no sign of deeper intestinal lesion. Dur- 
ing the decline of the epidemic this diarrhoea was very persis- 
tent, but its alarming character abated with the abatement in 
the severity of the disease. 

In two houses diphtheritic sore throat followed measles, but 
in one of the houses at least the drainage was so defective 
that little blame could be attached to the measles. 

All the other complications noted were due simply to a 
want of sufficient care on the part of those in charge of the 
patients, and cannot be fairly ascribed to the disease. 

Four cases of apparent repetition of the disease within a 
short period deserve notice. 



Dh. Aikman — Ri-cnif J'Jit/ilciuic of Measles in Guernsejj. 189 

Case 1. A tViuale cliiM about 5 years ot" age was asserted 
to have had well marked measles, but was not attended. Her 
younger sister, aged 4, took measles and was attended. About 
three weeks later the elder child had a fully developed attack 
of measles. 

Case 2. A female child, the only one in the family, had 
well marked measles, followed by troublesome diarrhoea, which 
confined her to her room, until about three weeks later she 
passed through a second attack of distinct measles. 

Case 8. A male child, in family who had all had measles, 
was thought to have escaped, but was attacked ten days after 
the rest. The rash, which was masked by extensive eczema, 
only lasted two days. A fortnight later this chiM had well 
developed measles. 

Case 4. A family of six children, cousins to case 1. All 
had measles sharply. Two children remained weakly, and 
were kept in the room of the mother, who had been confined 
since the last case was convalescent. One of these children, 
at the interval of nearh' a month, had a second attack of 
measles. Neither the mother nor newly -born child suffered. 
This form of repetition was, I believe, noted during the Lon- 
don epidemic of last summer, and elsewhere. 

It is perhaps worthy of remark that the exposure to measles' 
infection does not seem to be prejudicial to lying-in women. 
Dr. Le Page tells me that a patient of his was confined at full 
time during an attack of measles, but that it did not prejudice 
her recovery. The child was born covered with a measles 
ra.sh, and died next day. I have no experience on this point. 
The earliest age at which I saw the disease was fourteen days ; 
the ca.se was mild, and the child recovered. No age seems to 
have been exempt. I saw patients from 14 days old to over 
(iO years, and I believe in one instance a couple who were both 
()\er 80 years of age were attacked. 

Treatment. — The milder cases required no more than atten- 
tion to diet. During the eruptive stage milk and water and 
thin gruels appeared to answer better than any thicker foods. 
More solid material, when taken, increased the headache, and 
produced restless nights. Beef tea was avoided, as it tended 
to favour diarrhoea, and gave an unpleasant odour to the 
secretions in the mouth. When the teiDperature fell, chicken 
or veal broth, lightly boiled eggs, and the more solid farina- 
ceous foods were rapidly added to the dietary, followed by 
chicken, fish, and game, and at the end of a few days mutton 
an<l beef. Stimulants were not much used. 



190 Dr. Aikman — Recent Epidein.ic of Measles in Guernsey. 

When a patient was ffVfi'ish and restless, a little saline 
mixture lessened his discomfort and kept the mouth moist. 

In a few instances the temperature rose sufficientl}^ to call 
for special treatment. Intense headache always indicated 
this condition, and the good effected by application of cold 
water in india-rubber bags, or as ice, was most marked. In 
no instance did any chest complication follow its use. When 
the rash l^ecame petechial or heemorrhagic, and the patient 
verged upon a typhoid condition, no amount of alcoholic 
stimulant gave such good results as did the administration of 
nux vomica or the ]i(jUor str3xhni9e, combined first with bark, 
and later with quinine and iron. This line of treatment 
seemed natural in a purpuric condition, and was strongly 
endorsed by previous results in ha3mor]'hagic small-pox during 
the epidemic of 1871, which were recorded in this Journal for 
November of that year. Even cases which did not call for 
special treatment during the acute stage sometimes developed 
petechise during convalescence, but the blood stains rapidly 
disappeared under the use of Easton^s syrup. 

The cough was occasionally very troublesome and intractable 
to remedies. Probably small doses of carbolic acid, with a 
little tincture of belladonna, gave the best results, and some- 
times a bronchitis kettle, in which was boiled a very weak 
solution of carbolic acid, seemed to give marked relief. 

The diarrhciea was notably affected by diet. It undoubtedly 
occurred without dietetic error, but lemonade, ginger beer, 
or fruit produced it in a troublesome degree with absolute 
certainty. A small dose of castor oil, followed by one or two 
grain doses of carbolic acid in chloroform water never failed 
to check it. The stools contained abundant evidence of 
desquamation from the intestinal mucous membrane. 

A few cases of pneumonia and pleurisy occurred late in 
convalescence, but w^ere always due to careless exposure to 
cold. No case of inflammatory chest affection during the 
height of the disease fell under my notice, except the two 
children before mentioned. 

Such is a record of my personal observation of this curious 
epidemic. It seems worthy of record, because the disease 
presented features which gave promise of a much higher 
rate of mortality than is actually recorded. Because, also, 
it occurred in an island where epidemics are exceptionally 
rare, and fairly calls for a careful examination of the present 
sanitation of the place. 

Lastly, it cannot be overlooked that diarrhoea as a com- 



Dk. J)()U(;all — Case of Trauviuflc Tetanus. 191 

plication was unusually counuon. Whether the same feature 
has been observed in the epidemic in other places I know not, 
but it appears to me to merit en(|uiry with regard to its 
bearing upon a possibly prevailing type in epidemic disease. 

I have been asked many questions about prophylaxis, but had 
no extensive opportunity of putting suggestions to the test. 
In my own household, all milk and all drinking water were 
boiled before each meal ; and most of the inmates had small 
doses of Easton's syrup once a day. There is nothing specific 
in this treatment ; but it is satisfactory to note that, though 
constantly exposed to infection, no one developed the disease. 



A CASE OF TRAUMATIC TETANUS SUCCESSFULLY 
TREATED WITH CALABAR BEAN. 

By JOHN DOUGALL, M.D., 

Assistant Physician Glasgow Royal Infirmary, and Lecturer on Materia 
Medica in the Infirmary >School of Medicine. 

As traumatic tetanus usually terminates fatally, the following 
case is interesting : — 

While acting vice Dr. Scott Orr, Jessie L., aged 16, 
farm servant, was admitted to Ward I on 5th September, 
1884. About 12 days previous to admission, while milking a 
cow which had sore teats it became restive, and tramped on 
her right great toe, tearing off the nail and bruising it severely. 
After a few rude dressings it healed. About a week after 
the accident she felt her mouth " sore and stiti'," i. e., lockjaw. 
After two daj's the stiffness extended to her neck, and in about 
three daj-s to her back, which became so rigid and painful that 
she could only rest on the occiput and buttocks, her 
.shoulders not even touching the bed. This condition lasted for 
two days, after which she was able to leave her l)ed, although 
still a little stiti" and pained. On admission to the Infirmary 
she complained of a pain which darted at intervals from the 
medullary region to the sacrum when attempting to turn in 
bed ; during the night the pain gradually subsided so that she 
was able to turn, although she still felt stiff. Next night she 
had little sleep from sudden attacks of pain, causing pleuris- 
thotonos and opisthotonos. Never had convulsions, had not 
been exposed to damp or cold, family history good. Physical 
examination: — Back tonically arched; muscles rigid from neck 



192 Dr. Dougall — Case of Trawmatic Tetanu.s. 

to sacrum ; no pain on pressure over cervical and lumbar 
vertebras ; sensation normal ; plantar and patellar reflexes not 
exaggerated; arms and legs flaccid and painless; no headache: 
darting pains down back ; tongue furred; no difficulty or pain 
in swallowing ; appetite good ; bowels regular ; respiration, 
circulation, menstruation, urination, and temperature normal. 
Treatment, 5th September.- — • 

R. Pot. bromidi, gr. xxx. 

Fiat pulv. 
Sig. — One every 4 hours. 

Cth September. — Pain in back more severe; frequent marked 
opisthotonos on attempting to turn in bed; rests almost 
constantly on right side, with thighs and knees much flexed. 
7th September. — 

R. Liq. morph. liydroch., . - - - 5SS. 

Sig. — n\^10 to he taken with the bromide powder. 

8th September. — No improvement. Bowels confined, probably 
from the morphia. 

R. Pulv. scam, co., - - - - - gr. vi. 

Hydrarg. subchlor., ----- gr. iv. 

Fiat pulv. 

Sig. — To be taken at once. 

Powder acted freely; pain in back still severe; opisthotonos 
frequent. As patient was not improving under the treatment, 
I resolved to try Calabar bean pn- .sr as follows : — 
10th September. — 

R. Ext. physostig. fab.. - - - - gr. J-. 

Ext. gent., ----- gr. iii. 

Fiat pil. 

Mitte tales., ------ xxiv. 

Sig. —One every hour. 

1.2th September. — Last night she had a severe attack of 
trismus and opisthotonos, which lasted about 10 seconds, her 
body resting on her head and heels. Hence the dose of 
Calabar bean was increased: — 

R. Ext. physostig. fab., - - - - gr. I. 

Ext. gent., ------ gr. iii. 

Fiat pil. 

Mitte tales., ------ xxiv. 

Sig. — One every hour. 

14th September. — Feels much easier ; attacks of spasm less 
frequent, less prolonped, less painful ; no dysphagia. Sleeps 
well. 



Current Tapirs. 1.93 

17th September. — Tonic curvature of spine less marked ; 
general condition improving. Dose of Calabar bean further 
increased, thus : — 

18th September — 

R. Ext. physostig. fab., - - - gr. ^. 

Ext. gent., ----- gr. iii. 
Fiat pil. 

Mitte tales .... xxxvi. 

Sig. — One every hour. 

1st October. — The improvement noted on 17th September 
has continued. Can now sit and stand, yet her back is still 
abnormally curved and rigid. During the past three days has 
only been getting \ grain of the ext. physostig. fab. every two 
hours, and during the day only; the medicine having previously 
been given both night and day, excepting when she was asleep. 

11th October. — Patient still improving ; was up for a short 
time to-day. Back still a little rigid and arched. No trismus 
for at least two weeks past. Dose of medicine further in- 
creased thus — 

R. Ext. physostig. fab., - - - gr. J. 
Ext. gent., - - - - gr. iii. 

Fiat pil. 

Mitte tales . . . . xxiv. 

Sig. — One every two hours during the day. 

17th October. — Patient has been up the greater part of the 
day ; has no complaint ; can walk, run, stoop, and rise with 
perfect ease; spinal curvature gone. Medicine being gradually 
withdrawn. 

^Oth October. — Dismissed well. 



CURRENT TOPICS. 



It may now be regarded as certain that Glasgow will entertain 
the British Medical Association in August 1888. There have 
been some difficulties in bringing about this result, which for 
the sake of our readers we may briefly refer to. 

It is not to be denied that many of our leading men in 
(ilasgow have a considerable feeling of distrust of the British 
Medical As.sociation as a political or quasi-political organisa- 
No. .3. O Vol. XXIII. 



194 Current Topics. 

tion, while entertaining a strong feeling of respect for it as 
the representative association of the medical profession. In a 
profession such as ours in which the individual members are 
each occupied with serious duties which take up not only his 
time but his intelligence to the utmost, there is little inclina- 
tion, except among the few, to engage in any pursuits outside 
the direct road of professional work. It is notorious that 
medical men rarely appear in public affairs, or only put in a 
formal appearance ; and it may even be said that the profession 
views with a certain degree of suspicion those who make 
themselves prominent in political or municipal matters. There 
seems to be the instinctive feeling that a man should have so 
much interest in his work as to find no energy left for outside 
affairs — our profession, with its manifold relations, being differ- 
ent in this respect from other callings. It is perhaps for this 
reason that Glasgow has viewed with considerable distrust the 
political leaders of the British Medical Association, distinguish- 
ing them as men not specially eminent in their profession, 
but as, in many respects, outsiders, whose interests are not 
always strictly those of the professional man. It will be 
found also that, in the annual meetings of the Association, 
the bulk of the members take comparatively little interest in 
the quasi-political proceedings, these being left to the small 
band who make it specially their business. 

It must be confessed also that Glasgow has received scant 
justice from this band of medical politicians. They have 
threatened the withdrawal of the power of conferring licenses 
from the Faculty of Physicians and Surgeons. They have 
encouraged legislation which the University of Glasgow has 
felt compelled to oppose strenuously, and which meant virtually 
the withdrawal of the power of the Scottish Universities to 
confer a complete license to practise. For all these reasons 
there is in Glasgow a decided feeling of coldness towards the 
British Medical Association in its more public aspects, and 
there has been on the part of many a great disinclination to 
invite it to hold a meeting in Glasgow. 

But with all this there is a very strong feeling, and a feeling 
which has now prevailed, that Glasgow would gladly welcome 
the Association to the city. The British Medical Association 
includes the great bulk of the intelligent members of the 
medical profession, and we in Glasgow have been anxious to 
show hospitality and exhibit a brotherly feeling towards our 
professional brethren. We may be sure that when the Associa- 
tion comes there will be many happy reunions, and warm 
greetings between friends long parted, and there will be many 



Current ToplcH. L95 

close acquaintanceships institute! I among those who know how 
to find out kindred minds. To huiKh-eds tlie opportunity ot" 
seeing and hearing men of reputation in the profession, and of 
listening to the discussion of topics of paramount interest, will 
be a great stimulus in their daily work. Many of us have felt 
the advantage of a visit to (jtlier schools, and to such meetings 
as those of the International Medical Congress and the British 
Medical Association, and we in Glasgow have no reason to 
shrink from comparison with an}' place in the kingdom in the 
completeness of equipment of our medical schools. In fact, it 
may be regarded as one of the more important reasons for 
inviting the Association, that the profession generally have no 
proper conception of the character of the medical schools in 
Gla-sgow. In the mind of the English practitioner there is 
no medical school in Scotland Init that of Edinburgli, and we 
can imagine a great deal of surprise to be evinced at sight of 
the class-rooms, laboratories, and museums of the University, 
Western Infirmary, and Royal Infirmary. We believe that 
there is scarcely anywhere a more fully equipped small medical 
school than that of the Royal Infirmar}', while the arrange- 
ments for practical teaching in connection with the University, 
although by no means perfectly complete, are well adapted to 
the requirements of a large school. 

We trust that the movement for a University Students' 
and Graduates' Union, inaugurated a few days ago, will have 
attained some degree of fruition by the year 1888. One of 
the more pleasant features in the Edinburgh University Ter- 
centenary' Meeting was the prominent part whicli the students 
and younger graduates took in the proceedings. It will augur 
well for the future of our medical schools if the body of the 
students show more inclination to take part, in an organised 
form, in the various affairs of the profession in which they are 
entering, and if the Students' Union could extend a formal 
welcome to old University graduates at the meeting in 1888, 
perhaps in a house of their own, we are sure that they would 
advance the interests of tha University and the medical schools. 

Glasgow and West of Scotland Medical Association. — 
The Annual Meeting of this Association was held on 30th Janu- 
ary, in the Faculty Hall — the President, Dr: Finlayson, in the 
chair. There was not a very large attendance of members. 
After the minutes of last meeting had been read and approved, 
the Treasurer submitted his statement, which showed that the 
income of the Journal for the year, as against the expenditure, 
showed a profit of about £45, which was voted to the editors 



19G Current Topics. 

and their assistants. There was noticed a very gratifying 
advance in the revenue from advertisements and cash sales. 
During the year 19 new members had joined the Association; 
there had been 16 deaths and withdrawals. As regards pay- 
ment for eno-ravino^s it was arranged that in future authors 
should pay the engraver in full, and should then be entitled to 
recover half the account from the Journal. The Treasurer's 
report was adopted. 

The Chairman, in the name of the Index Committee, 
reported that the whole of the First Series of the Journal 
had been indexed, and about half of the Second Series. This 
Committee was reappointed, with the omission of the name of 
Dr. F. Henderson, who was unfortunately laid aside by illness. 

The Editors reported that there had been no lack of literary 
material during the past year. It was noted as satisfactory 
that the number of books sent for review had much increased — 
from 78 in 1878 (the first year in which the monthly issue of 
the Journal was adopted) to 81 in 1880, and 149 in 1884, not 
reckoning innumerable pamphlets and reprints. This, along 
with the excess of cash sales over any previous year, may be 
held as indicating that the Journal is rising in favour as a 
medium for giving publicity to the various contributions to 
medical literature. The Editors then noticed the fact that a 
considerable lull had taken place in the activity of the various 
Societies in the city; and suggested to subscribers the impor- 
tance of sending their most valuable contributions to the pages 
of the Journal. The Editors' report was adopted. 

The Ofiice-bearers for 1885 were then elected. 

A motion was adopted that the General Business Committee 
should reconsider the Constitution of the Association, in view of 
the great changes which had taken place in the position of 
the Association, since the time when its constitution was drawn 
up. 

Ofpice-Bearers for 1885. 
President, Dr. Jas. Finlayson. 

Vice-Presidents,. . . . j S^"" S' ?''''''■ 
' 1 Dr. D. Fraser. 

E'j %, I Dr. J. Coats. 

iLdltOrS, -{ T4 A XT...x^r, 

' 1^ Dr. a. Napier. 

Treasurer, Dr. G. T. Beatson. 

Secretary, Dr. A. Napier. 

General Business Committee. 
The Office-Bearers, ex officiis. 



Dr. W. G. Dun. 
Dr. W. Macewek. 
Dr. J. L. Steven. 
Dr. S. Gemmell. 



Dr. J. B. Russell. 

Dr. B. Goff. 

Dr. W. T. Gairdner. 

Dr. D. N. Knox. 



Current Topics. 197 

Glasgow University Union. — On Saturday, February 
14th, at a largely attended meeting of students and graduates 
held in the Bute Hall, it was unanimously resolved to form a 
Glasgow University Union, " for the purpose of promoting 
social intercourse among the students, past and present, of the 
University, and of acting as a central body representing the 
Students' interests ; and especially for making adequate pro- 
vision for the accommodation of the various college societies." 
A connuittee, composed of 20 students and 10 graduates, was 
appointed to take the steps necessary to carry out this resolu- 
tion. In the selection of this committee care has been taken 
to make it as fully as possible representative of the various 
faculties, and of the various students' interests. To provide 
the accommodation desired a large sum of money will be 
required ; and no doubt the gentlemen on this committee., 
when they have arranged their method of procedure, will seek 
the assistance, pecuniarj^ and personal, of the medical gradu- 
ates of the University. In the meantime, we wish to draw 
the attention of our readers to the proposed Union, and to 
bespeak their favourable consideration of its claims on their 
support. Many will recollect that such a Union has been 
frequently talked of, but has never reached the stage it has 
now attained, the difficulties in the way having always 
appeared insuperable. All the more credit is, therefore, due 
to the gentlemen who have so successfully conducted the 
necessary preliminary arrangements. It may be added that 
in Edinburgh University, where a Students' Representative 
Council and a University Union were practically inaugurated 
last session, good results have already accrued. It is safe to 
assume that a Union will also be to the advantage of our 
University, and we heartily wish it all success. 

Visitation of the Universities. — The General Medical 
Council has appointed Visitors to report on the Examinations 
for Degrees in Medicine and Surgery in all the Universities of 
Great Britain and Ireland. 

The Visitors are chosen in equal number from England, 
Scotland, and Ireland. 

The Representatives on the Board of Visitation for England 
are Dr. Barnes, Dr. Bristowe, and T. Holmes, Esq., F.R.C.S. 

The Representatives for Scotland are Professors Leishman 
and George Buchanan, of Glasgow University, and Dr. George 
Balfour, of Edinburgh. 

The Representatives for Ireland are Dr. Finney and Dr. Kidd, 
and Rawdon Macnamara, Esq., F.R.C.S. I., of Dublin. 



198 Correspondence. 

The Medical School of Glasgow. — The class lists have 
now been made up for the current session. It is not easy to 
estimate the exact number of students of medicine in Glasgow, 
as some attend lectures in more than one school. But this is 
not the case with the students of anatomy, so that they can 
be exactly enumerated. 

The total number of students who have enrolled in anatomy 
in the different schools is 439. Of these 211 are juniors 
attending in their lirst winter session. 

The attendance in the University is 309, and of these 170 
are juniors. 

The total number of students is usually rather more than 
double the number attending anatomy, so that the total 
number of students of medicine in Glasgow must be close 
upon 900. 

Correction. — We regret that in the review of Parker's 
Mammalian Descent in our last issue, a printer's error 
occurred in a quotation from the work reviewed. The quota- 
tion is at the bottom of page 112, and was rendered in our 
pages — "If in human society the toe of the peasant now 
and then galls the ribs of the courtier . . ," instead of 
" the kibe of the courtier," as correctly quoted by Mr. Parkei'. 



CORRESPONDENCE. 



To the Editors of the Glasgow Medical Journal. 

Sirs, — You have not hitherto sought to encourage corres- 
pondence in your Journal, especially on subjects not strictly 
bearing on the medical sciences. It seems to me, however, 
that your columns are the proper place in which to draw 
attention to a practice, long in vogue in Glasgow, and now 
very prevalent, and which ought, I think, to be strongly 
discouraged. I refer to the practice of inserting in the 
windows of druggists' shops advertisements of Courses of 
Lectures to Medical Students. To say the least of it, this is 
absolutely unnecessary, as all such notices can readily be 
posted up at the Infirmaries and at the various schools, where 
all students interested will see them. If it be contended that 
the practice is adopted because some junior practitioners 



Reviews. 19^ 

might like to know of sucli courses, a sufficient reply is, 
that the}' coulil be more easily reached by advertisement in 
your own advertising pages or in those of the weekly medical 
journals. I believe this only requires to be pointed out to 
those responsible; their own good sense will pi'ovide the 
remedy. 

It may not be out of place to add that our medical charities 
sometimes also err in the matter of the distribution of their 
advertisements. For instance, in walking up Sauchiehall 
Street at the present time, one is confronted at almost every 
close with a notice of Free Vaccination at the Faculty Hall ; 
and again, in Church Street, Partick, and in other streets 
adjoining the Western Infirmary, notices may be found in 
almost every close to the effect that Obstetric cases will be 
attended gratis from the Infirmary. Surely these are not the 
situations in which such information is likely to prove useful. 
Patients can be drawn from such localities only at the expense 
of the general practitioner. Yet similar advertisements have 
never, in the more destitute parts of the city, attracted the 
attention of 

A Subscriber. 

Februari/, 1885. 



REVIEWS. 



A Treatise on Bright' s Disease of the Kidneys : its Pathology, 
Diagnosis, and Treatment. With Chapters on the Anatomy 
of the Kidney, Albuminuria, and the Urinary Secretion. 
By Henry B. Millard, M.D., A.M., Vice-President of the 
New York Medico-Chirurgical Society, &c. With Numerous 
Original Illustrations. Pp. 246. London: Sampson, Low% 
Marston, Searle, & Rivington. 1884. 

It is not often that we are called upon to notice the purely 
literarj^ merits or demerits of any medical work. We are so 
much engrossed with the importance of the subjects treated, 
that the form in which these are presented to us becomes a 
matter of comparative indifference. It is quite a mistake to 
suppose, however, that attention to style can be disregarded 
by the medical writer; and still worse to imagine that the 
simplest rules of grammar can be set at open df fiance, as the 
present writer seems to have done. We do not look for the 
lucidity of Dr. Roberts, or the terse and incisive style of Dr. 



200 Revieivs. 

Johnson, in every medical work ; but we have a right to expect 
that any one who attempts to pose as an author should at 
least express himself in clear and intelligible language. We 
are safe in saying that the present writer lamentably fails in 
these requirements. Not to mention manifest slips due to 
slovenliness and haste, the half of which have not been noted 
in the list of errata, his pages fairly bristle with words 
employed in unusual senses, with peculiar phrases, and con- 
fused and ungrammatical sentences. On the very first page 
he startles the reader by referring to the kidney as a "region," 
he calls the renal cells "epithelia," a single cell thus becoming 
an "epithelium," a word which is made to do double duty, 
being also used to designate epithelial tissue in the ordinary 
sense; he emploj^s in the same manner endothelium and 
endothelia; he has albuminuria for albumen, as "albuminuria 
occurs in the urine;" and in several instances peptonuria for 
peptone, as "it is not possible for us to say that the supposed 
albumen was not peptonuria," "the substance found was 
undoubtedly peptonuria;" and so on with various other words. 
He abounds in such phrases as "composed by" for "composed 
of;" "interference of" for "interference with;" "failed in 
obtaining," " the urine of well persons," &c. The reader may 
judge of the effect of these, and other similar peculiarities, in 
"the aggregate. In entire sentences he is often confused and 
intricate ; sometimes, indeed, almost unintelligible. The 
following two may suffice as an illustration of the structure of 
some of his more lengthy periods. Speaking of prognosis in 
interstitial nephritis, he says, p. 155 — "When the new for- 
mation and interstitial growth have with the inflammatory 
corpuscles and liquid plasma developed a fully organised 
tissue, be permeated with new blood-vessels; when the tubules 
and corpora Malpighiana are practically desti'oyed, it would be 
irrational to suppose that the normal structure of the kidney 
could be restored." Not very rational, certainly! We suppose 
that in the first half of this sentence instead of "be permeated," 
the author meant to say "when they have been permeated." 
Our second example occurs on the next page. " Again, there 
is sometimes a period when there is simply serous effusion 
into the connective tissue, and the alterations of the epithelia 
consist only in cloudy swelling, perhaps even after the infil- 
tration into the connective tissue has become inflammatory, 
and a portion of the epithelia has desquamated, that an entirely 
normal state in the first of the above conditions, and a 
practically healthy state in the second, may be brought 
about." 



Reviews. 201 

These faults are the more to be regretted as the author 
states that his work is the result of the experience of twenty- 
six years of hospital, and extensive private, practice, and it 
contains some excellent plates, mostly representing original 
preparations of the kidneys of " men and animals." Some 
parts of the book are mainly a reproduction of papers 
previously published in the Medical Journals, and in these we 
find an account of the original work done by the writer, with 
an exposition of such views as may be considered more par- 
ticularly his own. Among the latter may be mentioned his 
observations on the rods of Heidenhain in the kidneys of the 
rabbit, pig, dog, and man ; the rod-like structure he claims to 
have observed in some parts where it had not been previously 
noticed, for instance, in a portion of the descending tubules in 
the rabbit. While remarking that Heidenhain and Klein have 
nothing to suggest as to the intimate nature of these formations, 
he asserts his belief that his own researches will prove their 
true character, and he advances arguments which, as far as we 
have been al)le to apprehend them, do not seem very conclusive, 
in favour of the view that they constitute the living matter 
proper of the epithelium. In the next chapter he claims to 
have observed an endothelial layer between the base of the 
epithelial cells and the structureless membrane in the inflamed 
kidney in various forms of Bright's disease, and to have been 
the first to recognise its pathological significance. Another 
subject which has largely engaged his attention is that of 
urinary casts, and here he claims to have shown (for the first 
time) that the formation of every cast is accompanied by "the 
destruction of the epithelia lining the tubule, which lost or 
perished epithelia are invariabl}^ replaced by an endothelial 
investment which had not previously existed of the structure- 
less membrane." 

Besides the features above noticed, the reader will not find 
much that is new in the author's descriptions of the various 
forms of Bright's disease ; on the contrary, these are generally 
not so complete or exhaustive as .such an extensive subject 
demands. The book has the advantage of being recent, how- 
ever, and it contains a tolerably good account of the new tests 
for albumen which have not yet found their way into former 
works on the same subject. The same remark may be applied 
to the question of the treatment of Bright's disease, under 
which the author discusses the merits of some comparatively 
recent remedies, as jaborandi, convallaria, fuchsin, rosanilin, 
tannate of sodium, nitro-glycerine, euonymin, and other drugs. 
He believes he has obtained very good results in both acute 



202 Mevieivs. 

and chronic cases of the affection from repeated small doses 
of mercury. It is fair to confess that the chapters on treat- 
ment are among the best in the book, and that here the style 
of the author so much improves that he even becomes tolerably 
readable. 

On the whole we cannot speak very highly of the volume 
before us, and we are afraid we have not said much to 
commend it to the reader. Nevertheless, we remember an 
ingenious friend of ours who was never more strongly 
impelled to examine any new book or other work than when 
it was disparaged or severely criticised ; he then felt sure it 
contained something original and probably valuable, and on 
this principle the reader may be tempted to look for himself 
in the present instance. 



Lehrhuch der Physiologle, filr akademische Vorlesiingen und, 

zuni Selhsfstudlum, begriindet von RuD. Wagner, fortgefiihrt 

von Otto Funke, neu herausgegeben von Dr. A. Gruen- 

HAGEN. Siebente neu bearbeitete Auflage. Erste, zweite. 

und dritte Lieferungen. Hamburg und Leipzig : Verlag 

von Leopold Voss. 1884. 

[Manual of Physiology for Academic Lectures and Private 

Study, begun by RuD. Wagner, completed by Otto Funke, 

newly edited by Dr. A. Gruenhagen. Seventh edition, 1st, 

2nd, and 3rd parts.] 

Otto Funke's Lehrhuch is well known to all physiologists, and 

has a recognised place as a work of reference for specialists. 

We have found it an exceedingly satisfactory work to consult, 

as it gives a complete account of what is known in each 

department of the subject. So far as we have gathered from 

a survey of the parts of this new edition already issued, the 

work preserves its character as a full and trustworthy book of 

reference. It is surely an evidence of the estimation in which 

it is held that it is scarcely four years since the completion of 

the last edition, especially when we consider that the book 

appeals to a comparatively limited constituency. 

The three parts of the work which lie before us comprise 
Chap. I, Physiology of the Blood ; Chap. II, Physiology of 
Digestion ; Chap. Ill, Physiology of the Chyle and Lymph ; 
Chap. IV, Physiology of Respiration ; Chap. V, Physiology of 
the Excrcitions ; Cliap. VI, Survey of the Animal Economy. 
Each section is fully elaborated and illustrated by wood 
engravings in the text, chiefly of apparatus for physiological 
experiment. 



Revieivs. 203 

We observe that the author in this edition has adopted a 
reformed system ,of spelling, which we can hardly regard as an 
improvement. It seems to he the principle to cut off all 
superfluous letters, so that " Thier " is spelt " Tier," " Kentniss " 
has one s, " todteten " is toteten," &c. But the system is not 
fully carried out for we And "Thatsache" spelt as usual, 
" Aufschluss " with two ss, &c. We notice also that in case 
of double s, the author prints the first s in the old form 
resembling the letter f, and there is quite a perceptible 
addition to the difficulty of reading. It is many years since 
English printers gave up this sj^stem as putting an unnecessary 
strain on the eyes, the difference between the letters f and s 
being merely that of the cross stroke. There may be some 
principle in all this, but we fail to see how, for instance, Gerinnsel 
should retain its double n, or how Wasser should be spelt with 
an ordinary s, and grosser with the old form of the letter. 
These changes all savour of pedantry, and we would recom- 
mend the editor to recur to the more usual style which was 
that of the last edition under the same editor. 



A Practical Treatise on Disease in Children. By Eustace 
Smith, M.D., Physician to the East London Children's Hos- 
pital, &c. London : J. & A. Churchill. 1884. 

The appearance of this book constitutes a new feature, so far 
as we are aware, in medical publishing. A work by an 
English physician has been written for a New York firm — 
viz., for Messrs Wood & Co. ; it is apparently printed there, 
although Ijearing the name of Messrs J. & A. Churchill when 
issued in this country. This plan may at least serve to secure 
for the author some more substantial remuneration from the 
American sales than is commonly experienced by English 
medical authors. 

We can well believe that the author had, as he says in his 
preface, some hesitation in undertaking to write such a work. 
Dr. Eustace Smith's writings are, indeed, well known, and 
they have all been very favourably received ; but the writing of 
a complete treatise is a very diflerent thing from writing on 
special subjects. The execution of the present work seems to 
be good, and it is designed to meet the wants of the practitioner; 
these have been kept steadily in view, and the subjects are 
discussed chiefly from the clinical standpoint. The description 
of the symptoms, the diagnosis, and the treatment are, so far 
as we have gone into the book by way of reference, very well 



204 Revieivs. 

discussed ; and the reader may be referred with confidence to 
this book for an exposition of modern practice in tliis depart- 
ment of medicine. The pathology of the diseases is not wholly 
neglected, but this part of the subject is purposely curtailed. 
The writer, moreover, very wisely tries to keep in view that 
what is wanted is not a full treatise on the practice of 
medicine, but a guide to the peculiarities of disease occurring 
in the young when, as so often happens, the disease discussed 
may effect both young and old. The scope of this present 
work, consisting of over SOO pages, seems to us to meet exactly 
a want often expressed for a new book on the subject. The 
well known lectures of Dr. West, even after their careful 
revision, including much that is new in every way, necessarily 
bear the marks of being origimilly conceived and written many 
years ago ; at that time very different ideas of disease and 
treatment were current, and so they are less easily assimilated 
by the younger readers. The present volume forms an excel- 
lent companion to these lectures of Dr. West, and although it 
can scarcely take rank with the works of West, Rilliet and 
Barthez, and some others, it is no mere compilation, but bears 
the impress of an original mind and of a wide clinical ex- 
perience. We cordially recommend it, and anticipate for it an 
extensive sale in this country. 



The Alpine Winter Care, tuith Notes on Davos Platz, Wiesen, 
St. Moritz, and the Maloja. By A. Tucker Wise, M.D., &c. 
London: Bailliere, Tindall, & Cox. 1884. 

Those who desire information on the subject will not grudge 
the trouble of reading Dr. Wise's book. It is, unlike the usual 
productions of fact collectors, possessed of a literary style 
which is pleasant and often even elegant. There is an 
abundance of information in its pages ; but the reader is not 
oppressed by it, while he learns many things not dreamt of 
in his philosophy. It nmst not however be supposed that 
accurate detail is sacrificed to render the book readable. On 
the contrary', it contains tables and figures sufficient to arm a 
valetudinarian for a dinner party ; but he who wishes may 
learn results without the trouble of reading them. 

We have long found it difficult to assign to books like the 
present a fitting sphere of usefulness. They are a little more 
than guide books, and insomuch as they overstep the confines 
of the guide book they are medical. He who is seriously ill 
will choose his winter quarters abroad in accordance with the 



Reviews. 205 

views of his physician. For him the medical part of the 
book will have little interest. He who is not seriously ill will 
enjoy it, and it would be an interference with the liberty of the 
subject to object to his woi'rying his health with its assistance. 
Meteorology, in the widest acceptation of the term, is a harmless 
study, and with the societ)'' and surroundings of an Alpine 
hotel a pleasant occupation for the winter. Its amateur 
devotees are as safely incarcerated by the snow as we could 
wish them to be at home, and we who remain may eat our 
dinners without a vertiginous accompaniment of irritating 
decimals. It is interesting to hear how these health seekers 
do spend their winters — we know too much of how they spend 
their summers. 

There is one way in which popular treatises like the present 
tend to do good — they deal largely of sanitary measures— a 
subject upon which it is very desirable that the public should 
be enlightened. He who learns sanitation abroad will not dis- 
regard it when he comes home, and if his talk is objectionable 
to his fellows, his more silent surroundings are likely to be 
less so. 

Probably a great future is in store for the Winter Cure when 
we know more about it. Meanwhile we collect experience and 
play with meteorology. 



An Introduction to the Stiuhj of tlte Diseases of the Nervous 
System, being Lectures delivered in the University of Edin- 
burgh during the tercentenary year. By Thomas Grainger 
Stewart, M.D. Edinburgh : Bell & Bradfute. 1884. 

As a specimen of the regular instruction given by the Professor 
of the Practice of Physic to his class in the University of 
Edinburgh, these Lectures deserve every praise. They proceed 
on a good method in the desci'iption of the anatomical and 
physiological points to be borne in view by the student, and 
in the detailed description of nervous symptoms, and of the 
methods of investigating them at the bedside ; we find through- 
out an order and clearness likely to impress and benefit the 
hearer. We have, moreover, in this little book a wealth of 
illustration — no less than 98 illustrations in 220 pages of text. 
Some of these are very attractive, as the well known plates of 
the fundus of the eye from Liebreich's Atlas, seven of which 
are introduced ; there are eight diagrams to illustrate the field 
of vision in its relationship to colours, and also as contracted 
in disease. Several of Professor Hamilton's beautiful sections 
of the brain, .shown at the Faculty Lectures delivered by him 



20G Reviews. 

in Glasgow, are also introduced, and many other striking, and 
for the most part useful, illustrations, such as Ziemssen's motor 
points, portraits of hemi-atroph}^ of the face, wasting palsy, 
&c. One cannot avoid, however, having the feeling that with 
so much in these lectures that is admirable, we would like still 
more ; that the book, as it stands, is too elaborately got up for 
a mere sketch or introduction, and that more should follow in 
the way of a serious discussion of the diiferent forms of nervous 
disease. From Dr. Grainger Stewart's reputation and experi- 
ence, we are entitled to look for more substantial contributions 
to the subject, and if he could find time to publish a treatise 
containing the results of his observation in this interesting 
department, we feel sure, from the present sketch, that we 
would find much that is important. As it is, we can recom- 
mend the work to students and practitioners for what it 
professes to be — viz., an " introduction " to the subject. 



Fat and Blood : an Essay on the Treatment of certain Forms 
of Neurasthenia and Hysteria. By S. Weir Mitchell, 
M.D. Third Edition, Revised, with Additions. Phila- 
delphia : J. B. Lippincott & Co. 1884. 

It was in this book, under the title of " Fat and Blood," that 
Dr. Weir Mitchell first promulgated his treatment of nervous 
aifections by " Massage," of which so much has been heard of 
late. This method, although not new as regards the individual 
parts of the complex system recommended V)y him, was cer- 
tainly entitled to be considered as a novelty in treatment 
when these were co-ordinated as he described. Since then the 
advocacy of Dr. Playfair, in London, of this plan of treatment 
has made it widely known in this country. It is v/ell, there- 
fore, in this new edition, to have Dr. Weir Mitchell's detailed 
expression of opinion, with his later and more extended 
experience, from his own pen ; for this is really a new edition 
with substantial revision and additions as stated on the title- 
page. The great divisions of the plan of treatment are dealt 
with in separate chapters, under the headings of " Seclusion," 
" Rest," " Massage," " Electricity," and " Dietetics and Thera- 
peutics." There is also an interesting chapter on " Gain or 
Loss in Weight Clinically considered." The next chapter, 
" On the Selection of Cases for Treatment," leads up to the 
real difficulty ; for most physicians are now disposed to admit 
the value of the treatment for certain cases; and this difficulty 
as to selection applies likewise to the selection of those cases 



I 



Reviews. 207 

where part of the treatment might be carried out with more 
benefit than the whole. There is reason to fear that some 
women have been subjected to the whole round of treatment, 
with unswerving rigour, and have suffered much without ade- 
quate benefit, who would have done just as well, and some of 
them much better, with a more lenient form of the treatment 
modified to suit their special requirements. We can recom- 
mend this little book a.s a valuable contribution, from a man 
of great experience in nervous disease, towards the efficient 
treatment of a most troublesome and yet most important class 
of disorders. 



Diabetes Mellitiis. By Harvey J. Philpott. London : Samp- 
son Low, Marston, Searle, and Rivington. 1884. 

We believe that Ave should be in accord with the opinion of 
our medical contemporaries if we objected to this book on 
the ground of its dedication to a layman. The Bishop of 
Niagara, we are told, interested Mr. Philpott in the study of 
diabetes, and this essay is the outcome of that study. The 
danger of most popular treatises upon medical matters is the 
pleasing simplicity to which the subject is reduced. Mr. Phil- 
pott has certainly avoided this error. He has made no attempt 
to show that our information is as yet at all complete. He 
has rather endeavoured to claim for us the standpoint of care- 
ful and attentive Agnostics. To support this position he collects 
largely from most of the known literature, and if he fails to 
substantiate it, it is not from want of information. But it is 
not given to every one to be a good teacher, and the more 
crowded the facts are the greater the need of the teaching gift. 
It is not too much to say that Mr. Philpott's facts are hopelessly 
crowded. A plain narrative would have been much more 
intelligible, with the references to authorities in foot-notes. 
, Frequently quotations are very difficult to handle, and when, 
in addition, the sentences are faulty both in construction and 
grammar, chaos is not an unnatural result. Thanks to our 
previous information, we have been able to follow Mr. Phil- 
pott's meaning in most instances, but not without difficulty. 

We cannot commend the essay as either pleasant to read or 
eminently useful. We hope the Bishop of Niagara, or some 
other well wisher, will interest Mr. Philpott in the study of 
grammar and composition. It seems a pity that the results of 
aji extensive study should be lost for want of suitable expres- 
sion. 



208 Hospital Practice. 

Index-Catalogue of the Library of the Surgeon-General's 
Office, United States Army. Authors and Subjects. Vol. V. 
Flaccus — Hearth. Washington : Government Printing 
Office. 1884. 

Another large volume in this gigantic undertaking is now 
issued. The preface tells us that it contains 15,555 author 
titles, 8,069 book titles as subject titles, and 34,127 subject 
titles in journal articles. The whole volume contains over 
1,000 large 4to pages. 

So far as we have examined this mass of titles we are glad 
to find throughout the same care and accuracy which charac- 
terised the first volumes, and the printing continues, as before, 
a model of neatness and clearness. The great size of the 
medical library at Washington makes its Catalogue of much 
value wherever a library exists, and the cataloguing of the 
articles in medical journals, under subject-headings, constitutes 
its great and unique value in medical bibliography. Wlien 
completed, if carried out as it has been begun, we will no 
doubt be entitled to regard it as the most important contribu- 
tion America has made to medical literature, great as has been 
the value of many of the medical works issued in that country. 



REPORTS OF HOSPITAL AND PRIVATE 
PRACTICE. 



WESTERN INFIRMARY. 

Reports under the Supervision of JOHN LINDSAY STEVEN, M.D. 

From Dr. Joseph Coats's Ward. 

GOUT — SUB-ACUTE BRIGHT's DISEASE — UREMIC CONVULSIONS' 

— DEATH. — This case is recorded as showing chiefly a connec- 
tion between gout and Bright's disease. 

A. K., a plumber aged 53, was attacked three years ago 
with acute pain and swelling in the left great toe, which soon 
extended to the right. The pain was so severe that he could 
not stand. Attention having been directed to the toes the 
legs were observed to be swollen, and there was also swelling 
of the arms and face. The pain in the toes remained very 
acute for eight days, and the swelling was specially marked 



Wcfitern Infirmary. 209 

in them. At the same time liis urine was small in (quantity 
and the colour of port wine, and it was totally suppressed for 
two days. The pain in the toes subsided and the dropsy 
disappeared under medical treatment about three weeks from 
the onset of the attack, but from that time onwards the 
urine became excessive in (piantity, so that he had to get up 
three times during the night to pass urine amounting to one 
or two pints. This state of matters continued till the onset of 
the attack for which he was admitted. This attack began 
about the middle of December, with general oedema, which 
existed at the time of admission. The urine was found on 
admission to be scanty and high coloured, but of a specific 
gravity of 1012. It contained abundant albumen, and the 
microscope revealed granular and epithelial casts, leucocytes 
and red corpuscles, and crystals of uric acid. Physical 
examination revealed general oedema, but not to an excessive 
degree, pleural effusion at both bases, and distinct enlargement 
of the left ventricle of the heart. The blood corpuscles hav- 
ing been counted they were found greatly diminished, being- 
only about 48 per cent of the normal, the hfemoglobin being 
about 52 per cent. The manner of the patient was queer, and 
there was a certain dry pasty appearance of the skin, which 
made Dr. Coats suspect that uraemia might supervene. This 
did occur on the morning of the 1.5th of January in the form 
of a violent o-eneral convulsion which lasted about five min- 
utes. This was followed by acute delirium, amounting to 
mania at times, which lasted for twenty-four hours. During this 
attack and afterwards, the retina of the left eye was examined, 
and there were several patches of haemorrhage observed, with 
a general redness of the disc. By degrees the patient recovered 
consciousness, but was never fully intelligent, and on 2nd 
February he had a second convulsive seizure, followed by 
renewed unconsciousness, during which the respiratory move- 
ments presented long pauses with occasional sighing inspira- 
tions. After this he continued more or less stupid and 
semi-conscious and died on the 10th February. He had 
convulsions on the 3rd, 4th, and 7th, and again on the day of 
his death. During the latter part of his illness the oidema 
completely disappeared, and he emaciated rapidly. 

On pod-iiiorteno examination the condition of the kidneys 
was found to be scarcely typical of any one form of disease. 
There was marked shrinking of the cortical substance with 
a granular condition of the surface, but the organs were not 
as a whole reduced in size, weighing 6 oz. each. The pyra- 
midal substance showed marked chalky deposits, afterwards 

P Vol. XXIII. 



210 Hospital Practice. 

determined to be uric acid. Under the microscope there were 
the usual evidences of interstitial nephritis in the form of a 
marked infiltration of round cells, and new formation of con- 
nection tissue with sclerosis of the Malpighian tufts, but there 
was also considerable fatty degeneration of the renal epithelium 
extending to the pyramids as well as the cortex. The left 
ventricle of the heart was greatly enlarged, the septum bulging 
towards the right so as considerably to reduce the capacity of 
the right ventricle. The heart weighed 20 oz., the increase 
being entirely due to hypertrophy of the left ventricle. The 
brain presented very marked dilatation of the ventricles. 

Remarks. — The occurrence of pain in the great toes at the 
outset of the attack, and the presence of uric acid in the 
kidneys after death are sufficient indications of the gouty 
habit in this case. The fact that the patient was an 

illegitimate son of Lord indicates the source of the 

gouty tendency, which may have been confirmed by the 
occupation of the patient which led him to handle red lead 
frequently. The condition of the kidneys is not that of the 
typical gouty kidney, but rather of a combination of this with 
the large white kidney. The history of the case also points 
to a combination of chronic interstitial nephritis (fi'equent 
micturition, urine of low specific gravity, hypertrophy of left 
ventricle) with acute parenchymatous nephritis (general 
oedema, excessive albumen in urine, fatty and epithelial casts). 
The condition of the retina should have been examined before 
the convulsive seizure, but it was that generally of albuminuric 
retinitis, and indicated an advanced staffe of the disease. 



From Professor M'Call Anderson's Wards. 

Cases from the Cutaneous Wards. 
[Reported by Duncan Love, M.B. and CM., House Physician,] 

I. CASE OF CHRONIC ECZEMA TREATED BY VACCINATION. — T. J., 

aged 82, a shepherd, was admitted into Ward V of the Western 
Infirmary, suffering from a widely diffused eczematous eruption 
of about 17 years' standing. With the exception of occasional 
attacks of bronchitis since he was eight years old, he has usually 
enjoyed good health. The eruption has been subject to 
exacerbations and remissions, sometimes completely disappear- 
ing, with the exception of a little over the flexure behind 
the knees. On its first appearance it began on the calves 
of the legs and gradually spread. On admission it was pretty 
generally, distributed, worst, however, on the arms and legs, 



Western InJirTnary. 211 

the body never having been at any time so seriously affected 
as the limbs. The face was then free, although it had also at 
times suffered. The eruption was reddish in colour, with some 
infiltration of the skin, and a little n)oist at the knees, but 
dry elsewhere and slightly itchy. He stated that during an 
exacerbation any part of the surface might exude, tluit at these 
times the itchiness was usually worse, and that he then 
suffered from constipation. 

On 2J4h Hoveinber he M'as vaccinated, and from that time 
onwards there was a gradual improvement, till by 13th 
January, 1885, there was only some redness and infiltration of 
the skin behind the knees, especially the right, the situation 
in which it has always persisted, even when completely 
disappearing elsewhere. 

II. CASE OF FAVUS TREATED BY EPILATION AND MERCURIAL 

LOTION. — D. M., aged 6, was admitted to Ward V of the Western 
Infirmary, on loth February, 188-i. He presented a well 
marked example of favus, the whole hairy scalp being in- 
volved, and covered with aliundant thick j^ellow crusts. 

The boy's mother stated that the eruption had been present 
for two years, and she believed it was got by infection from a 
dog which, she said, had the " mange." He was evidently of a 
strumous habit, having great protrusion of the abdomen, and 
curving of the tibia, and there was a distinct history of a 
similar taint in other members of the family. 

On ;?Oth February the crusts were removed by linseed poul- 
tices, after which epilation was commenced and continued 
daily, the head being sponged with adotion of bichloride of 
mercury, 2 grs. to the ounce after each epilation. 

By the beginning of August there was so great an improve- 
ment that the regular daily epilation was discontinued, and 
only occasional hairs pulled out, if suspicious crusts formed 
around them. 

On 10th September he was removed to the Fever Hospital 
at Belvidere, having been attacked with typhoid fever during 
an epidemic which at that time broke out in the Infirmary. 

On 4^^'- October he returned to the Western Infirmary. No 
signs of the skin affection had reappeared ; but on account of 
the debility following on the fever, and also his strumous 
habit, it was decided to keep him for some months. 

He was dismissed l^^h February, 1885. During this latter 
period of residence the treatment for favus was never resumed, 
nor was there the least evidence of a return of the disease. 

III. CASE OF SYPHILIS TREATED BY INUNCTION WITH MER- 
CUROUS OLEATE. — H. Y., aged 23, an engineer, was admitted to 



212 Hospital Practice. 

Ward V of the Western Infirmary, on 18th November, 1884, 
complaining of an affection of the skin of about five months' 
duration. Previous to the onset of the present disease he had 
always enjoyed health. 

About six months ago he observed a small sore on the glans 
penis, which he believed to be syphilitic in character. The 
sore healed in three weeks, and in about a month from its 
disappearance an eruption began to come out, first appearing 
as two or three patches on the left wrist, two weeks after on 
the rio-ht w^rist, in three weeks on the leos, and a little later on 
the palms and soles. 

On admission there was found to be an eruption, occupying 
principally the sites mentioned. The palms and soles were 
almost entirely covered with it, showing a great thickening of 
the epidermis, the underlying surface being of a coppery-red 
colour, and the edg-es forming segments of circles. Elsewhere 
the eruption was most abundant at the wrists and ankles, 
appearing then in the form of rounded, slightly raised patches. 
The glands, in both groins, in the neck, and above the elbows 
were all enlarged. There was a reddened inflamed condition 
of the fauces, with superficial ulceration of the tonsils. 

On 1st December lie commenced rubbing in daily one 
drachm of " Shoemaker's mercurous oleate ointment." The 
eruption gradually disappeared, and on 81st December there 
were only stains left where it had been, the ulceration of the 
tonsils was healed up, and the glandular enlargements con- 
siderably diminished. 

Dr. Anderson is of opinion that the best method of intro- 
ducing mercury into the system is through the skin. He has 
long been in search of some application which would be equal 
in therapeutic action to the ordinary blue ointment, but 
have the advantagfe of beinsj cleanly. He has found this in 
" Shoemaker's white mercurous oleate ointment.' 

From Professor George Buchanan's Wards. 

case of fractured ribs — surgical emphysema — threatened 
SUFFOCATION — VENESECTION — RECOVERY. (Reported by W. 
F. Somerville, M.B., F.F.P.S.)— H. T., vet 62, storeman, 
was admitted on 29th January, 1885, to Professor George 
Buchanan's wards, sufl'ering from great pain on the right side 
of the chest, and considerable dyspnt^a. Patient a few hours 
before had been kneeling on the roof of a hoist, which was 
suddenly . made to rise, doubling him up and crushing him 
between it and the roof of the well. 



Med ico-Chii'urg leal Society. 213 

On admission it was found there was no injury to the spine, 
but that the 5th-8th ribs on right side were broken at the 
angles. There was marked surgical emphysema in front and 
at the back of the chest on the right side, and consequent 
dyspnoea. 

A flannel bandage was applied round the chest, and the 
patient propped up in bed. 

The following morning the dyspnoea was very markedly 
increased. The face was bluish purple, and suffocation was 
imminent. Dr. Buchanan accordingly opened the right ulnar 
vein, and fifteen ounces of blood were removed. The breath- 
ing was at once much relieved, but towards the afternoon the 
patient gradually became very weak. Some stimulation was 
employed, and in the evening he had completely rallied. Next 
morning all danger was past, and from that time he made a 
speedy recovery. 



MEETINGS OF SOCIETIES. 



MEDICO-CHIRURGICAL SOCIETY. 



Session 1884-85. 
Meeting IV. — 9th January, 1885. 

Dr. Hugh Thomson, Vice-President, in the Chair. 

HERMAPHRODITE, AGED 9, IN WHOM TWO TESTICLES WERE 
EXCISED FROM THE LABIA MAJORA. 

Professor George Bu(;hanan introduced the above case. 
Before giving particulars he referred to the unusual classifica- 
tion of hermaphrodites into spurious and true, of which latter 
class the present is an example. 

Christina , aged 9, was admitted to the Western Infir- 
mary in consequence of some pain and swelling in the reo-ion 
of the pudendum. On examination. Dr. Buchanan found in 
the right labium a small movable tumour connected to the 
inguinal region by a cord. A similar one was found on the 
left side. On the left the inguinal ring was as large as to 
admit the point of the little finger. 



214 Meetinys of Societies. 

Dr. Buchanan had some doubt as to the nature of the case, 
conceiving it possible that it might be a hernial sac containing 
an ovary on each side, or possibly a testicle in a patient, 
otherwise with the external parts of a female. 

The external parts were to all appearance the normal 
organs of a female — vagina, nymphse, clitoris, and hymen. So 
enisfmatical was the case that Dr. Leishman and Dr. Cleland, 
as well as members of the Infirmary staff, were consulted, 
without absolute certainty as to diagnosis, the leaning being 
to believe that the organs were ovaries in hernial sacs in the 
labia. 

But it was observed that on touching the front of the 
thigh the two little bodies were suddenly i-etracted up into 
the groin, and Dr. Buchanan concluded that that was evidence 
of the presence of a crem aster. 

In any case he decided to cut down on the tumours of the 
left side. If it proved to be an ovary it was in a very unsuit- 
able position, for at the period of menstruation it would give 
rise to extreme discomforts, lying as it did in the labium, so 
that unless it could be slipped into the abdomen through the 
large inguinal ring he would cut it off. If it proved to be a 
testicle he certainly would excise it, as it would be a singu- 
larly unfortunate thing for a person with all the outward 
appearance of a female to develop into a man as to internal 
ororans and feelings. 

Accordingly he cut down on the left labium, and removed a 
V)ody the size of a Spanish nut, which proved to be a testicle 
with all its parts and structure complete and normal. 

Subsequently he performed the same operation on the right 
side with the same result. 

The operation wounds healed rapidly. 

The patient was then brought in ; the singular conforma- 
tion of the organs was demonstrated to the members of the 
Society. 

The testicles dissected by Professor Cleland were also 
exhibited. 

Professor Cleland, after showing two engravings in Miiller's 
Archives of 1882 of similar cases, but neither of which had 
been operated on, proceeded to give a clear and concise account 
of the development of the organs of generation. Remarking 
that he did not altogether agree with the principle on which 
hermaphrodism had been classified, he traced the foetal 
generative system from its earliest appearance as an addition 
to the Wolffian body, but not springing from it, on to its 
completion in the male and female. 



( 



Medico-C/i Iriirgical Society. 215 

He referred to the observation of Banks, and to some wliich 
he himself had made on the early condition of the Mlillerian 
duct, and then on that portion of blastema which, appearing- at 
first outside the Wolffian body as a conical patch, sub-divides 
itself — the lower half transforming itself in the male into 
a testicle, the upper half in the male shrivelling away 
altogether; while in the female the upper half transforms 
itself into the ovary, and the lower half shrivels away. 

The Mlillerian duct, he showed, coalesces with its fellow of 
the opposite side, and the fusion of the two constitutes the 
uterus and vagina in the female, and the sinus pocularis in the 
male. 

In this case there was female arrest in growth of erectile 
organs and urethra, and partial female development of the 
Mlillerian duct forming a vagina, but failing to form a uterus, 
the cornua only being present ; and tliere was male develop- 
ment of the essential organs of reproduction into testicles. He 
fully agreed with Professor Buchanan in the propriety of the 
operation. 

After some remarks from Dr. Morton — 

Dr. Murdoch Cameron mentioned a case occurring in his 
own practice, though not delivered by himself, in which the 
child with an enlarged clitoris, like a penis, and enlarged 
labia, was at first mistaken for and registered as a boy. The 
subsequent rectification of the registry entry was a matter 
of some difficulty. An extraordinary French case had been 
recently recorded. The person, aged 40 at the time of the 
record, was an only child, registered as a girl, and educated at 
a girl's school. She menstruated at the age of l.S| years 
abundantly for two days and a half ; also 8 months later, but 
less abundantly, and again in 8 months, still in a decreasing 
quantity. The breasts developed; at the age of 15 and 16 
she associated with girls, though she experienced emotions 
when with boys, especiallj' one of them. At the age of iTg 
years she married. Connection was incomplete. In coition 
she presented a disposition like her husband, ending in a 
similar ejaculation. They lived together 12|~ years, when hei' 
husband died. After that time her ideas and feelings changed, 
and she manifested a very ardent attachment for women. She 
had many mistresses, and she stated that the connection was 
quite normal. She admitted that whilst her husband was 
alive she had frequently connection with women. When 
examined, the height, beard, body, strength, pelvis, feet, and 
hands were found to be masculine ; the knees had no tendency 
to converge ; the voice was feminine; the breasts moderately 



216 Meetings of Societies. 

large, with the nipple and areola as in women. There was a 
penis like that of a child of 12 years, which, during erection, 
was about twice the size. There was a vulvar opening, and 
two labia of normal appearance, the left being the largest. In 
the labia were two hard bodies like testicles, painful on pressure, 
and the normal size of testicles. The labia minora were absent. 
The vagina was a cul de sac from 8 to 4 centimetres in length, 
in which was recognised the urethral orifice. There was no 
trace of uterine neck, vulvo-vaginal glands, or hymen. An 
examination per rectum disclosed the absence of prostate and 
uterus. Ejaculation could be made into the vagina ; the 
sperm being normal in appeai-ance, and stiffened linen. On 
microscopic examination it was found that spermatozoa were 
absent: 

Mr. Maylard said — the statement as put by Dr. Buchanan, 
that this patient had externally the organs of the female, but 
internally those of the male was open to question. In addition 
to the testicles removed, ovaries might possibly exist. Professor 
Cleland had mentioned that both originated from the same 
reproductive blastema ; but further on in his address, he sug- 
gested the possibility of a separate origin of each, — the testicle 
coming from one part of the blastema, and the ovary from 
another. Although the latter assumption had still to be 
verified, it seemed a warrantable conclusion from the very 
slight anatomical resemblance which existed between the two 
organs. On examining the other parts of the sexual apparatus, 
it was always found that all parts of it developed to a certain 
stage, and then disappeared partially or completely or con- 
tinued to increase according to the sex of the future individual. 
Thus, in the case of Miiller's duct, the upper portion completely 
disappeared in the male, but became the Fallopian tube in the 
female ; while the lower part remained as the vesicula pros- 
tatica in the male, and in the female developed into the uterus 
and vagina. In both sexes the mammary glands developed up 
to a certain period, but later on in the one case almost entirely 
disappeared, but continued to enlai-ge in the others. Occasion- 
ally they developed in the male. It would, therefore, reasoning 
from analogy, seem probable that both ovaries and testes are 
originally developed, but that eventually one entirely disap- 
pears ; and, just as a mammary gland did sometimes exist in a 
male, or an enlarged clitoris in a female, so a testicle might 
become developed and sink into its normal (or abnormal) 
position in the labium of the female. One question, also, he 
would put in reference to diagnosis in this case. Dr. Buchanan 
accepted the cremasteric reflex as a positive proof of the 



1 



PaUioloijlvai 1 1 nil Cilulcal Society. 217 

existence of testicles. Now, was there any reason to suppose 
that in a case where ovaries had descended, the reflex should 
not take place as etfectually in the case of the ovary as in that 
of the testes ? 

Professor Cleland, in rcpl}' to the question just put, said — 
that he did not believe a reflex cremasteric movement would 
take place in a case of descended ovary, if such even occurred, 
but he did not believe that it ever did, and douV»ted the 
evidence in cases in which it had been asserted that the 
ovaries had descended out of the abdomen. 

Dr. Bacltanan said that some cases of hernia in the female 
were said to be ovarian, yet he had not heard of a case where 
that had been verified on dissection, but even if it occurred, 
that was quite different from the descent of an ovary after the 
manner of a testicle, which he doubted ever to have occurred; 
and he believed the cremasteric reflex to be an absolute proof 
of the existence of a testicle. 



GLASGOW PATHOLOGICAL AND CLINICAL SOCIETY. 



Session 1884-85. 
Meeting V. — 9th February, 18S6. 



The Vice-President, Dr. James Finlayson, in the Chair. 

Dr. James Dunlop showed two patients on whom the opera- 
tion for the RADICAL cure of hernia had been performed, and 
also a servant girl, whose elbow he had excised eight 
years ago. 

I. John M., set. 3 years, admitted 26th Nov., with double 
ingL'INAL hernia. According to the statement of the mother, 
the hernial tumours first presented themselves when the child 
was 18 months old, and after an attack of scarlet fever, which 
he had about that time. From the date of their first appear- 
ance till that of the operation the tumours were gradually 
increasing in size, and, though several difl'erent forms of truss 
were tried, their descent into the scrotum was not prevented. 
When the child was admitted into the Ptoyal Infirmary he wore 
no truss at all. The tumours were found to be of lai-o-e size 



218 Meetings of Societies. 

and readily reducible. When the contents were returned 
within the cavity of the abdomen, the rings on both sides were 
felt to be widely apart, permitting a finger to pass with ease 
into the inguinal canal. 

On the 12th December the child was put under the influence 
of chloroform, and an operation for the radical cure of hernia 
was performed. 

There was nothing in the operation new to the Society, for 
during the last two years many cases have been shown to the 
members of which the results were very satisfactory. It was 
mentioned by Dr. Dunlop that the profession in the West of 
Scotland were indebted somewhat to the President of the 
Pathological and Clinical Society (Professor George Buchanan) 
for making the steps of the operation familiarly known in 
Glasgow, and they were also greatly indebted to Dr. Banks, of 
Liverpool, for his valuable papers on the same subject. 

The hernia on the right side was operated upon first, and 
then that on the left side. While the hernia was still in the 
scrotum the sac was cut down upon and exposed. Thereafter 
the contents were returned within the abdominal cavity and 
retained by the finger of an assistant. The sac was somewhat 
isolated from its surroundings, then slit up, and a portion of it 
removed entirely. Two ribbon-like strips were then cut, and 
both were carefully and with caution, so as not injure them, 
pushed away up into the canal as high up as the internal ring. 
They almost completely filled up the canal. By means of 
sufiiciently stout silver wire the pillars of the ring were 
brought closely together and the silver wire cut ofi" short ; the 
divided ends rounded and turned in so as not to prick were 
left in the wound, where they still are. The wire, in passing 
through the pillars of the ring, also passed through the ribbon- 
like pieces of the sac pushed into the canal. At the external 
ring, then within the noose of wire, were included portions of 
the sac and the pillars. 

The left side was operated upon the same way, and a noose 
of silver wire left. The wounds were dressed antisepticall}'. 
A special padded splint, first used in the Western Infirmary, 
was employed. It is so shaped that while the entire body, 
with the exception of the upper limbs and head, is securel}" 
fastened, the dressings can be applied and the patient receive 
every attention needed during the period of cure without the 
removal of the splint. This splint greatly facilitates the 
dressing of the wounds, with the least possible disturbance of 
the parts. 

On the loth day after operation the boy was removed 



PaUiological (ind Clinical Socletij. 219 

from the splint, as the wounds were ahnost completely 
cicatrised. The temperature throuojiout never rose above 100 
— except on New Year's day, when it rose to 103°. The increase, 
however, was found not to he due to anything in the wounds, 
but to some derangement of the stomach from irregular eating 
of oranges on that day. 

At this date the parts are perfectly consolidated and firm. 
There has been no appearance of any threatening of a return 
of the hernia, and the wires have given no trouljle. 

Dr. Dunlop mentioned that he has had quite a number of 
successful cases in children, and in adults as well, and in some 
the pillars of the ring were brought closely together by means 
of strong catgut, specially prepared by I3r. Macewen. He 
found the catgut served the purpose well. Ample experience 
of the practical value of leaving the noose of the silver wire 
has 3'et to be obtained. 

II. Thos. F., a carter, aged 22 3'ears, was admitted on 
the 17th October last, into the Royal Infirmary, suffering 

from A STRANGULATED INGUINAL HERNIA ON THE RIGHT SIDE. 

Immediately after admission he was operated upon, the sac 
opened, the stricture, which was at the internal ring, was 
divided, and the protruding intestine was returned within the 
cavity of the abdomen. Thereafter, ribbon-like portions of 
the sac were pushed up into the canal, and they were then 
transfixed by the silver wire, which included within the noose 
the pillars of the ring. As the man had never worn a truss, 
the pillars were widely separated, and the canal itself very 
patent. An additional wire suture was introduced, and the 
walls of the canal, as well as the pillars of the ring, were 
closely approximated by the tightly drawn noose. With the 
exception of some irritation in the canal set up by the upper 
wire suture, the case made a good recovery. The result being 
so far very satisfactory. 

The patient has been wearing a truss. There is as yet no 
inconvenience being experienced by the pressure of tlie truss 
upon the silver wire. The two nooses seem to be still holding 
on in the canal and at the external opening. 

There has not been the slightest threatening of a re-descent 
of the hernia. The patient will, however, continue to wear a 
truss at his lal)orious occupation — that of a carter — and time 
will tell us what the result of the operation will be. 

Dr. Dunlop also showed a young woman, now a servant 
in a country hotel, whose left elbow joint he excised on 

ACCOUNT OF EXTENSIVE DISEASE OF THE JOINT EIGHT YEARS 



220 Meet i n /y.s of Soc iet leK. 

AGO. The young woman was healthy and robust, with red 
fleshy arms. The movements of the artificial joint were as free 
and apparently as perfect and satisfactory as in the sound 
limb. She felt no inconvenience whatever in her work, whether 
in washing or baking, or in lifting. It was mentioned that the 
disease of the joint had been extensive, the articular end of 
the humerus having been removed nearly on a line with the 
the upper end of the olecranon fossa. Of the bones in the 
forearm, the articular surface of the olecranon and coronoid 
processes, and that of the head of the radius, were removed. 
The incision in the soft tissues was the straight one by which 
the lateral fibres of the triceps are preserved. 

It was explained that the operation performed was based on 
the recommendations made in the year 1855 by Mr. Syme. 

Dr. Finlayson showed a tumour of the brain from the 
CASE of boy 10 YEARS OLD, who had died at the Children's 
Hospital lately. The case had been watched for many months. 
The head was enlarged, measuring at death 2 If inches in its 
greatest circumference ; the dura mater on the convexity was 
not adherent, and no clots were found in the sinuses. The 
pia mater on the convexity presented a dry and glazed 
appearance, and on touching the surface of the brain a distinct 
sense of fluctuation was experienced. A puncture made into 
the lateral ventricle ffave issue to 16 oz. of clear fluid, and 
probably an ounce or two might be lost. On removing the 
brain the tentorium was found closely adherent to the cere- 
bellum at the posterior part, just to the right of the middle 
line, so that a portion had to be left attached. The base of 
the brain presented extensive inflammatory exudation, appar- 
ently recent, extending from the optic commissure back to the 
pons, gluing together the fissures of Sjdvius, and presenting 
the granular appearance usually seen in tubercular meningitis. 
The central lobe of the cerebellum was completely destroyed 
by scrofulous deposits, parts of which were softened, and else- 
where the appearance resembled creamy pus. At the right 
lobe of the cerebellum, where part of the dura mater was 
adherent, a few nodules of scrofulous deposit of firm consist- 
ence, varying from the size of a pea to that of a bean, were 
found. At the right peduncle of the brain, just to the right 
of the pons, and extending towards the peduncle of the cere- 
bellum, there was a large cheesy-looking tumoui", which, on 
section, measured about an inch and a half in diameter in all 
directions. The cavity of the ventricles was enormously 
increased, and the foramen commune was very wide. The 



Fdthological and Clinical Sociefi/. 221 

veins coursing over the tioor of the ventricles were greatly 
distended. Covering the corpus striatum and optic thalamus 
on both sides was a veil, which was at first supposed to be some 
inflammatory material deposited from the fluid, but it had 
sufficient consistence to allow of its being lifted by the fingers 
from the floor of the ventricle as a definite structure. It 
presented the same appearanct' exactly in both ventricles. 
Subsequently it was thought to be perhaps the thickened 
ependyma, but unfortunately this point was not determined. 
The cortical portions of the brain were of course much thinned, 
but the tissue seemed sound, and no lesion was found in the 
other portions of the brain, which were sliced carefully in the 
search. The eyeballs were removed, and will be subsequently 
reported on by Dr. Thomas Reid. 

The history of the case went back for two years, before 
which the boy had been healthy. At that time he fell off a 
boy's shoulder and hurt his occiput. This was no doubt an 
important point in the case, but no mention was made of it till 
symptoms appeared two months later. On admission, how- 
ever, to the Children's Hospital, a small scar was detected in 
the situation indicated, just a little to the right of the middle 
line over the occiput. His first complaint was, two months 
after the fall, of pain in his head ; and he seems to have had 
some " fit of the nerves," with unconsciousness about this time. 
WTien admitted to the Royal Infirmary in May, 1883, he seems" 
to have had pains referred to the temple and to the nape of the 
neck, and some tenderness on percussion over the occiput was 
entered then in the report ; he was, at that time, bad at walk- 
ing, and he staggered and trailed his legs, but appeared quite 
intelligent although his head was thought to be alread}' 
enlarged. 

On admission to the Children's Hospital on 29th November, 
1883, his head appeared large, and measured 21 inches in its 
greatest circumference. The scar referred to at the occiput 
was not tender to pressure, nor did percussion of the skull 
reveal any tender spot. Both legs were very weak, and he 
could not .stand alone ; if helped, he dragged his legs and 
staggered. There was a tendency to rigidity of the legs. 
The mo.st prominent symptoms were headache and sickness. 
The vomiting was often severe, and the headache was aggra- 
vated thereby. The vision in the right eye was fair; he could 
read well, and was very fond of reading. The vision in the 
left was bad, and he could only see in certain directions. On 
ophthalmoscopic examination by Dr. Thomas Reid, there was 
seen to be exudation into, and compression of, the left disc ; 



'222 Meetings of Societies. 

the deficiency was found to be in the nasal, upper, and lower 
sep-ments of the retina. The hearing was defective on the 
rio-ht side, but this was thouo^ht by Dr. Barr to be due to some 
changes m the tympanic membrane. 

As the case went on the condition got worse; by the end of 
February, 1884, he could only perceive light, and the optic 
nerves showed advancing atrophy. Next n»onth the shakiness 
was found to have extended seriously to the upper limbs, and 
he lost control of the sphincters. In the course of June some 
improvement occurred. The sickness and vomiting were 
o-reatly diminished, and for a time he regained power over the 
sphincters, although this was again lost in a month or two. 
The rigidity noticed in the legs on admission had almost 
disappeared, but the patellar tendon reflex was exaggerated, 
and the ankle clonus quite pronounced. The skin, which had 
been bluish before, was improved in colour. The intelligence 
was perfect, and he answered questions very shrewdly, and 
remembered visitors and recognised their voices and footsteps 
remarkably well. 

At the beginning of December, 1884, a change for the 
worse appeared. His memory and temper had begun to fail 
a little, and now his temperature, hitherto nearly normal, rose 
to 101 '^ F. More vomiting and headache came on, and on 
16th December he had convulsions in the evening, frequently 
' repeated during two and a half hours. During the convul- 
sions both eyes were turned to the left, and the head also was 
turned in the same direction. There was nystagmus. The 
convulsions chiefly aflected the left side of the body, including 
the face, and during some of them the body was arched 
laterally, the concavity being on the left side. During these 
convulsions, although they were violent, the boy did not lose 
consciousness, and he even tried to answer questions addressed 
to him. Some of the convulsions extended to the right side 
of the body, but these were quite exceptional. Next day the 
left arm, which had been convulsed, was partiall}^ paralysed; 
but this weakness passed off" in a day or so, by which time he 
appeared to have recovered the condition he had prior to the 
convulsions. In a day or two more, however, he became 
notably drowsy, and this condition deepened into profound 
coma, and led up to death on 4th January, 1885. 

In reviewing the symptoms in the light of the post-inorfem 
examination. Dr. Finlayson said — that all along the diagnosis 
of tumour of the brain had been pretty plain, and before the 
skull was opened he had tried, as usual, to say what might be 
expected:, he considered the existence of a tumour almost 



Pathological and Clinical Society. 223 

certain, and its situation in the cerebellum very pro1)able, 
owing to the staggering gait and the early implication of the 
vision with optic neuritis going on to atrophy. The lateral 
deviation of the eyes, with nystagmus, and the deviation of 
the head, with unilateral convulsions, seemed to indicate the 
implication of the peduncle of the brain, and from the con- 
vulsions being on the left the inference was that the rio'ht 
side was atiected. That was all the leno-th he could a"o. He 
said if he had been asked his opinion as to the nature of the 
tumour or tumours presumed to exist, he would have said, 
before the inspection, that they were probably not tubercular; 
for nothing in the history or appearance of the boy pointed in 
this direction, and even at the dissection there was a thick 
layer of subcutaneous fat. No doubt, however, the tumours 
were of this nature, and the terminal syn)ptoms were evidently 
due to the development of tubercular meningitis. The earliest 
part of the disease was obviously in the central lobe of the 
cerebellum, and this probably had to do with the staggering 
and blindness. The tumour in the right crus cerebri, much 
less advanced, had to do, no doubt, with the terminal con- 
vulsions on the left side and the deviation of the head, &c. 
It may also have exercised pressure on the veins, and so 
favoured the accumulation of fluid in the ventricles. This 
accumulation was evidently of some duration, as judged by 
the graducxl enlargement of the head, but it was probably 
aggravated at the end by the extensive meningitis. 

Dr. Raid said that the point of interest in the ophthalmo- 
scopic examination was that the swelling exudation and 
prominence of the papillte were apparently all along 
unaccompanied by engorgement of the vessels or by haemor- 
rhages. The swelling, which extended a considerable distance 
around the nerve, reaching nearly as far as the macula, 
projected to -f 2 D in the central part, and it was remarkable 
that this did not prevent the outline of the disc from being seen 
distinctly through the exudation, which was not at all granulai' 
but rather smooth and polished in appearance. The vessels, in 
particular the arteries, were diminished in calibre, and were 
in some cases accompanied by whitish lines. In the course of 
some months the swelling receded, the usual process of 
absorption taking place, so that the nerve entrance came to be 
on a level with the surrounding retina ; with this the nerve 
became pale with a bluish tint, and the vessels became still 
more diminished in size. The loss of vision and the changes in 
the nerve seemed to go on together. 

On removal of the eyes from the body it was found that the 



224 Meetings of Societies. 

optic nerve sheath was thickened considerably, with a 
considerable space between it and the inner sheath, but without 
any evidence of bulbous dilatation at the entrance nerve to 
the eye. The optic nerve behind the eye was seen to be of 
normal size and consistence. On making a horizontal section 
of the eyeball (after being hardened for some time in 
chromic acid) through the centre of the optic nerve entrance, 
the congenital cup was found to be completely filled up and level 
with the retina, and coincided with the curve of that structure. 
A longitudinal section of the nerve under the microscope 
showed that the bundles of nerve fibres were almost completely 
replaced by a granular structure showing faint indications of 
nuclei presenting a condensed appearance, and the connective 
tissue lying between the bundles was increased in amount, 
which was well seen in a transverse section. Here and there 
well defined circular spaces were observed filled with a 
hyaline material, occasionally containing granular material 
and atrophied nuclei; these spaces sometimes appeared to be 
distinctly tubular in character, and were probably capillary 
blood-vessels. 

Dr. Ehen. Duncan said that he had at present under obser- 
vation a case very similar to that recorded by Dr. Finlayson, 
in which he had concluded that his patient was suffering from 
a tumour of the cerebellum with affection of the optic nerve. 
Dr. Reid had seen the case with him. The intelligence is 
perfect; there is apparent enlargement of the head; staggering 
crait with drao-Qfino' of the limbs: and attacks of sickness and 
vomiting. The symptoms m his patient now were similar to 
those in Dr. Finlayson's a year ago. 

Dr. Alex. Rohertson complimented Dr. Finlayson upon the 
care and accuracy with which he had worked out the case in 
all its bearings, and said that the symptoms generally were 
those of tumour of the cerebellum. The occurrence of one- 
sided convulsions with preservation of consciousness was of 
interest to him. He had recorded a case where there was a 
surface lesion in the motor area of one side of the brain. In it 
unilateral convulsions, which were followed by a temporary 
hemiplegia, occurred without loss of consciousness. He was 
aware of the occurrence of lateral deviation of the eyes in 
surface lesions of the motor area, and it was interesting to him 
to know that this might occur in cerebellar disease. 

Mr. MayJard suggested that the distension of the ventricles 
might be due to pressure of tumour on the iter a tertio ad 
quartum ventriculum, or on the foramen of Majendie, and 
that some of the symptoms might be due to this distension. 



Pathological and Clinical Society. 225 

Dr. Macewen, in reply to i\Ii'. Ma^-lard's observation, said — 
that he had seen cases of hydrocephalus drained by a puncture 
of the spinal cord. He had been surprised to hear it said that 
a surface lesion of the motor area was followed by a tem- 
porary hemiplegia. This was in opposition to the teaching of 
Charcot and Pitre, who say that hemiplegia from a surface 
lesion is always permanent. 

Dr. Robertson, referring to Dr. Macewen's remark, stated — 
that the lesion was a progressive one, and the occurrence of 
convulsions exhausting the nerve power for the time being 
might be followed by a temporary hemiplegia. 

Dr. Finla>/'SOiiHiiid that it accorded with his own experience 
that a lesion of the cortex may be followed by convulsions and 
hemiplegia which afterwards passes away. 

Dr. Love, of Gartnavel, showed two cases of osteoma of the 
BRAIN, and read the following notes — 

I. CASE of osteoma OF THE BRAIN. — W. D., aet. 55, admitted 
29th January, 1869 ; died 20th May, 1884. The patient was 
40 on admission, a toll-keeper, and died after a residence of 15 
years. On admission he was said to be epileptic, but had only 
become insane three days before admission. As is usual in 
parish cases, the history is very fragmentary, and nothing is 
known as to the history of the epileptic. When admitted he 
even then seems to have lieen far sunk into dementia, apathetic, 
memorj^ bad, and he expressed himself with difficulty. Fits 
continued to the end, and for many years he had several eveiy 
day, always single and very severe, and they were peculiar in 
so far as that at the commencement of the attack he would 
jump straight up into the air, to about the height of a man's 
head or shoulder, and then plunge down, alighting always on his 
head or face—" towering " like a bird when shot dead — so that 
his face bore many marks. After the fits he was often greatly 
excited and very dangerous, blindly attacking any one who 
came in his way, or beating the air when no one was within 
range. Latterly he was deeply demented, apathetic, drowsy and 
vacant in expression, and speechless. Death due to persistent 
and uncontrollable diarrhoea : but his bulk was preserved 
well, and he had no cachectic look. 

At the post-nwrtem the brain is said to have been of good con- 
sistence but anaemic, and the grey matter pale, the membranes 
(edematous, and ventricles .slightly dilated; vessels not notably 
atheromatous; but the chief inteix'st lay in the large bony mass 
which was discovered in the right occipital mass. The tumour 
was of bony hardness, not unlike the kernel of a walnut in 

No. 3. Q Vol. XXIII. 



226 Meetings of Societies. 

appearance and size, rough and spicular, and occupying a situa- 
tion deep in the white substance of the riglit occipital lobe 
behind the optic thalamus; no connection could be found either 
with the pia mater or with the lining of the ventricle. The 
brain substance around was softened. 

There was some recent pleurisy of right side without 
effusion, and at the apices of both lungs several small masses 
of caseous material. Heart soft but practically normal. In 
abdomen there was a large cancerous mass in the region of 
caecum, the csecal part of ascending colon, mesentery, and 
omentum being all worked up into the mass, but the appendix 
was free and the lumen of the bowel not much encroached 
on. 

A case not very unlike this I see in the Lancet (11th Oct., 
1884, page 65.5), and in the note it is said that the apparent 
rarity of such tumour is probably due to the infrequency of 
post-mortem examinations of the cranial cavities of senile indi- 
viduals ; but Ross (Diseases of Nervous System, vol. ii, page 
426), on the contrary, says such tumours are the rarest of all 
intra-cranial growths, althouo-h osseous formation of the dura 
mater after injuries are more common. This mass seems to be 
a true osteoma and not a cancer which has become calcified, 
as on microscopic examination abundance of lacunas and 
Haversian canals, characteristic of bone, are to be seen, although 
in the envelope a large quantity of probably calcareous material 
is to be seen. 

II. CASE OF OSTEOMA OF FALX CEREBRI. — W. M'C, aet. 28, 
admitted 5th February, 1881; died 19th September, 1884. 
This man was a grocer, insane for some four years ; mania 
ending in dementia — death from gangrene of the lung. At 
post-mortem diffuse gangrene of right lung was found ; the 
upper and middle lobes being one mass of foul smelling olive 
coloured material, with sundry small cavities in it. The 
cavities ragged ; bronchi full of putrid secretion and greatly 
reddened. Nothing specially noticed in the brain other than 
that the grey matter was rather reddened at points, and that 
the arrangement of the convolutions was very intricate, more 
especially on left side ; vessels not atheromatous; but along the 
free margin of the falx there were several plaques of bony 
substance, the largest rather larger than a shilling, and limpet 
shell like in shape, others flatter and growing in the substance 
of the membrane and covered by it. 



Medical Items. 227 

MEDICAL ITEMS. 

UXDER THE DIRECTION OF 

ALEX. N A P I E R, M.D. 

Orede's Method of Delivery of the Placenta. — Dr. W. 
H. Taylor, in the C'nic'uimdl Lancet and Clinic, says — The 
vigorous controversy over " Credo's method," which has 
recently involved so many obstetricians, has led Crede to 
restate in detail the manipulation he advises. As many 
American practitioners habitually adopt what they believe is 
his practice, I think it will be of interest to know exactly 
what that method is ; I therefore have translated his own 
description, giving the italics as found in the original, in the 
ArcJilv far Gijnakologie, xxiii, 2, 213: — 

. . . " The natural detachment of the placenta occurs 
within a few minutes after the birth of the child, and is 
recognised by a discharge of blood and by marked diminution 
of the size of the uterus, which may now be felt as a firm ball, 
the size of a child's head, between the umbilicus and pubes. 
As soon as any after-pains have occurred the midwife grasps 
the entire uterus through the al)dominal walls with both hands 
and presses it toward the concavity of the sacrum, she repeats 
this several times, if necessary, bat only during a pain, until 
the placenta is found at the vulva or is entirely expelled. If, 
from imperfect contraction of the uterus, or from tenderness 
of the abdominal walls, sufficient pressure to expel the placenta 
cannot be made, the attendant, guided by the umbilical cord, 
feels carefully in the vagina for the placenta ; if a portion is 
felt, then, with one hand, gentle traction is made on the 
umbilical cord, while with the other pressure is made over 
the uterus. If the point of insertion of the cord in the 
placenta cannot be reached, or if on gentle traction of the 
cord resistance is felt, no further effort to deliver the placenta 
in this way may be made until after several uterine contrac- 
tions have occurred, which may be increased by gentle 
rubbing and pressui'c. If the placenta is found low in the 
vagina, and readily reached by the linger, then the attendant 
shall pass the index and middle fingers as far upon the 
placenta as possible and press it gently downward and back- 
ward, while with the left hand the cord is made tense. When 
the placenta appears at the vulva the attendant shall grasp 
it with the fingers of one hand, and draw it gently upward 
and slowly turn it upon itself several times in order that the 



228 Medical Items. 

membranes may form a cord and not be torn away. When 
delivered the entire after-birth and any coagula are removed 
under the flexed leg of the woman and placed in an empty 
basin. 

" All strong tracti 071 on the umbilical cord, or attempts to 
extract the placenta when high up by introducing a part of 
the whole hand, or to aid the efforts at extraction by strain- 
ing, coughing, blowing in the hands, &c., are very dangerous 
and therefore dixe forbidden." — Canada Lancet. February, 1885. 

Experimental Researches on the Physiological Ac- 
tion of Veratria. MM. Pecholier and Redier, published in 
the Montpelier Medical (1888) a series of articles on this 
subject, and have since issued them in the form of a brochure 
(Paris, Asselin). From experiments on frogs, rabbits, and 
dogs, they conclude as follows : — 

Veratria has a local action on the skin and mucous mem- 
branes, irritating them, and this irritant action is increased 
when the derma is denuded. When taken into the stomach, 
it provokes great vomiting and copious stools, being a power- 
ful emetic and cathartic. It increases the secretion of nasal 
mucus and of saliva; but it does not determine diuresis, and 
but rarely diaphoresis. Its action on the circulation is of 
two kinds ; it causes primarily acceleration, due in great 
part to the efforts at vomiting, then a secondary slowing of 
the circulation, which may go on to collapse. Respiration is 
at first accelerated, then diminished in frequency, always 
embarrassed ; in animals under the influence of veratria there 
is a respiratory rhythm the opposite of that which occurs in 
(ledema of the glottis in man — i. e., inspii-ation is easy, while 
expiration is very difficult. The temperature is always dimin- 
ished. The action of veratria on the muscles is one of enfeeble- 
ment and paralysis ; but this action is preceded by a period of 
excitement variable in intensity and in duration, according to 
the dose which has been administered. This action, therefore, 
is the opposite of that of strychnia. Veratria acts also on the 
nervous system ; nervous mobility is not affected ; it is the 
contact of the veratrised blood \^'ith the muscular fibres, and 
not the action of veratria on the motor nerves, which deter- 
mines the primary excitement of the muscles. It has no effect 
on the spinal cord. To the topical effect there soon succeed 
analgesia and anaesthesia. It has no effect on the intelligence, 
and post-mortcTn examination reveals no lesion of the nerves 
or of the brain. — La France Afedicale. 3rd May, 1884. — 
G. S. M. 



Mf'dlcal Item.^. 229 

Boroglyceride in Ringworm of the Scalp. — Dr. 
ShoeiDaker states that instead of following the old procedure, 
he generally has the affected spots sponged with a weak 
alcoholic solution of thymol, borax, naphthol, or corrosive 
chloride of mercur}^ every day or two. To the surface thus 
cleansed, he immediately applies a 50 per cent solution of 
boroglyceride until the entire scalp seems saturated with it. 
The borax he believes to be one of the most efficacious anti- 
septic and antiparasitic agents, having at the same time a 
mild astringent action, and thus tending to allay the irritation 
and soothe the parts. The glycerine at the same time 
peneti'ates and carries the substance into the follicles to the 
parasite. Glycerine has a great affinity for water, and with- 
draws this from the tissues, thus depriving the fungus of one 
of its main elements of development. He cannot speak too 
highly of this simple application, from which alone he has 
observed rapid cures in some early cases of ringworm of the 
scalp. Boroglyceride solution is likewise devoid of any 
poisonous properties, and will be borne by even the most 
irritable scalp. This solution should be applied night and 
morning with a little sponge or mop, and must be well rubbed 
into follicles with the tips of the fingers. {Journal of Gutan- 
eous and Venereal Diseases, No. 7, Vol. 2.) — The Practitioner. 
December, 1884. 

Extirpation of the Right Kidney, with Recovery. — 
M. Boeckel reported to the Socie'te de Chiriirgie, on 4th June, 
1884, a case in which he had extirpated the right kidney. 
The patient, aged 41 years, had the uterus wholly excised for 
epithelioma of the cervix on 2Gth October, 188-3. She made a 
good recovery, but it was found that the urine escaped by the 
vagina owing to the right ureter having been divided. It was 
determined then to excise the right kidney, which was healthy, 
and this was done antiseptically on 27th November. The 
temperature was normal on .5th December, and cicatrisation 
complete on the 20th. On the day following the operation the 
urine measured about 87 oz., the next day about 25 oz., the 
smallest quantity passed. Thereafter it usually measured from 
38 oz. to 59 oz. Five months later the patient died from exten- 
sion of the cancerous disease to the abdominal glands. At the 
post-mortem examination there was found amyloid degenera- 
tion of the liver and of the remaining kidney. M. Verneuil 
pointed out that, M. Beckel having removed a healthy kidney, 
the odds were that the other kidney was healthy also. The 
remaining kidney secreted as much, or even more, urine than 



230 Medical Items. 

the two kidneys normally do ; and then a change took place in 
that kidney such that, if the patient had not died from cancer, 
she would have succumbed to amyloid disease. He looked 
upon this as of importance in its bearings on nephrectomy. — 
La France Medicale, 7th June, 1884. — G. S. M. 

Chapois : The Resolving Action of Calomel in very 
Minute Doses in the Treatment of Pneumonia. {Bull. 
Gen. de Therajx, 30th July, 1884.) 

The value of this means was suggested to the author by his 
experience with a case of pneumonia in a child twelve years 
of age, in which blisters, leeching, and other means of treat- 
ment had been unavailing. The eighteenth day of the disease 
had been reached and still resolution had not begun, nor had the 
fever abated. It then occurred to him to try the administra- 
tion of calomel, in doses of two milligrammes, every hour. 
Twenty-four hours later the patient was revisited, and was 
found to have a moist skin and a pulse of eighty per minute. 
The tongue was also moist and a sub-crepitant rale redux 
could be heard over the affected lung. Recovery followed 
without interruption. The same treatment was subsequently 
used by the author in many cases of pneumonia, at all ages, 
with complete satisfaction. The phenomena which usually 
follow the use of this agent for twenty-four to forty-eight 
hours are the following: Moisture of the skin, then of the 
tongue and the mouth ; next a diminution of body heat, and 
of the sense of oppression. After fifteen or twenty doses have 
been taken there may be a fluid evacuation of the bowels. 
The author does not claim that calomel is a specific for 
pneumonia, and in some cases other remedies will answer 
equally well. The advantage of the very small doses is that a 
different end is sought from that which is manifest when 
purgative doses of calomel are given, the effect of the latter 
being to prostrate the individual already greatly weakened. 
Given in such small doses absorption is favoured, the salivary 
glands, the liver, the intestinal, and other mucous glands, also 
the glands of the skin, are stimulated ; in a word, there is a 
general derivative action. — Archives of Pediatrics. 15th 
October, 1884. 

Poisoning by Tinned Food. — Dr. J. G. Johnson, in a paper 
read before the Medico-Legal Society of New York, comments 
on six cases of corrosive poisoning from eating " canned " 
tomatoes. The symptoms were intense gastric and intestinal 
disturbance, followed in the worst cases by epileptiform convul- 



Medical Items. 231 

sions and coma. Dr. Johnson's investigations led him to con- 
clude that the noxious substance was a combination of muriate 
of zinc and muriate of tin. From his remarks it appears that 
in some establishments the tops of preserving tins are soldered 
on, not with a resin amalgam, but with a saturated solution of 
zinc in muriatic acid. When this mixture is too freely applied 
it overflows into the tin and poisons its contents. The danger 
from this process has been so far recognised that in the State 
of Maryland there is a law prohibiting the use of "muriate of 
zinc flux." Dr. Johnson appends to his paper a few useful 
rules for the detection of unwholesome tinned meats by the 
appearance or handling of the tins. " If the lid of a tin has 
two solder holes instead of one (showing that the tin has been 
exhausted a second time to liberate decomposition gases), 
the contents are likely to be unwholesome. Press up the 
bottom of the can. If decomposition is commencing the tin 
will rattle the same as the bottom of the oiler of your sewing- 
machine does. If the goods are sound it will be solid, and 
there will be no rattle to the tin." Rust round the inside of 
the head of the tin produced by the eating away of the tin- 
plating by a corrosive substance should also be looked on as 
SiUHi)icions.-^(]\[edico-Legal Jourmd of New York, April, 1884.) 
The Practitioner. February, 1885. 

The New Cardiac Medicines, Convallaria and 
CafiPeine. — In a lecture on this subject, delivered at the 
Hopital Cochin, M. Dujardin-Beaumetz explained that by the 
term " new " he meant the medicines which have come into 
common use within the last five years in the treatment of 
cardiac diseases: convallaria, caffeine, and nitro-glycerine, the 
first two being applicable to the treatment of mitral diseases 
and acting as cardiac tonics, the third being more particularly 
directed to the treatment of diseases of the aoi'tic orifice and 
the aorta. This distinction, in a therapeutic sense, between 
mitral and aortic diseases, which was established in his Logons 
de Clinique The'rapeutique, seems now to be quite generally 
admitted ; and a« regards their cure, a marked difference 
should be estaVilished between them. In mitral diseases 
the object is to increase the force of the heart, and for this 
purpose the cardiac tonics are given. In order to better 
indicate the time when the cardiac tonics act most efficiently, 
the time over which the cardiac affection runs is divided 
into several periods, extending from the simple lesion to the 
period of cachexia. In the first period, to which Fernet and 
Huchard have given the name "eusystolic," the simple 



232 Medical Items. 

valvular lesion exists without alteration of the muscular 
structure; in this period hygienic care is alone applicable. In 
the second period, the " hypersystolic," cardiac hj'pertrophy 
compensates the troubles arising from the valvular lesions: 
and here, also, hygienic care is sufficient. In the third, the 
" hyposystolic" period, the compensation is ruptured and 
cardiac tonics are necessary. In the fourth, the "asystolic" 
period, the heart is in a state of fatty degeneration, or of 
cardioplegia, as Gubler said, and the most energetic of the 
cardiac tonics, with the exception perhaps of catfeine, are 
powerless. In aortic diseases our medication must be directed 
differently, and against the cerel)ral anaemia and the irritation 
of the nerve plexuses surrounding the aorta, which result 
from the aortic lesions; it is here that drugs which stimulate 
the cerebral circulation and diminish the nervous sensibility 
are applicable. It should be well understood that this 
distinction in treatment is applicable only to o"ne phase of 
cardiac diseases, and that in aortic diseases, insufficiency foi- 
example, there comes a time when on account of dilatation of 
the heart the mitral valve becomes insufficient, and both 
diseases must be treated at the same time. 

Most important among the cardiac tonics must be placed 
digitalis, then bromide of potassium, and to these are now 
added convallaria and cafieine. As regards its action on tlie 
human system, convallaria is known as one of the most 
powerful diuretics, Germain See placing it even before digitalis. 
It is, therefore, especially applicable to mitral diseases accom- 
panied by dropsy; but it should be stated that the diuretic 
action is decreased when there is albuminuria. It has, more- 
over, a calming effect upon the palpitations and disorders of 
the heart which do not properly belong to a valvular lesion, 
and if it be added tliat its preparations do not cause toxic 
phenomena in man, its principal advantages have been stated. 
Although it must be admitted that its action is at times very 
uncertain, it is a valuable cardiac tonic, for it may be used 
when we cannot use disfitalis, and it has no inconveniences. 
It is well known that digitalis cannot be used continuously, 
and it is during the intervals that convallaria may be em- 
ployed, taking care at the same time not to attribute all the 
diuretic effects which may result to the action of the latter, 
as the action of digitalis is kept up for some time after it is 
discontinued. The most useful preparation is the extract of 
the leaves and flowers, which may be prescribed in the follow- 
ing formula: — 



Medical Items. 28.S 

Extract of leaves and flowers of convallaria, 9 vss. 
Syrup of orange flowers. 
* Syrup of five roots, aa f.^iv. 

The syrup of Langlebert, who has specially studied the pre- 
parations of convallaria, may also be prescribed ; it contains 
grs. vij to the teaspoonful. Grs. xx or xxx of the extract ma}- 
be given during the day, or three or four teaspoonfuls of one 
or the other of these preparations. The tincture of the flowers 
may also be given in doses of f 5 ss-j per diem, but this pre- 
paration is not very certain. 

Catieine is one of the best cardiac tonics, and in the last 
staijes of a cardiac disease it is of more service than digitalis. 
Properly speaking, according to Tanret, there is neither an 
acetate, a valerianate, a lactate, nor a citrate of caffeine. The 
bromhydrate and the hydrochlorate are unstable. Tanret has, 
therefore, proposed a perfectly stable compound of caffeine and 
salicylate or benzoate of soda ; the first containing 45*8 per 
cent, the latter 61 per cent of caffeine. They are perfectly 
soluble, have no local irritant action, and may be used hypo- 
dermically, or per os : — 

Benzoate of soda, gr. xliv|, or 2-95 parts by weight ; 
Caffeine, gr. xxxviiss, or 2 '50 parts by weight ; 
Distilled water, f^ijss, or 6 '00 parts by weight. 
Each sixteen minims contain gr. iijf of cafTeine. 

Salicylate of soda, 9 i j gr. iss, or 3-10 parts by weight ; 
Caffeine, 3j or 4*00 parts, by weight ; 
Distilled water, foijss, or 6-00 parts by weight. 
Make a cold solution : ll\,xvi contain gr. vj of caffeine. 

Caffeine should be given hypodermicallj?^ only in exceptional 
cases, as when the patient cannot retain it when taken per os, 
or when it causes pain in the stomach. It is usually adminis- 
tered in the form of pills, granules, cachets, or in solution. A 
great advantage of caffeine is that its diuretic effects are seen 
even when the kidneys are altered, and it is in the last stage 
of heart disease that its effects seem to be best. — {Bull. Gen de 
Therap., 15th August, 1884; Amier. Jov^rn. Med. Sciences.) 
The Practitioner. February, 1885. 

The Treatment of Sycosis. — Dr. H. v. Hebra recom- 
mends the ujodified Wilkinson's ointment as an excellent 
application in sycosis. (The formula is — 

* The sirop des cinq racines, is an aperient or diuretic syrnp made with 
the dried roots of the wild celery (apium graveolens), fennel, parsley, 
asparagus, and common butcher's broom (ruscus aculeatus). 



234 Medical Itemis. 

R. Sulphur. Sublimat. 
01. Cadini aa J)\y. 
Saponis mollis. 
Adipis aa §j. 
Cretse praeparatae "^iiss. 

M. Ft. Ungt.) 

The hair on and around the affected part i.s cut short, and 
the scabs and crusts removed by the application of any simple 
ointment. After twenty-four hours the affected part is soaped, 
shaved, and thoroughly brushed with the Wilkinson's oint- 
ment. It is then covered with flannel and a bandage applied. 
The dressing is changed daily and the ointment washed ofi', 
and all the hairs which are surrounded by pustules are epi- 
lated and the pus squeezed out. This is continued so long as 
pustules form, but even in obstinate cases this ceases in about 
ten to fourteen days. In slighter cases there are no pustules 
after the first few days. The part is then shaved only when 
necessary for the proper application of the ointment. The 
tender scaling skin soon acquires, by the application of oxide 
of zinc ointment prepared with vaseline, its usual smoothness 
and appearance. — {Wien. inediz. Bldtter, 1884, No. 17, and 
Monatshefte fur praktische Dermatologie, vol. iii. No. 6.) The 
Practitioner. February, 1885. 

Leloir on Purpura. — In a contribution to the study of 
purpura (Annales de Derm, et de Syph., Jan., 1884), M. Leloir 
says that the pathogenesis of purpura is still surrounded by 
great obscurit}^ Few cases are recorded in which the vascular 
lesions have been ascertained. The author gives two cases in 
full detail, the first being a good example of vascular purpura, 
the lesions of the cutaneous vessels found, on p)ost-morte7)i 
examination, being an enormous dilatation of the vessels, and 
pronounced alterations of the vascular walls. In contrast with 
this case, in which the vascular origin appeared undeniable, he 
relates a second, in which no vascular lesion could be found, 
although there were numerous deep and extensive cutaneous 
haemorrhages. Here the cause evidently was an alteration of 
the blood. But in the first case, with appreciable lesions of 
the capillary vessels, the haemorrhages were small and limited ; 
while in the second, with vessels apparently intact, the haemor- 
rhages were extensive and situated in the middle region of the 
derma. Diapedesis does not seem sufficient to account for so 
pronounced haemorrhages. In some part there must be vas- 
cular rupture. One may suppose (with Hayem) that in 



Medical Jtevis. 285 

certain diseases the blood-plasma acfiuircs the property of 
provoking concretions b}^ precipitation, leading to nmltiple 
capillary embolisms, and thus causing certain purpura ha3mor- 
rhagia from hoemorrhagic infarcts. Certain forms of purpura 
of the lower extremities in cachectic subjects may be explained 
by stagnation of blood (often with (edema) and alteration of 
the blood ; intravascular fibrinous coagulation, formation of 
embolic clots, hiiemorrhagic infarcts, and cutaneous haemor- 
rhage. It is probable that many cases of purpura from 
alteration of the blood, perhaps even sometimes purpura a 
frlgore, purpura of rheumatism, ^c, arise from blood-dyscrasia 
leading to intravascular coagulation, clots by precipitation, or 
capillary embolisms. As to the nature of the alterations of 
the blood, many authors speak of the too great fluidity of the 
blood ; but the quantity of flbrine, far from being diminished, 
is frequently increased in purpura. The author would group 
the pathogenic causes of purpura thus : — 

A. Purpura from Modification of the Vessels. — 1. From 
perturbation of the capillary circulation, whatever its origin, 
leading to active or passive hyperoemia, producing haemorrhage 
by diapedesis or by vascular rupture. 2. Purpura telangiec- 
tasique of Cornil. 8. Purpura from primary alteration of the 
vascular walls, and consecutive rupture of these walls. 

B. Piirpubra from Modifications of the Blood. — 1. Too great 
fluidity of the blood ? (purpura by diapedesis). 2. From 
vascular obstructions determined by certain elements contained 
in the blood leading to the formation of thromboses and embo- 
lisms. This purpura might occur from simple diapedesis, it is 
more often hsemorrhagic infarction of the skin. a. From 
formation of clots in blood -dj'scrasiaj. h. From embolism 
formed by white corpuscles (leucocythaemia, &c.) c. From 
embolisms formed b}^ bacteria or micrococci (septic diseases, 
(fee.) d. from eml)olisms formed b}" altered blood elements. 

(J. Ptirpiira Nervosa. — In practice, however, many cases 
will not fall completely into either group ; very often the 
origin seems to be complex. Alteration of the blood, troubles 
of the circulation, vascular lesions, disturbances of innervation, 
all causes of cutaneous haemorrhage, may co-exist in the same 
subject. In all probabilitj', even dyscrasic purpura may be in 
certain cases the origin of secondary vascular lesions, of 
secondary endarteritis. And it is probable that alteration of 
the blood often modifles the action of the va,so-motor nervous 
apparatus, central oi- peripheral. In studying a case of 
purpura, it must not be forgotten, then, that its pathogenesis 
may be complex. The relative importance of the different 



236 Medical Items. 

causes must be sought ; and an attempt must be made to 
determine the relations between the determining primary or 
predisposing causes and the occasional or secondary causes. — 
The London Medical Record, loth August, 1884. 

Paraldehyde. — In a note read at the Societe de Biologic, 
M. Ch. Quinquand records his experience of paraldehyde in 
insomnia, administered in doses of from 50 co-rm. to 3 o-rni. in 
an aromatic vehicle. In some cases it provoked disgust ; in 
others it was readily taken. After a variable time it induced 
a calm sleep, but its activity diminished with repetition, for the 
dose has to be increased. It is a hypnotic, its chief indication 
being insomnia, and it is specially useful in those who have 
no gross organic lesion. It is an agent which may serve to 
diminish or prevent the morphia habit. 

To determine its physiological effects various experiments 
were tried, with the following results — 

1st. Paraldehyde acts primarily on the cerebral lobes ; and 
secondarily, according to the dose, on the medulla and on the 
spinal cord. 

2nd. It is not a true anaesthetic, although anaesthesia may 
be induced by large doses, which are dangerous. 

3rd. It may cause death, with arrest of respiration, the heart, 
continuing to beat. Given in small doses the arterial tension 
is modified but little in the way of diminution ; in a large 
dose the heart's action becomes less rapid. 

4th. Inhalation for an hour, either of equal parts of alcohol 
and of paraldehyde, or of paraldehyde alone, did not produce 
sleep. 

5th, The appearance of methaemoglobin is one of the effects 
of its action on the blood. 

6th. It causes a reduction of the temperature and a diminu- 
tion of the carbonic acid exhaled by the lungs. — La France 
Medicale, .Srd April, 1884.— G. S. M. 

[For other notes on paraldehyde, see the January and March 
numbers of this Journal for 1884.] 

Anrep and Poehl on Ptomaines. — Professors V. K. Anrep 
and A. V. Poehl, of St. Petersburg, sum up (Vestnik Sicdebnoi 
Meditziny ee Ohshtchestvennoi Hyghieny [The Herald of 
Forensic Medicine and Social Hygiene], 1884, vol. i, pp. 
1-29) an interesting article based on their own investigations 
and a full view of the literature, as follows : — 

1. Putrefaction, fermentation, and other as yet indefinable 



Medical Iteriiif. 287 

alterations of albuminous substances, ai'e accompanied by the 
generation of alkaloid-like bodies, ptomaines. 

2. The number of ptomaines is very great, and their chemical 
and poisonous properties are very different. 

8. There are known fixed and volatile, tluid and solid, 
amorphous and crystalline ptomaines. It is interesting to 
note that all fluid ptomaines, like all fluid vegetable alkaloids 
(with the exception of pilocarpine) do not contain oxygen. 

4. Almost all ptomaines change red litmus to blue, and 
syrup of violets to green. 

5. Like alkaloids, they form salts with acids, the formation 
proceeding without giving off water (again similarly to 
alkaloids and ammonia.) 

6. In regard to their solubility, ptomaines behave very 
differently ; some of them being soluble in water, others in 
ether, alcohol, benzine, chloroform, and amyl-alcohol. Ptomaine- 
salts are easily soluble in w^ater. 

7. Some ptomaines are tasteless and colourless ; others 
possess an intense bitter taste or aromatic sweetish odour ; 
and others ao-ain evolve a cadaveric odour, or one resembling; 
coniine or nicotine. When treated with acids, they sometines 
emit a pleasant floral odour. 

8. Ptomaines obtained from rye-meal which has been sub- 
jected to fermentation, give the same reactions as the ptomaines 
of any other extractions. These reactions are as follows :— 
((() A solution of iodide of potassium with bin iodide of 
mercury produces a whitish precipitate in a ptomaine solution 
slightly acidulated with hydrochloric acid. Twenty-four hours 
later, microscopic examination detects that the precipitate 
consists of minute prismatic crystals, (b) A solution of iodide 
i)f potassium, with iodide being added to an acidulated 
ptomaine solution, produces either a flocculent or a finely 
granular red-brown precipitate, which is insoluble in diluted 
hydrochloric acid, (c) A solution of phospho-molybdenate of 
soda gives a yellowish amorphous precipitate which is insoluble 
in diluted nitric acid, but on the addition of liquor ammonia? 
in excess, at first takes a l)lue-green colour and afterwards 
dissolves, giving either a bright blue or a green solution. The 
blue colour is mostly observed during the first stages of putrid 
decomposition. The original precipitate produced by phospho- 
molybdenate of soda, on being heated, assumes a green colour, 
without any addition of anmionia. (d) Phospho-wolframic 
acid . (prepared after Scheibler's method) gives whitish or 
greenish precipitates which are insoluble in diluted sulphuric 
and hydrochloric acids, but easily soluble in annnonia. 



238 Medical Ite7)is. 

{r) A solution of tannic acid gives a Avhite precipitate ; the 
latter does not appear if tartaric acid be prcseiit. ((/) A 
solution of iodide of potassium with iodide of bismuth in 
presence of diluted sulphuric acid, gives a yellowish precipitate, 
part of which passes into solution on heating, and reappears 
again on evolving. (Jl) A solution of iodide of potassium with 
iodide of cadmium sometimes produces precipitates which are 
soluble in the excess of the reagent, and which, by degrees, 
assume a crystalline structure. This reagent precipitates the 
products of the first stages of putrefaction ; later on in the 
course of the latter, there appear some products which are not 
precipitated by iodides of potassium and cadmium. (^) In 
some cases, a solution of corrosive sublimate gives precipitates 
which gradually take a crystalline structure ; in otlier cases, 
however, ptomaines are quite indifferent to this reagent. 
{j) A solution of chloride of platinum gives, with some of 
the ptomaines, precipitates which are usually crj^stalline and 
soluble in hydrochloric acid, and consist of a double salt 
(chloride of platinum plus chloride of ptomaine). Similar 
double salts are given by chlorides of gold and zinc. 

9. Ptomaines are optically inactive bodies. 

10. The colour-reactions of ptomaines ai'e as various as those 
of vegetable alkaloids. 

11. In the course of a forensic chemical examination, it is 
advisable to discard the use of sulphuric acid, and to use 
tartaric acid. The further treatment is to be performed after 
Dragendorf}"s method. — The London Medical Record. 15th 
August, 1884. 

Flitner on the Thermonietry of the ear in a Physio- 
logical and Pathological Aspect. — Dr. Bogdan Flitner 
{St. Petershihrg; Tnaugaral Dissertation, 1882) has made 100 
measurements of the temperature in the meatus in healthy 
subjects, and 114 in the patients suffering from various acute 
and chronic affections of the ear. The measurements were 
taken by means of a special thermometer invented by Dr. R. 
R. Wreden. 

[A description of this very convenient little instrument may 
be found in the St. Petershvbrg Medic. Zeitschr., November, 
1879. It is prepared by Mr. Reinhardt in St. Petersburg, at 
the price of 8 rouljles.] 

The author found that the average temperature in the 
meatus in healthy persons was 36*8° C, the averages for the 
axilla and rectum being at the same time equal to 37'5° C, 
and 37'8° C The results of the measurements in the cases of 



Medical Items. 239 

ear-disease (otitis media purulenta, otitis media catarrhalis, 
myringitis, otitis externa, and otitis interna) are given as 
follows. 1. The ditlerence between local and general tem- 
perature, which, under normal conditions, is equal to 1'0° C, 
oscillates in all acute ear-aftections between 0"3° and 0'4°, and 
in all chronic, between 0-3° and 0"5°. That is, in cases of in- 
flammation of the ear this difference is diminished more than 
half a degree (Cent.) comparatively with the standard. 2. In 
cases of inflammatory processes in the middle and external ear, 
the temperature of the diseased ear rises above the normal in 
acute forms from 1-0° to 1-2° C, and in chronic Oo° to 0"5°, 

3. In inflammations of the internal ear the temperature of the 
diseased organ rises in acute cases 2'0° C, and in chronic 0"7°. 

4. In acute inflammations of the middle and external ear, the 
rectal temperature rises 0-4° to 07° C; in those of the internal 
ear, 1*6° C. 5. In chronic ear-inflammations, the rectal tem- 
perature remains at the standard, or even falls below it. 
G. In acute ear-diseases, the temperature of the healthy ear 
rises from 0*6° to 1'1° C. above the standard; and in chronic, 
from 0'2° to 0-4°. 7. In affections of the internal ear the dif- 
ference between the temperature of the diseased organ and 
that of the intact is less (being only 0*2°) than in aflections of 
the external and middle ear (where it is equal to 0"3° to 0'4°.) 
The general conclusions as summarised by Dr. Flitner are these. 

1. Daily measurements of the temperature in the course of 
inflammations of the ear show that the temperature of the 
latter stands in a constant regular connection with the general 
temperature of the body. Therefore, in ear-affections, the 
local measurements not only may be substituted for, but even 
must be preferred to, measurements of the temperature in the 
rectum and axilla. 

2. The same may be asserted in regard to ear-affections 
complicated with pneumonia, erysipelas, and other diseases. 

3. In cases of ear-affections complicated with morbid pro- 
cesses in the cranial cavity, or even on the surface of the skull 
(caries, phlebitis of the sinuses, erysipelas) the temperature in 
the meatus sometimes stands higher than in the rectum. 
Hence, the measurements in the ear-canal give us a clearer 
indication as to the course of morbid process in the head than 
the rectal measurements, and are preferable to the latter 
beyond any comparison. — The London Medical Record. 15th 
August, 1884. 



240 Books, c&c, Received. 



Books, Pamphlets, (jfc, Received. 

Saint Thomas's Hospital Reports. New Series. Edited by Dr 
Seymour J. Sharkey and Mr. Francis Mason. Vol. XIII. 
London : J. & A. Churchill. 1884. 
The International Encyclopedia of Surgery : a Systematic Treatise 
on the Theory and Practice of Surgery by authors of various 
nations. Edited by John Ashhurst, Jun., M.D. Illustrated 
with chrorao-lithographs and woodcuts. In six vols. Vol. V. 
London : Macmillan & Co. 1885. 
Contributions to the Topographical and Sectional Anatomy of the 
Female Pelvis. By D. Berry Hart, M.D. Edinburgh and 
London. W. k A. K. Johnstone. 1885. 
On Renal and Urinary Affections. By W. Howship Dickinson, 
M.D. In three parts. Part III. Miscellaneous Afiections of 
the Kidneys and Urine. London : Longmans, Green & Co. 
1885. 
Practical Manual of Diseases of Women and Uterine Therapeutics. 
By H. Macnaughton Jones, M.D. Second edition. London: 
Bailliere, Tindall & Cox. 1885. 
Aids to the Analysis of Food and Drugs. By H. Aubrey Husband. 

M.B., CM. London : Bailliere, Tindall & Cox. 1885. ■ 
Arnials of Surgery : a Monthly Review of Surgical Science and 
Practice. Edited by L. S. Pilcher, M.D., Brooklyn, and C. B. 
Keetley, F.R.C.S., London. London : Bailliere, Tindall & Cox. 
St. Louis : J. H. Chambers & Co. Vol. I, No. 7. January, 
1885. 
Lehrbuch der Physiologie fiir akademische Vorlesungen und zum 
Selbststudium. Wagner, Otto Funke, Gruenhagen. Siebente 
Auflage. Vierte Lieferung. Hamburg : Leopold Voss. 1885. 
The Curability and Treatment of Pulmonary Phthisis. By S. 
Jaccoud. Translated and edited by Montague Lubbock, M.D. 
London : Kegan Paul, Trench k Co. 1885.' 
Die Krankheiten der Frauen, Aerzten und Studirenden geschildert, 
von Dr. Heinrich Fritsch, zweite umgearbeitete und vermehrte 
Auflage. Mit 164 Abbildungen in Holzschnitt. Braunschweig. 
Verlag von Friedrich Wreden. 1884. 
The Care of Infants : a Manual for Mothers and Nurses. By Sophia 

Jex-Blake, M.D. London : Macmillan k Co. 1884. 
The Health Condition of Southport, &c., &c. By Strethill H. 

Wright, M.D. London: John Hey wood. 1885. 
Nature's Hygiene : a Systematic Manual of Natural Hygiene, con- 
taining also an account of the Chemistry and Hygiene of the 
Eucalyptus and the Pine. By C. T. Kingzett, F.C.S. Second 
edition. London : Bailliere, Tindall k Cox. 1884. 



THE 



GLASGOW MEDICAL JOURNAL. 



No. IV. April, 1885. 



ORIGINAL ARTICLES. 



CASE OF UTERO-OVARIAN AMPUTATION FOR UTER- 
INE FIBROID, COMBINED WITH PREGNANCY. 

By ALEXANDER PATTERSON, M.D., 

Surgeon to the Wfestem Infirmary. 

(Read before the O'lasr/ow Soutliei'ii Medical Society/, Fehruary^ 1885.) 

( With a Photo;jraph.) 

Mrs. M., aged 30, of medium height and well formed, has been 
married for nine years, and hitherto has had no familj-. 
Menstruation has been always regular, until the last few 
months, when there was entire cessation of tlie menstrual 
flow. The mammae show no signs of pregnancy. For some 
\'ears back the discharge had lasted for a longer period, 
and was more profuse than in earlier years. Patient at 
present is pale, and presents an anxious and rather careworn 
aspect. Dating from a few months after marriage, Mrs. M. 
has been subject to what she understood as displacement of 
the womb, for which she was treated for years. Accidentally, 
about the second week in August, 1884, a tumour, hard, 
smooth, round, and painless, about the size of a large plum was 
<liscovered on the left side of the abdomen, in the iliac region. 

For some time previous to this discovery, back pain had 
Iseen complained of. No appreciable increase in bulk of 
tumour took place until 10th September, 1884, when she was 
suddenly seized with very severe pain, extending over the 
whole abdomen, 'pain tvhick was neither increased nor relieved 
by j^ressure, and which was immediately followed by a rapid 
increase in the size of the growth. The family attendant 

No. 4. R Vol. XXIII. 



242 Dr. Patterson — Case of Utero-Ovarian Amputation 

ordered a sedative liniment for the relief of this pain, and 
with temporary benefit. The pain lasted for ten or twelve 
days, and during the last two days of this period it carae in 
severe spasms, when it left at once, as suddenly as it appeared. 
Soon afterwards it returned, and came and went with great 
violence in the back and down the posterior and outer aspect 
of both inferior extremities, more particularly in the left. 
There was entire absence of rigor in connection 'ivith the pain. 
From the exceptional nature of this case, it was only to have 
been expected that regarding it difl^'erent opinions were enter- 
tained and expressed. 

On the 22nd September a consultant specially qualified to 
give an opinion in such a case was called in, and his diagnosis 
was that there was a " blood tumour " in Douglas' space, and 
the impression left on the mind of the lady's husband was 
that this "blood tumour" would burst and cure itself. As 
matters were now wearing a serious aspect a most eminent 
surgeon was called in consultation, who gave his opinion, in 
very decided terms, that the case was one of uterine fibroid, 
so firmly adherent in the pelvis that it could not be removed, 
and that any operative interference would only hasten the 
inevitably fatal result. I was called in on the 2nd of December, 
and made out the case to be one of uterine fibroid, probably 
jammed in the pelvis, and hazarded the opinion that it might 
be removed and the patient recover. Mr. and Mrs. M. at once 
agreed to submit to whatever might be deemed necessary. 

In left iliac fossa, close over pelvic brim, the tumour is 
most readily encountered, as here it rises most prominently 
from the pelvis ; from this situation it can be traced across 
the lower part of abdomen, getting gradually to a lower level. 
As you approach the right side the growth is firm to the 
touch, elastic, nodular, and painless on pressure ; examination 
per vaginam tells us that the pelvis is filled by the same mass; 
that the vagina is roofed across, and that the inferior surface 
of the growth is nodulated, and the uterus completely fixed. 
Wishing to have my opinion, if possible, sustained, prior to 
undertaking such a hazardous work, permission was asked, 
and at once granted, to call in as adviser a medical friend who 
is very familiar with such matters. After a very prolonged 
and careful examination he gave it as his opinion, that it was 
a case of ovarian disease, probably double, and that seeing 
patient's state, in either case, an operation ought to be per- 
formed at once. The last consultant endeavoured to introduce 
the uterine sound, but could insert it only one inch and a half. 
The reason of this was discovered at the operation, which was 



I 



For Uterine Fibroid, (\)inhinecl ivith Pregnancy. 243 

performed on the 11th of December, 1884, Drs. W. L. Reid, 
James Chahners, Macartney, and Downie being present. Dr. 
Reid gave me his most vahiable assistance, whilst chloroform 
was administered by Dr. Macartney. 

The operation was commenced by making an incision two 
or three inches in length, afterwards increased to eight inches, 
in the middle line, between pubes and umbilicus, and on 
dividing the peritoneum the nature of the tumour became 
evident at once. The mass was greyish in appearance, 
irregular on the surface, firmly elastic to the touch, and was 
found to be doubled back on itself into Douglas' space and 
jammed there. By insinuating one hand in the ol jliquf diameter 
in front, and the other behind, the mass was with considerable 
difficulty dragged up out of the pelvis. Fortunately there 
were no adhesions. Dr. Reid having the tumour well elevated, 
thus bringing into view the cervix uteri which formed its 
pedicle, I passed round it, about three quarters of an inch from 
the OS externum, a piece of gold wire, twisting it tightly, but 
with the strain it yielded and broke. A strong straight needle, 
with an eye in the point, was passed through the pedicle, 
then threaded with stout catgut carbolised, drawn back, the 
ligature cut, and each lateral half of the pedicle surrounded 
and firmly tied ; immediately below this, nearer to the os, a 
second gut ligature encircled the neck, was tightly tied, the 
ends cut short, the tumour removed, and the stump dropped 
back into the cavity. Previous to the application of the 
ligatures, a metallic catheter was passed into the bladder for 
the purpose of defining accurately its upper border. Patient 
lost no blood, no ligatures having been iised with the exception 
of those on the pedicle. The wound was stitched with deep 
and superficial sutures of prepared silk, and a morphia 
suppository introduced. The operation lasted forty-five 
minutes. There was of course very considerable shock, 
necessitating the free use of brandy. Severe pain was com- 
plained of, which in turn was combated with morphia. Early 
in the morning of the 14th of December I got a hurried 
message from the nurse, stating that patient was extremely 
faint, and I dreaded that our ligatures might have slipped and 
that we should have to deal with internal ha3morrhage; 
however, on arrival at patient's residence, I was much gratified . 
to find that the faintness had passed off, and from patient's 
look, was satisfied that bleeding had not been the cause of the 
faintish attack. Nurse had wisely given a tablespoonful of 
Vjrandy every half hour during the turn. From the time of 
operation until the evening of the 18th, patient had nothing 



244 Dr. Pattersox — Case of Utero-Ovarlan Ampvbtatlon 

except brandy and ice water and potass water ; from the 13th 
to the 19th the diet consisted solely of milk and ice water. 
On the 19th, eight days after the operation, the bowels moved 
spontaneously six times, when patient was put on boiled milk 
and toast, and a single dose of morphia was administered. On 
the 18th, one week after date of operation, wound was dressed 
for the first time, under the eucalyptus spray (as the opera- 
tion had been so performed), when all was found in a satis- 
factory state. The catheter was used only twice, the lady being 
able, and preferring to pass her urine without instrumental aid. 
The highest temperature recorded was on the morning of the 
14th, when it reached 101-4" ; it kept steadily about 99° or 100°, 
and the pulse never rose above 110. On the 22nd December, 
eleven days after operation, the temperature was normal, and 
pulse 84. From this date nurse ceased to keep a journal as 
Mrs. M. was practically well. There was no vomiting from 
first to last in connection with the removal of the tumour. 
Mrs. M. was a capital patient ; two days prior to operating, 
she said that if I risked the operation she knew that she 
would recover, and certainly the idea helped both surgeon 
and patient. She maintained her calm, cheerful manner all 
through, which doubtless contributed much to her excellent 
recovery. A four months' foetus was found in the uterus. 

In this book which I show you, entitled Arcana Micro- 
cosnii ; or, The Hid Secrets of Mans Body Discovered, <tc., by 
Alex. Ross, and published in London in 1658, is one of the 
earliest references to removal of the uterus. At page 79, he 
says — " As a man can live without testicles, so can a woman 
without the matrix, these members being given by nature not 
for the conversation of the individuals, but for continuation of 
the species ; therefore, Zacutus, who was born in 1575 and 
died in 1642, speaks of a woman who lived thirty years after 
her matrix was cut out ; which, by a fall that she had from a 
high tree, had slipt out of its place and could never again be 
replaced." 

Dr. Godson, in comiection with the very valuable tables 
published by him in the British Medical Journal, January 
1884, and January 1885, states that — " The first to arrive at 
the conclusion that recovery might be expected to follow the 
removal of the gravid uterus with its contents, was Dr. Joseph 
Cavallini, who, in 1768, published in Florence a paper entitled 
" Medico-Chirurgical Experiments on the Successful Excision 
of the Uterus in Certain Animals," &c. He ends by saying — 
"All which things having been duly weighed, I do not doubt that 
the uterus is not at all necessary to life ; but, whether it may 



For Uterine Fibroid, Combined tvifh Pregaancij. 24to 

be plucked out with impunity from the liuman body we can- 
not be certain without a further series of experiments of this 
kind, which perhaps a more fortunate generation will obtain." 

Those experiments were repeated by various surgeons at 
different times; but, in 18G9, the gravid uterus was for the 
first time removed from a living woman by Dr. Horatio Storer, 
of Boston, U.S., as the only means of arresting hiiemorrhage, 
during C;i3sarian section in a tibro-cystic uterus, the patient 
dying in sixty-eight hours. 

The first really planned operation for the removal of a 
uterus pregnant at the full time was performed by Professor 
Porro, on the 21st May, 1876, and in this case the lives of both 
mother and child were saved, so that Porro's operation consists 
in the performance of the Cffisarian section with the removal 
of the uterus to complete the operation. According to Dr. 
Godson's table, this operation has now been performed 152 
times, with 66 recoveries and 86 deaths, and there have been, 
I think, three cases since, all terminating fatally. 

Utero-ovarian amputation during pregnancy, but before the 
foetus is viable, of which Mrs. M.'s is an example, has been 
performed four times in England. First in 1877, by Dr. 
Robert Barnes, London, in which patient died in thirty hours ; 
second, by Dr. Knowsley Thornton in 1882, recovery ; third, 
by Dr. T. Savage, Rugby, with recovery ; and fourth, by D]-. 
T. Savage, Birmingham, also with a successful result. 

Three times in Germany — first by Professor Kaltenbach, of 
Freiburg, in 1880, with success; second, by Prof essor Schr(eder, 
of Berlin, in 1883, successful ; and again by the same gentle- 
man in 188-i, in which also recovery took place. In Belgium 
once, by Professor Wassiege, of Liege, in 1880, which proved 
fatal. Once in the United States by Professor D. Hayes, of 
Philadelphia, in 1880, also fatal ; and once in New South Wales 
bj^ Dr. George Fortescue, in which patient recovered. Mrs. 
M.'s case is thus the eleventh on rcicord, and the first in Scot- 
land, so far as I am aware. 

Dr. Keith, whose wonderful list of hysterectomies stands 
unrivalled in the annals of surgery, and which, I think, 
is likely so to remain, was compelled to follow the extra- 
peritonecd method of dealing with the pedicle in most 
of his cases, whilst Professor Schneder, of Berlin, treats 
the pedicle in such a manner that he can drop it back 
into the pelvis. One would have expected from the results of 
ovariotomy that any treatment which enables you to close up 
your abdominal wound would give the more favourable 
results; yet. Professor Schr^eder, in 1883, had operated on GO 



246 Dr. Napier— 77;c Oleates. 

cases of uterine-fibroid, with 20 deaths, whereas Dr. Keith, 
with his enforced extra-peritoneal method, lost only 3 cases in 38. 
I wrote my friend Dr. Keith regarding the pedicle question, 
and in reply he says — " Most of ni}'^ fibroids were extra- 
peritoneal, or rather, in most, I had to leave in the broad 
and round ligaments, and bring the cervix or base of the 
tumour out. This is not the right way ; a complete intra- 
peritoTieal method must he the best. In the extra-peritoneal 
method the grand crux is to disinfect the stump." 



THE OLEATES. 



By ALEX. NAPIEE, M.D., 

Assistant to the Professor of Materia Medica and Therapeutics, Glasgow- 
University. 

{A Pcqjcr read before the University Medico- Chirurcjical Society.) 

Gentlemen, — I desire to-night to direct your attention to 
these preparations for various reasons. They are not official 
drugs, though they are largely used and destined I believe 
to come into still more extended" use as external applications ; 
they are of considerable importance from a therapeutical 
point of view; and there is a good deal of confusion prevalent 
as to their nature and properties. 

Various methods are adopted for obtaining these oleates. 

1. The method by solution, in which the alkaloids and 
metallic oxides are simply dissolved in oleic acid. This is a 
process which is very commonly adopted at the present time, 
but is not that which is most to be recommended, as we shall 
see. This is the mode of preparation usually associated 
with' the name of Mr. John Marshall, who advocated it in 
1872, though ten years earlier Professor Attfield had suggested 
the solution of alkaloids in oleic acid as a means whereby the 
ready absorption of such drugs might be secured. Attfield 
thought that in this way alkaloids and other active drugs 
might advantageously be given internally in solution in what 
is a fatty body, but this we now know to be a mode of 
administration which is far from being reliable, however 
active such solutions may be when used externally. These 
preparations are simply oleic solutions, solutions of an oleate 
in excess, of oleic acid, and their strength is generally indicated 



Dr. Napier— ne Oleates. 247 

in percentages ; thus a 5, 10, or 20 per cent oleate of mercury 
made by this method means that o, 10, or 20 parts of yellow 
oxide of mercury are simply dissolved in 95, 90, or 80 parts 
of oleic acid. Further, it is believed that the alkaloidal 
oleates prepared in this fashion are simply solutions and not 
in any sense chemical combinations; on standing for a time the 
original alkaloid separates and is deposited from its solvent. 

2. In what is known as Wolti's method, we have a distinct 
step in advance. Here the oleates are made by double decom- 
position, and an effort is made to obtain chemically true 
oleates, solutions of metallic salts being added to a solution of 
Castile soap, an oleo-palmitate of sodium. This, though an 
improvement on Marshall's process, is not, on the whole, a 
good plan, as we have precipitated in most instances not pure 
oleates but oleo-palmitates ; for example, when a solution of 
sulphate of zinc is added to a solution of Castile soap we have 
a true oleo-palmitate of zinc thrown down, which may be 
separated, washed, and dried. There are two instances, how- 
ever, in which this mode will give true oleates, iron and copper ; 
their solutions act only on the sodium oleate and not on the 
sodium palmitate, and thus it comes that a pure oleate of these 
metals is thrown down. 

3. The third method, known as Shoemaker's, also a double 
decomposition method, is the best. In it a pure sodium oleate, 
prepared by adding caustic soda to pure oleic acid, is used as 
the basis of the reaction and the source of all the true oleates. 
When to a solution of this pure sodium oleate we add a 
solution of a metallic salt, we have double decomposition tak- 
ing place and true oleates, true neutral chemical compounds, 
with an excess neither of acid nor of base, thrown down. 

In pursuing this method it comes to be of importance to 
have pure oleic acid to begin with, and this may be obtained 
in various ways. Olive oil, which consists mainly of oleine, 
with some stearine and palmitine — that is, oleate, palmitate, 
and stearate of glyceryl, combinations of the radical glyceryl 
(C3 H-) with oleic, palmitic, and stearic acids, may be made 
to yield it. If the oil be cooled, the palmitine and stearine 
solidify and separate, leaving the oleine, the pure oleate of 
glyceryl (C3 H5 SC^g H33 Og.) From this, by a somewhat com- 
plex process, the pure sodium oleate (Na C^g H33 O^) is made. 

Or, the oleic acid may be got from olive oil, or even from 
ordinary fats, by passing through them a current of super- 
heated steam ; glycerine (the hydrate of glyceryl), together 
with the fatty acids, pass over, the glycerine remaining in 
solution in the condensed water on which the fatty acids float. 



248 Dr. Napier— TAe Oleates. 

I mention all this because it is of importance, especially^ it" 
the first method of preparing the oleates be adopted, to work 
with a perfectly pure oleic acid ; oleates made with an impure 
acid, such as the " red oil " of the candlemakers (which 
contains oxy-oleic acid and other impurities) are apt to prove 
extremely irritating to the skin, and to have properties quite 
different from those of chemically true oleates. It is quite 
conceivable that much undeserved discredit may have been 
brought on the oleates in this way. 

In considering the physiological action of the oleates, the 
first question which arises has reference to absorption by the 
sound skin, and the possibility of inducing the remote, con- 
stitutional action of a drug by this means ; and here we meet 
with some difference of opinion among authorities. For 
example, Mr. Marshall states that his oleic solutions, especially 
of mercury in combination with morphia, penetrate the skin 
very speedily and affect the deep tissues, lessening pain and 
controlling the inflammatory process ; and Squibb, an eminent 
American pharmacist, reports that he has seen the pupil dilate 
within a quarter of an hour after applying an oleate of 
atropine ointment to the knee joint. On the other hand we 
have Shoemaker, the introducer of these true oleates, who 
might therefore be supposed to be prejudiced in their favour, 
stating most positively that, except in the case of the 
viercurous oleate, these preparations do not enter the cir- 
culation through the skin, and accordingly produce no con- 
stitutional action. He finds that the quinine oleate is not in the 
least degree absorbed, that after its free use externally no 
quinine appears in the ui'ine, and that the treatment of inter- 
mittent fevers by applying quinine oleate externally was 
absolutely without result in cases which afterwards yielded 
readily to quinine given internally in the usual way. He finds 
further that onerciiric oleate applied freely externally fails to 
bring the system under the influence of mercury ; and similar 
negative results followed the free employment of the oleates 
of copper, strychnia, and aconitia. With zinc oleate Shoe- 
maker reports a very curious observation: — on rubbing a 
quantity of it on the shaven abdomen of a rabbit, the animal 
became stupid and partially paralysed ; after twenty-four 
hours it was killed, and on examination the tissues under 
the part of the skin so treated were found full of a gelatinous 
material and the cutaneous vessels were enlarged. This is the 
more striking, as experience shows that the zinc oleate is 
a most soothing and sedative external application — not an 
irritant. This matter needs fuller investigation. 



Dr. Napier— TAe Oleates. 249 

The only oleate -whicli actually affects the system at large 
is the tnercurons oleate, in which the metal is very loosely 
combined with the acid, separates readily from it and enters 
into combination with the acids of the sebaceous secretions 
and fluid perspiration, some of it also passing into the system 
possibly in the form of a double chloride. Bearing in mind 
what we know as to the action of the strong alkaloidal 
ointments, that the danger lies less in applying them to the 
sound unbroken skin than in the possible presence of abrasions 
or scratches through which such active drugs may readily enter 
the system, one would hesitate to use very freely the strong 
alkalodial oleates, and for the same reason ; nevertheless, 
making all these deductions, it must be held, in the meantime, 
as proved by Shoemaker's experiments, that the degree of 
penetration, or the kind of penetrative power possessed by the 
oleates, has been greatly mistaken or overrated. It is not a 
question, as some have held, of the direct passage of the drug 
through the superficial tissues into the lymphatics and Vjlood- 
vessels of a part, and so into the general circulation ; this 
occurs, so far as we at present know, only in the case of the 
mercurous oleate. The real limit and the real kind of the 
penetrative power of the oleates are these — their fatty nature 
and combination enable them to penetrate very readily into 
the natural recesses of the skin, more especially the hair 
follicles. 

This seems but a small advantage after all to claim for 
the oleates, but see the importance of it. An immense 
number of skin aft'ections have their origin in and around 
the hair follicles and sweat glands ; and of the parasitic 
diseases, such as ringworm, it may be said that they 
become obstinate and formidable only when the fungus 
reaches the depths of the hair follicles, a part to which ordi- 
nary ointments and lotions quite fail to penetrate. The ring- 
worm fungus, in particular, spreads along the skin in the 
deeper layer of the epidermis, and dips into the follicles by 
extending in the epithelial linings of the same, so that 
ultimately it flourishes at the verj^ bottom of the follicle and 
around the hair-papilla, sometimes even, in very chronic cases, 
in the substance of tlie true skin itself, parts where it is quite 
Ijeyond the influence of ordinary ointments. The advantages 
of the oleates are here conspicuously seen. Being themselves 
fatty in their nature, they can be actually dissolved, not aimjAy 
suspended, in the fatty ointment basis, and thus pass at once 
and readily through the sebaceous secretion, and so to the 
bottom of the follicles. It is obvious that an ordinary oint- 



250 Dr. Napier— TAe Oleates. 

ment, in which such a substance as oxide of zinc or red oxide 
of mercury is simply mixed or susiyended, will fail to carry 
the coarse particles of the drug to such a depth as an appli- 
cation the active ingredient of which is actually in solution 
in the fatty vehicle. And it is just here that the importance 
of the vehicle comes to be apparent. Vaseline and the allied 
paraffin derivatives, being simply protective, are bad vehicles : 
it has been experimentally proved that they hinder penetration 
and absorption. Whenever we have these ends in view, there- 
fore, it is better to avoid using them as ointment bases. 
Watery menstrua are equally objectionable as vehicles ; they 
do not combine with or penetrate the contents of the follicles, 
while they are apt to swell the epidermis, and thus to block 
up the openings of the ducts. Fats and fatty acids, on the 
other hand, combine with the sebaceous matter and penetrate 
it speedil3\ The oleate should, therefore, as a rule, be ordered 
with fats or fatty acids, such as fine lard, or in solution in 
oleic acid. Further, the druggist should be directed to 
dissolve the oleate in the lard by heat. 

You may convince yourselves of the importance of these 
points by a very simple but striking experiment; melt and filter 
first an ordinary ointment, and then treat in the same way 
an oleate ointment, and the difference in the material which 
passes through in the two cases will be most marked. I show 
you here a little of the pharmacopoeial ointment of the red 
oxide of mercury, which was heated and passed through filter 
paper ; you will notice that it is slightly yellowish in colour, 
doubtless from the presence of the yellow wax contained in 
the ointment, while most, if not all, of the red oxide has been 
separated and retained in the filter ; and the change so 
produced will become more plain if you compare this filtered 
with the original unfiltered ointment. Here again I show you 
the oleate of copper ointment, made by dissolving the copper 
oleate in lard by the aid of heat ; beside it I place a little of 
the same ointment which I melted and filtered, and you can 
see that it differs in no respect from the unfiltered ointment. 
The oleate, being in solution in the lard, passed in its entirety 
through the paper filter with the lard ; when melted it had the 
appearance of a clear and transparent deep greenish-blue 
solution. There can be no two opinions as to the difference in 
the phj'sical condition of these two kinds of ointments, and the 
greater penetrating power which the oleate ointments must 
thus possess. 

Similarly, for preparations intended to be kept permanently 
in the fluid form, the oleates may be dissolved in oleic acid. 



Dr. Javier— The Oleates. 251 

The oleato ointments or the oleic acid sokitions may be 
painted on the skin or rubbed in in the ordinary way ; and, as 
Shoemaker points out, they will be found to be not only 
active but cleanly and economical as well. When rubbed on 
the skin they soon disappear, leaving little or no greasy 
accumulation on the skin to stain the clothing. 

Therapeutic uses of the Oleates. — As regards the 
alkaloidal oleates, I have already stated that there is much 
difference of opinion as to their absorption ; there is not 
absolute agreement as to their therapeutic value. On the one 
hand, Dr. Shoemaker states positively that neither oleate of 
aconitia, nor oleate of atropine or morphia, has any but a very 
limited local action, while Mr, Marshall writes very enthusi- 
astically about the oleate of morphia especially, praising it 
highly (one grain of the alkaloid in each drachm of oleic acid) 
as a local application in neuralgia and in herpes zoster. The 
failure of the oleate of quinia to control intermittents has 
already been referred to. 

With regard to the alkaloidal oleates, then, we shall proba- 
bly not be far wrong if we say that they have mainly a 
local action ; that, like other oleates, they sink rapidly to the 
bottom of the natural recesses in the skin ; that they may 
there be absorbed in small {|uantity, and may so affect the 
terminations of the local sensory nerves; but that it is scarcely 
possible by their means to affect the system as a whole to 
produce any marked remote systemic effects, unless very 
large quantities are applied over a large surface, a practice 
which would be one of some danger, for reasons already 
given. 

In preparing the alkaloidal oleates, it is the alkaloids 
themselves, and not their salts, which are dissolved in oleic 
acid. 

Of the metallic oleates, probably the most valuable, and 
that which was earliest written about, is the oleate of 
mercuiy. We have two mercurial oleates, the mercurous and 
the mercuric. 

The narcurous oleate is made l)y double decomposition by 
adding a solution of mercurous nitrate to the sodium oleate ; 
it is not prepared by the solution method. This is a powerful 
salt, and contains a relatively large proportion of mercury, 
about li times the amount present in the mercuric oleate. 
It is a drug which has to be handled with some caution when 
used in the treatment of syphilis by inunction, as it so rapidly 
enters the system, and brings it under the action of mercury. 
It is much more effective than the " blue ointment," and more 



252 Dr. Napier— r/ie Oleates. 

cleanl}^* The inunction of the mercurous oleate is ])erhaps 
the readiest and least objectionable mode of using mercury in 
syphilis, or indeed of bringing the system under the influence 
of mercury in any circumstances in which this may be 
advisable. As in all inunction modes of treatment, the use 
of hot baths is an important adjuvant. 

Locally the mercurous oleate is a tolerably powerful stimu- 
lant, and in this capacity may be of service in the treatment 
of obstinate hard eczema of the palms and soles. 

The mercuric oleate is not less useful, though less irritating 
and less likely to be absorbed and to aflect the system. It 
may be prepared, though with some difficulty, by double 
decomposition, by adding a solution of the perchloride of 
mercury to a solution of sodium oleate; it is more commonly 
and quite satisfactorily made by the solution process. Its 
great value lies in this, that while it yields the local action of 
mercury on the superflcial tissues, such as the hair and 
epidermic structures, in parasitic diseases, and also acts locally 
in promoting absorption of chronic inflammatory products, 
there is practically no danger of its being absorbed into the 
system in such amount as to prove prejudicial to the general 
health. For example, I have often caused the 5 per cent solution 
to be applied for weeks to the entire scalp of a child, and have 
never yet seen any trace of salivation. Marshall used solutions 
of 5 per cent to 20 per cent, generally combined with morphia 
(one grain to each drachm), this furnishing a liniment repre- 
senting in an elegant form a combination of mercuiy and 
opium. This combination is a most valuable application in 
what Marshall terms " persistent inflammation," especially of 
joints ; he records cases of inflammations of old standing, 
recurrent, associated with much pain, defoi-mity, and swelling, 
which were promptly controlled by it. Some of these cases 
were very striking, having lasted from one to three or four 

* In last uiimber of this Journal, Professor M'Call Anderson, in report- 
ing a case of syphilis successfully treated by the inuu'-tiou of mercurous 
oleate, says, he "has long been in search of some apjjlication wbich would 
be equal in therapeutic effect to the ordinary blue ointment, but have the 
ailvantage of being cleanly. He has found this in ' Shoemaker's white 
mercurous oleate ointment.' " In this case, 3j of the ointment was rubbed 
in daily. 

The " white " ointment here referred to is made, not with a perfectly pure 
mercurous oleate, but with a mercvirous oleate containing a considerable 
proportion of water, and occurring in the form of greyish-white, com- 
pressed, slightly firm cakes, from which the water has to only a slight 
degree been pressed. The ointment, moreover, is not, like the other oleate 
ointments, made by melting, but by simply rubbing together equal parts 
of this watery oleate and lard. 



Dr. Napier— T/ie Oleates. 253 

years, and being accompanied 1)}' nuich pain and thickening of 
the parts, apparently by suppuration, starting at night, and 
an oedeniatous and glazed condition of skin; cases, in short, 
in which there seemed to be inflammation of the synovial 
membrane, the fibrous capsule and ligaments. In these cases 
the oleate combination took the place very well of the usual 
" Scott's dressing." Aided by gentle compression from well 
padded splints and a bandage, this combination yielded 
excellent results, the morphia easing the pain at once, the 
mercury facilitating the disintegration of the inflammatory 
material and pi-ocuring rapid absorption. I am able to 
corroborate much that Marshall says with reference to the 
good ertects of the oleate of mercury and morphia in 
threatenmg suppuration, whether this occur in lymphatic 
or other glands, such as the mamma. In such cases it is 
simply painted on externally. 

The 20 per cent mercuric oleate is occasionally used as an 
inunction in syphilis ; it is absorbed to a very slight extent, 
and thus attects the system gently. 

Parasitic skin att'ections are very amenable to treatment by 
mercuric oleate. In pediculosis, for example, it not only kills 
the fully developed pediculi, but also destroys the " nits " ; in 
tinea versicolor it is very effective, and in tinea tonsurans 
(ringworm of the head), especially in old-standing chronic 
cases, it is one of the most reliable of remedies, particularly if 
its use is accompanied by patient epilation of all diseased hair 
stumps. I have for a number of years, and with much satis- 
faction, prescribed the 5 per cent solution, with one-seventh 
part of acetic ether added to it to facilitate penetration ; this 
can be used freely even in young children. 

The lead oleate forms another very useful external appli- 
cation ; it may be made by dissolving litharge in oleic acid, or 
better, by doulde decomposition by adding solution of subace- 
tate of lead to solution of sodium oleate. We have for centuries 
used an impure oleate of lead in the form of the well known lead 
plaster, the adhesiveness of which is to some extent due to its 
impurity, for the pure oleate is not so adhesive. An excellent 
ointment is made by melting one part of the lead oleate with 
one or two jmrts of lard. This has all the usual sedative and 
astringent properties which are characteristic of the lead pre- 
parations ; it allays irritation and lessens discharge. These 
properties indicate its uses in acute and subacute eczemata, 
intertrigo, and so on. 

Zinc oleate, made sometimes (but imperfectly) by dissolv- 
ing the oxide in oleic acid, but much better by adding solution 



254 Dr. Napier— TA/? Oleates. 

of ac^tat€ of zinc to solution of sodium oleate, is one of the 
most commonly used pure oleates. In its piu-e form, the 
precipitated oleate, it occui-s as a pearl grey powder, smooth to 
the touch, with not the slightest grittiness, and astringent and 
sedative in action. Used alone, or diluted with powdered 
arrowroot, starch, or subnitrate of bismuth, it makes an excel- 
lent dusting powder for irritable surfaces, iind has, to a notable 
degree, the power to lessen localised perspiration. As a sooth- 
ing application to inflamed and acutely eczematous parts, it 
fulfils all the purposes sened by the oxide, and much more 
satLsfactoiily than that time honoured preparation. One part 
of the zinc oleate, melted with four parts of lard, gives a suit- 
able ointment. 

Bismuth oleate is even more sedative, astringent, and 
emollient than the zinc oleate ; one part of it to three of lard 
makes a good ointment. It is serviceable, more especially in 
pustular eruptions, such as pustular eczema, cases of non- 
parasitic sycosis, and of acne. It relieves the buniing heat of 
the skin in erysipelas and in the acute en-thema caused by 
sunburn. 

Copper oleate is a powerful and efficient parasiticide, and 
is best made by double decomposition, by adding solution of 
sulphate of copper to sodium oleate. It is applied in the fomi 
of an ointment, diluted with from foui- to eight parts of lard. 
This is found not to have much eflect on the .sound skin, 
though it may slightly irritate delicate parts ; when applied to 
an abrasion, it acts as a stimulant and astiiaigent, coagulating 
albuminous discharges. The gi-eat u.se of the preparation is 
as a parasiticide, in the various kinds of tinea. For example, 
in tinea tonsurans, it .seems to have a more prompt and 
thorough eflect than almost any other substance ; even chronic 
old-standing cases, which are very tedious and obstinate when 
treated by other applications, will usually yield in a very few 
weeks to the copper oleate. This mode of treatment has the 
great advantage that by it the troublesome process of epilation 
may practically be dispensed with. Washing the parts with 
water during the coui-se of the treatment should Ije avoided, 
as this tends to diminish the penetration of the oleate. I have 
used this oleate for some time in cases of ringworm with much 
satisfaction, though in two cases (brothers), the application 
had to be suspended on account of the appearance of a pustular 
eruption over the scalp, caused doubtless by the oleate. In 
other varieties of tinea the favourable action of the copper 
oleate is equally marked. 

The remaining metallic oleates are, for the most part, 



Dr. Javier— The Oleates. 255 

pharmaceutical curiosities ; in the meantime, at any rate, they 
have not found many therapeutical applications. The oleate 
of arsenic (arsenious oleate) may be used in the form of an 
ointiiKMit, containing 1 part of the precipitated oleate to 5 
or 10 parts of lard. This is found to be slightly alterative 
and mildly escharotic; if applied to a raw surface it may act 
with some violence as a caustic. It is mainly in the latter 
capacity that it has been used, for the removal of warts, 
superficial cancerous growths, patches of lupus, nsevi, &c. 
The iron oleate is a ferric salt, and is best made with the 
U. S. P. solution of the tersulphate of iron. It has l)een given 
internally dissolved in fats, and also rubbed in externally, 
with the view of obtaining the action of iron on the system ; 
but. so far as I know, with no success. It has no systemic 
influence; its action is strictly local, and styptic and astringent 
in cliaracter. In the form of a weak ointment it may be 
applied as a stimulant in chronic eczema and in the early 
stages of acne rosacea. Shoemaker also states that he has 
found the ointment markedly stimulate the healing process in 
obstinate ulcers caused by arsenical poisoning. Silver oleate 
is a stable salt which acts as a superficial caustic, coagulating 
discharges on a raw surface and causing crusting. In the 
form of a weak ointment (5 to GO grains of the oleate with an 
equal quantity of oleic acid and an ounce of lard) it makes an 
excellent application in erysipelas and in some cases of 
f urunculus. The cadmium and the nickel oleates are markedly 
stimulating ; that of aluminium, astringent. The tin oleate 
is also astringent, and in the form of an ointment (1 in 8) 
makes a valuable application in cases in which the nails are 
dry and cracked, as after injury. The addition of a little 
carmine to the ointment improves its properties as a 
cosmetic. 

Finally, I woul<l say that I believe these oleates are destined 
to play an important part in therapeutics, more particularly in 
the treatment of diseases of the skin. In ordering the pure 
chemically true oleate, it is advisable to put in the prescription 
the word " precipitated " in brackets after the name of the 
particular oleate ; and to direct the preparation to be made by 
heat, thus ensuring that the oleate shall be dissolved in the 
fatty vehicle. 



256 Dr. Munro — The Scientific Basis of Medicine. 
THE SCIENTIFIC BASIS OF MEDICINE. 

By ROBERT MUNRO, M.A., M.D. 

{Continued from page ISJf.) 

Passing from these remarks on the simple prevention of diseases 
to the consideration of the actual instruments of treatment, 
you will observe that I have noted a transition stage, in which 
the physician's interference is supposed to be necessary only 
to the extent of discovering and removing their primary causes, 
and thereby restoring the equilibrium of the conditions of 
health. It is on the principle involved in this assumption that 
all recommendations as to change of food, drink, and clothing, 
are made ; that exercise in the open air is prescribed to persons 
suffering from dyspepsia due to sedentary habits ; that the 
poor, sickly children of our crowded dens and alleys regain 
their natural vigour and health when removed to a Convales- 
cent Home ; and that gouty, rheumatic, and scrofulous people 
are so much benefited by clear mountain air. But it is need- 
less to multiply illustrations. Let me rather look ahead to the 
boundless field for genuine medical skill and practical good to 
humanity which is here forced on our consideration ! To the 
immense labour of acquiring a tolerable acquaintance with the 
marvellous complexity of the structure and functions of the 
human body must be added an exact knowledge of the ex- 
ternal environments of the patient, his mode of living and 
habits of life, and such other preliminary inquiries as have 
already engaged our attention when discussing the problems 
of preventive medicine. What a grasp of the secret workings 
of nature — what a variet}'" of methods of investigation, delicate 
experiments, and manipulative research — what powers of ob- 
servation and inductive philosophy — and above all, what w^ide 
experience and mature judgment are requisite to unravel the 
tangled skein of disease, and enable the physician to form a 
correct opinion of the multitudinous ailments he is called on 
to investigate ! 

But why, it may be asked, do I restrict the physician to the 
mere rectification of the physical causes of disease ? When 
the morbid lesion and its exciting causes are discovered and 
the conditions of normal health readjusted, is there nothing 
else that can be done either to hasten the cure or relieve the 
sufferings of the patient ? Is medical interference like a 
vacuum abhorrent to nature ? And is she alone henceforth 
sufficient to establish convalescence ? These questions naturally 



Dr. MuNiio — The Scientijie Basis of Medicine. 257 

suggest a few remarks on the respective claims of the power 
of nature and the appliances of art in the cure of disease. 

That nature possesses within her own resources, as manifested 
in the combined action of the metabolic forces of the human 
body, an inherent power of removing pathological products and 
reconstructmg new tissues, after the disturbing elements have 
been removed, there can be no doubt at all in the mind of any- 
observant person who has watched the natui-al termination of 
disease and accidents among men and the lower animals, in 
circumstances where no human aid was given or available. 
Her successful resistance against epidemic diseases by ulti- 
mately eliminating the organic poison and its morbid products 
from the system, is now recognised by all competent physicians. 
Sydenham believed in this vis mcdicatrix naturcv, and com- 
mends the great sagacity of Hippocrates in discovering that 
" Nature by herself determines diseases, and is of herself 
sufficient in all things against (dl of them." (P. 17, vol. i, 
Syd. Soc.) 

The same opinion is amply confirmed by an intelligent 
survey of the fluctuating means and instruments of medical 
art as practised at different times and in various countries. As 
long as treatment was confined to the effects of amulets, 
charms, spells, or other imaginary influences, and included no 
more potent drugs than the inert substances of many celebrated 
(juack nostrums, and the infinitesimal globules of Hahnemann, 
it must be admitted that the numberless cures recorded under 
such conditions were entirely due to the natural and unaided 
efforts of nature. Such treatment merely justifies the well 
known definition of physic, that "it is -the art of anmsing the 
patient while nature cures the disease." It would have been 
better for the reputation of the healing art, and perhaps for 
humanity at large, had its injunctions in many instances been 
of a less heroic character than tlie treatment we find described 
in the medical records of the past. Thus, for example, when 
the terribly fatal disease, known as the English sweating- 
sickness, first broke out in London, in the year 1485, it was 
treated by such active measures as were then in vogue. But 
drastic pills, electuaries, and the famous feather beds by which 
the patients were made to sweat for 24 hours, had no effect in 
lessening its mortality. In fact, medical science completely 
broke down, and was considered so utterly useless that, 
according to Hecker, its professors are nowhere alluded to 
throughout this epidemic. " No resource," says this writer 
{Epidemics of the Middle Ages, p. 186) " was therefore left to 
the terrified people of England but their own good sense, and 

No. 4. S Vol. xxin. 



258 Dr. Munro — Tlw Scientific Basis of Medicine. 

this led them to the adoption of a plan of treatment than 
which no physician in the world could have given them a 
better — viz., not to resort to any violent medicines, but to 
apply moderate heat, to abstain from food, taking only a small 
quantity of mild drink, and quietly to wait for four-and- twenty 
hours the crisis of this formidable malady." On the Continent 
the consequences of medical interference with the natural course 
of this disease were still more deplorable, and many sufferers 
were said to have been actually " stewed to death " by the 
feather bed treatment. When the success of the English 
expectant method became known, many pamphlets were pub- 
lished recommending it to the afflicted communities, and even 
the Council at Berne went so far as to issue an " exhortation 
to patience and unshaken courage, in which the use of feather 
beds and all medicines, except cinnamon water, was earnestly 
deprecated during the disease." Hecker, referring to a pam- 
phlet by Caspar Kegeler, of Leipzig, on the treatment of this 
disease, says — " It is a melancholy monument of the credulity 
which, from Herophilus to the present day, has pervaded the 
whole medical art. It is a regular pharmacopoeia for the 
sweating sickness, thrown together at a venture, without any 
insicjht into the nature of the disease. A mine of wonderful 
pills and electuaries composed of numberless ingredients where- 
with this 'mysterious worthy' undertakes to raise a commotion 
in the bodies of his patients. If he had but seen even a single 
case of the disease he would at least have known how im- 
possible it would be to administer, within the space of four- 
and-twenty hours, the hundredth part of his pills and draughts. 
With what approbation this little pharmacopoeia was received 
by physicians of equal penetration and understanding as 
himself, is shown by the eight editions which it passed through, 
and the melancholy reflection is therefore forced upon us that 
possibly thousands of sick persons were maltreated and sacri- 
liced from the employment of Kegeler's medicines." {Ibid, 
p. 272.) Farther on, the same author, while commending the 
English method of treatment, adds, " We have, therefore, 
nothing further to add to this judicious and truly scientific 
practice but our unqualified approbation ; /or it is the part of 
the physician, in diseases which have a sijontaneous poiver of 
curing themselves, to leave this jjoiver free scope to act, and 
merely by fostering care to remove all obstacles to its exercise. 
Should it be the destiny of mankind to be again visited by the 
disease of the sixteenth century (and it is by no means im- 
possible that at some time or other similar events may recur), 
we would recommend our posterity to bear in mind this eternal 



Dr. Munro — The Scientific BasU of Medicine. 259 

truth, and to treasure up the golden words of the Witten- 
berg pamphlet — viz., to guard the healing art from strange and 
unnatural farragos, for it is only when it is subordinafe to 
nature that it bears the stamp of reason — the 'inistress of all 
earthly things." (Ibid, p. 289.) 

A similar criticism is applicable to the practice of phlebo- 
tomy, and other debilitating measures, almost invariably 
adopted in the treatment of fever, rheumatism, pneumonia, 
and all kinds of acute inflammations, from the time of Hippo- 
crates down to the middle of the present century. Sydenham 
thus describes the symptoms in a fever patient that guided 
him in the use of the lancet : — " Whenever I have to deal with 
a patient whose blood is in itself of a weak character (as it is 
for the most part with children), or else deficient in animal 
spirits (as it is with men in the decline of life, and youths that 
have long been invalids), I keep my fingers from tlie lancet. 
. . . Whenever, on the other hand, the state of the blood is 
of a different description (such as I find it amongst youths of 
an athletic habit and a sanguine temperament), venesection is 
my leading remedy. Except in certain cases it cannot with 
safety be omitted. Neglect it, and you run the risk of frenzies, 
pleurisies, and such like inflammations, which originate in the 
preternatural ebullition of the blood. More than this — from 
the excess of the blood the circulation is impeded ; you smother 
it." (Syd. Genuine Works, p. 46, vol. i.) 

Regarding rheumatism, he says, " As soon as I am sent for, 
I draw blood from the arm of the side afiected to ten ounces, 
and then prescribe the following julep.; — 
R. Water of water-hhes, 

Purslain- water, 

Lettuce-water, aa 5iv. 

Syrup of lemons, 5SS. 

iSyrup of violets, 5J. 
Mix, and make into a julep ; to be taken ad libitum. 

" The following day I order the same amount of blood to be 
drawn, and a day or two after, according to the strength of 
the patient, I bleed again. Three or four days after this I 
bleed for the fourth time, and this fourth bleeding is generally 
the last," &c. (Ibid, p. 2oG.) 

If this celebrated engine of medical art has been such a 
benefit to mankind during the long period of 2,000 years, why 
has it now been so completely discarded ? If it has not been 
a benefit, but, on the contrary, the means in many cases (as 
acknowledged by Sydenham himself), of weakening and 
retarding the powers of nature against disease, what shall we 



260 Dr. Munro — The Scientific Basis of Medicine. 

say of the accumulated experience and clinical observation 
(the supposed infallible instruments of medical skill), which 
never, during all these long years, detected its dangerous effects ! 
Some assert that diseases have changed their character, and 
that we no longer encounter the sthenic symptoms which 
formerly justified bleeding. If so, it is curious that those 
diseases should have remained so lono- unchano-ed, and that 
the change, when once initiated, should be so rapid as to be 
accomplished within the short compass of a man's life-time. 
It is still more curious, and perhaps somewhat more significant, 
to find that bleeding held its ground so long, and only so long, 
as the old humoral pathology was an accepted theory. As to 
the shifting methods of treatment, and frequent fashions in 
drugs adopted in these later times, it does not appear that the 
bills of mortality have been sensibly affected under the pre- 
valence of any particular system of moderate therapeutics. 

We have thus positive evidence of the existence, in the natural 
forces and organic processes of the body, of a power of healing 
disease, independent of all medical skill and its appliances. I 
have often wondered, on mere philosophical grounds, why the 
existence of this power should ever have been called in ques- 
tion. Its action is not more mysterious than the marvellous 
and unquestioned teleological principles on which the body 
was originally constructed. What guided the molecular forces 
during fa?tal development ? The functions of every cell, or 
group of cells, of every localised bundle of tissues, and of every 
organ of the body, were all intended and specially adapted for 
the general good of the living organism. Their continued 
action and subsequent changes are also directed towards the 
same end, and continue till all the life energies of the indi- 
vidual are exhausted. It would, therefore, be very strange 
that the natural forces which guided the functions of so many 
different organs for a special purpose — viz., the preservation 
of the normal health of the organism, should cease to act in 
the same direction when disturbed by any foreign element. 
The vis niedicatrix natuoxc is, therefore, not a new principle 
nor a peculiar property of the human being. It extends to all 
living organisms. The late Sir J. Forbes, M.D., D.C.L., F.R.S., 
sums up his estimate of its value in the following words : — 
" The one great result obtained from the study of those various 
authorities is this — that the power of nature to cure diseases 
is infinitely greater than is generally believed by the great 
body of medical practitioners, and by the public generally. So 
great, indeed, is this power, and so universally operative, that 
it is a simple statement of the facts to say — that of all diseases 



Dr. Munro — The Scientific Basis of Medicine. 201 

that are curable and cured, the vast majority are cured by 
nature independently of art ; and of the number of diseases 
that, according to our present mode of viewing things, may be 
fairly said to be curable by art — the far larger proportion may 
be justly set down as cured by nature and art conjointly. 
The number of diseases cured entirely by art (of course I omit 
in all these statements surgical art), and in spite of nature, in 
other words, the number of cases that recover, and would have 
tlied had art not interfered, is extremely small." (Xature and 
Art in the Treatment of Disease, p. 170.) 

And now we come to consider medical science in its highest 
aspect — viz., that of assisting the efforts of nature in curing 
diseases by the administration of whatever means or agents 
medical skill can suggest. This is supposed to be the special 
province of the skilled and accomplished physician ; all others, 
however important to the public health in general, being con- 
sidered mere accessories to the high calling of writing prescrip- 
tions in doggerel Latin. I have underlined the words, assisting 
the e forts of nature, in order to emphasise the fact that, in all 
morbid states, the healing powers of nature are enlisted, 
wdiether they are, or are not, able to effect a cure ; and, 
hence, the physician can always count on their co-operation. 
And here I would further note that, whatever the agents, 
instruments, or appliances of medical art vaaj be, they 
are but a preliminary adjustment of circumstances by means 
of which nature operates, so that when a cure is effected, or a 
definite result produced, the process by which this is accom- 
plished is as much the work of nature. as if the physician had 
merely removed the obstructing causes. There is no medical 
art independent of nature. The part of the physician is to 
bring certain animal or chemical substances into contact with 
the diseased tissues or the fluids of the body, the rest, i. e., the 
modus operandi of the cure, is as much a mystery as any of 
the ordinary physiological phenomena of organic life. In the 
present state of knowledge of these organic processes it may 
be difficult to give an intelligible explanation of what really 
takes place in the process of removing abnormal conditions, 
but we carmot be far astray if Ave say that it is due to some 
chemical alteration in the fluids of the body, or some chano-e in 
the functional activity of one or other of its numerous organs. 
The causes that produce such changes are numerous, and of 
varied character. Besides the effect of food, and so-called 
remedies, on the body, we have to consider the influence upon 
it of certain mental states, originating eitlier in the brain itself 
or suggested to the mind by external phenomena. Thus, the 



262 Dk. Munro — The Scientific Basis of Medicine. 

salivary glands are stimulated by the scratching of a pencil on 
a slate, or the prospect of a savoury dish, causing, in common 
parlance, the teeth to water. On the other hand, fear dries 
them up, makes the hair stand on end, and sometimes renders 
the animal completely powerless. The bowels, kidneys, and 
other excretory organs, are also affected by a variety of causes, 
such, for example, as the immediate prospect of a critical 
examination, the fear of losing a train, &c. A disgusting sight, 
as is well known, sometimes causes jaundice. Love, hope, 
anger, disappointment, thwarted ambition, and all other mov- 
ing springs of human action, find their representation in the 
body by well marked physical symptoms. The influence of 
a strong presentiment is often the chief agent in bringing- 
about the dreaded result ; and hence, it is well said that the 
imagination kills and cures. Its effects are well illustrated 
by hypochondriasm, hysteria, and many other diseases. That 
music powerfully affects the moral and intellectual faculties is 
too patent to require illustration ; and as a curative agent, in 
removing distressing despondency and melancholy associations, 
has been frequently taken advantage of, both in ancient and 
modern times. The ancients attached much importance to the 
influence of the moon and stars, and believed that a knowledge 
of astronomy was indispensable to a physician. On this point 
the medical faculty of Paris, the most celebrated of the 14th 
century, in delivering their opinion of the causes of the black 
plague, make use of the following words : — " We are of opinion 
that the constellations, with the aid of nature, strive by virtue 
of their divine might to protect and heal the human race ; and 
to this end, in union with the rays of the sun, acting through 
the power of fire, endeavour to break through the mist." 
(Hecker's Epidemics of Middle Ages, p. 51.) 

Another class of physical means, which are available in the 
healing art, comprehends such applications as water baths, 
abstraction or temporary displacement of blood, regulation of 
temperature, removal of atmospheric pressure, anaesthetics, 
electricity, &c. But all these influences, though curious, 
interesting, and sometimes valuable, as aids to the physician, 
are entirely overshadowed by the importance popularly 
ascribed to pharmaceutical agencies in the treatment of disease. 
These so-called remedies are derived from all departments of 
nature, and comprise an enormous mass of substances in the 
form of gases, liquids, and solids. They are administered for 
various purposes, sometimes with the intention of enriching 
protoplasm, or supplying some deficiency in the quality of 
blood, as . when iron or its compounds, and cod-liver oil, are 



Dr. MuNRO — lite Scientific Basis of MedAcine. 268^ 

prescribed in chlorotic anfemia ; and hence between such and 
food there is Httle or no distinction. Others, again, are 
observed to have some decided action on one or otlier of the 
metabohc phenomena of the body, and for this reason they are 
classified into groups corresponding with the organs, tissues, 
or functions, which they are supposed capable of affecting, as 
narcotics, tonics, stimulants, astringents, alteratives, anti- 
pyretics, diaphoretics, diuretics, expectorants, &c. Excluding 
the former, as belonging to the category of food, medicines 
may, therefore, be defined as substances which have the 
property of modifying the actual state of the body or its 
functions, independent of any nutritive qualities they may 
possess. That many substances, when introduced into the 
blood, have the power of acting in this manner is an admitted 
fact; and this may be true, though their modus operandi 
may be obscure or entirely unknown. But, supposing a 
medicine is known to have the property of invariably 
aftecting the living animal in a given manner, either chemi- 
cally, physically, physiologically, or psychicall}^ — and this is 
a matter capable of being determined experimentally- — a still 
higher problem falls to be considered by the responsible 
ph^'sician — viz., what effect will its action have on the general 
constitution and well-being of the individual ? It is not 
sufficient to demonstrate that a drug possesses some peculiar 
physiological action ; it must also be shown that this action, 
when induced in a diseased and enfeebled body, is to be for its 
ultimate good by putting something right that was previously 
wrong. 

To prosecute the inquiry here suggested requires more 
practical skill and special knowledge than I can lay claim to; 
but, nevertheless, I am tempted to advance a few considerations 
which, if not sufficient as a plea for the moderate use of 
empirical remedies, will, at least, remove any possibility of 
harbouring the idea of therapeutic nihilism. And first let me 
draw attention to the marvellous precision and nicety with 
which the selective power possessed by the respective organs 
and tissues of the body is exercised. How each working cell 
takes from the circulating fluid, which continuously Ijathes it 
with a rich choice of prepared materials, what it specially 
needs and allows what it does not need to pass by ! Thus, the 
various glandular cells .select what is requisite for the manu- 
facture of their proper secretions. Muscular tissue not only 
seizes upon the materials from which, as in a laboratory, force 
and heat are generated, but also the proteid ingredients 
necessary- to keep its own proper work in repair. And so with 



2G4 Dr. Munro — The Scientific Basis of Medicine. 

the other tissues. Brain selects one thing, bone another, and 
cartilage a third, &c. Within certain limits it matters not 
though the blood should contain too much of these constructive 
materials, as they either remain harndess in the vascular 
reservoir, or become stored up as fat for future use. It is quite 
a different thing, however, if there is a deficiency, for then the 
work is diminished. Ko food — no tcork, is an absolute rule 
amonof all the cellular communities which constitute the animal 
economy. When foreign bodies, such as drugs, enter the 
blood a general commotion ensues, and every organ, though not 
all equally afiected, begins more or less to expel the unwelcome 
intruders. The result of the struggle that ensues is one of 
two eventualities, according to the dose administered, either 
the expulsion of the disturbing elements and the restoration 
of the organism to its normal condition, or its own complete 
disoro-anisation and death. These foreiirn elements act differ- 
ently on the different tissues, and are probably influenced in 
this respect by their respective chemical constituents and 
affinities. Thus, prussic acid acts on some central portion of 
the brain substance and produces symptoms closely resembling 
those of epilepsy. Other narcotics are followed by various 
well known symptoms, such as obscurity of sight, paralysis of 
the muscles of voluntary motion, coma, &c. One drug is a 
local anaesthetic, another contracts or relaxes a muscle. It is in- 
teresting to note that narcotics, like the substances they affect, 
are all highly organised products, and belong exclusively to 
the animal or vegetable kino-dom. Besides the obscure action 
of interfering with the metabolic processes of the body, drugs, 
in virtue of their chemical and mechanical properties, often play 
an important part in general health or disease. Acids and 
alkalies are neutralised by their corresponding reagents ; 
foreign bodies are rejected from the stomach by induced 
vomiting ; the peristaltic and secretive actions of the bowels 
are stimulated by chemical or mechanical irritants, with the 
object of expelling deleterious matters ; parasites are killed 
and rooted out by various applications found to be destructive 
to the lower forms of life ; local congestions are relieved by 
temporary derivation or displacement of the blood ; and super- 
ficial inflammations are soothed by evaporating and cooling- 
lotions. When drugs are therefore administered, with certain 
limitations as to quantity and frequency, their action m&j 
often be turned to good account by promoting the function of the 
mechanism by which they are being eliminated as in the case of 
deobstruents, diuretics, evacuants, &c. When, however, these 
ascertained limits of safety are exceeded, their action becomes 



Dr. Munro — The Scientific Basis of Medicine. 265 

too violent and injurious, and hence the same substance may be 
both a remedy and a poison. Taking advantage of these facts, 
the physician sometimes prescribes, as medicine, a substance 
which may not have any specific action on the diseased organ, 
but only the power of stimulating some other organ or organs, 
with the object of lessening the work of the former, as when 
perspiration is promoted to relieve the function of the kidneys. 
The great store of therapeutic agents which constitute the 
remedial instruments of medical art is therefore resorted to for 
a variet}' of reasons which, so far as our present purpose is 
concerned, may be classified under the three following 
groups : — 

1. Substances which have the power to relieve pain, pro- 
mote sleep, or allay convulsions, or other spasmodic actions, 
which, if allowed to go on, might lead to secondary results of 
a more dangerous character. The object here is to allow 
nature to restore the equilibrium of the disturbed functions, 
or to permit of further interference by art, as in surgical 
operations. 

2. The second group comprises such drugs as are prescribed 
with the intention of modifying the function of some other 
part of the body, though the medicines themselves may be 
acknowledged to have no direct action on the actual morbid 
state. 

3. To the third group belong all remedies which act directly 
on morbid tissues, or are supposed, in some other mysterious 
manner, to remove or destroy the cause of the disease. 

Although many of the objects here .contemplated are suf- 
ficiently ol)vious, and attainable by appropriate remedies, as to 
require no further notice, such as the palliation of pain, and 
the local application of drugs to skin diseases and aftections of 
mucous meml)ranes, it must be acknowledged that there 
remains a much larger proportion of maladies over which these 
agencies have little or no control. In these circumstances, 
treatment is merely conjectural, having for our guidance 
neither precise indications nor positive results. 

The stud}' and classification of diseases from mere symptoms, 
irrespective of their pathological conditions, in conjunction 
with the acknowledged influence of drugs in modifying various 
states of the body, and producing in some instances phenomena 
closely resembling those of natural disease, have given rise 
from time to time to most contradictory theories regarding the 
rationale of the therapeutic action of medicines. The belief 
that Providence could not permit a disease to scourge 
humanity without also supplying the means of curing it, was 



26G Dr. Munro— T/ic Scientific Basis of Medicine. 

as firmly fixed in the popular mind as that every poisonous 
plant in a field was accompanied by an appropriate antidote, a 
fact said to be discovered by the natural instinct of grazino- 
animals. Of the conflicting opinions and ephemeral theories 
on this point, which agitated the medical schools of former 
days, there are only two which have come down to the present 
time. These are the rival theories of allopathy and liommo- 
pathy — both of which were known to Hippocrates. The prin- 
ciple of the former, which, as a rule, guided Hippocrates in his 
practice, was epitomised in the words, contraria contrariis 
curantur, but that of the latter, though clearly discerned, was 
only available in exceptional cases. It was not till the close of 
the last century, when an ardent German visionary of the 
name of Hahnemann surrounded the words, similiaj similibus 
curantur, with a sufficientl}' pretentious fabric of mysticism and 
vaunted cures, that the medical system known under the name 
of Homoeopathy was founded. The views of Hahnemann, when 
divested of their fanciful and absurd speculations, will be found 
to contain but one germ of truth, and that one is probably 
based on the acknowledged diversit}'^ of the action of drugs on 
the body — some acting on one set of organs or tissues and 
others on a different set. And even these vicarious processes 
may be merely the natural methods of expelling irritating and 
poisonous elements out of the system. Thus, arsenic and 
mercury, when administered in regular doses for a continued 
period, produce certain eruptions of the skin resembling some 
forms of skin disease, probably for the same reason that the 
virus of small-pox causes a pustule after a given interval of 
time. Sulphur, in the course of its elimination as sulphurous 
acid, irritates the pores of the skin, on the same principle that 
alcohol affects the epithelium of the uriniferous ducts of the 
kidneys. As long as the structure, organic functions, and 
cellular metabolism of the body were a sealed book, homoeo- 
pathy was a plausible method of treatment, but, philosophi- 
cally considered, its practice is only comparable to the habit of 
shaking a watch, when it mysterioush' stops, with the hope 
that the agitation will put it right again. On the other hand, 
allopathists founded their practice on the principle of com- 
bating the phenomena of disease by striking at their morbid 
causes, a result which was supposed to be attained by giving 
something that had properties or produced eflfects of an 
opposite character. Between these theories there is little 
room for choice. Both may be true to a certain extent, but 
neither is comprehensive enough to form the basis of an 
exclusive system of therapy. 



Dr. Munro — Tlte Scientific Basis of Medicine. 267 

Regarding tlie treatment of disease by specific remedies, 
which has also elicited from time to time various contradictory 
theories, Sir John Forbes thus writes : — " In the earlier ages of 
physic, physicians, naturally participating in the notions of 
the vulgar, regarded the greater proportion of medicines as 
possessing some m3^stcrious or special power over particular 
affections, and consequently placed the greater number of 
diseases in the class now under consideration. Overlooking 
the wonderful powei's of nature to cure diseases, and trusting 
to an experience and observation most imperfect, and beset by 
every sort of fallacy, they thought themselves justified in 
placing on the list of remedies, possessing absolute and specific 
virtues to cure particular diseases, hundreds of substances 
utterly without any power to affect the human body in either 
its healthy or its morbid conditions. Like the more ignorant 
practitioners of the present day, and the lay and amateur 
doctors of all times, they sought for no further verification of 
their inferences than the mere sequence of coincident but 
unconnected events — j^'^-'^^ ^^^^ ^'^V^ 'propter hoc, the everlasting 
stumblins: block in the reasonino- of common minds. 

" In all the works on practical medicine compiled previously 
to the last century, we see long lists of such so-called specifics 
ranged under the head of almost every disease ; and their 
respective virtues set forth and vouched for, not merely on the 
ground of specious and subtle theory, but from the alleged 
evidence of the manifold and long experience of the most 
learned and most honest men ! 

" As general science made progress, and the medical art, in 
the hands of scientific professors, gradually assumed a more 
philosophical form, and observation and experience began to 
be more and more sultjected to the dominion of a rational 
logic, those imaginary remedies fell, one after another, out of 
the armoury of phj'sic, until nearly all had disappeared. 
. . . This expurgation has gone on increasing with the 
advance of medical science ever since, until at last it seems 
impossible to name even half a dozen remedies that can fairly 
be retained in the special or specific class." (Nature and Art 
in the Tncdnient of Disease, p. 215.) 

The diseases which this author mentions as amenable to 
specific remedies are the following six, and even with regard 
to them he makes the reservation that they are only generally 
so curable, and leaves it to be clearly understood that the 
medicines may have only removed " obstacles to the exercise 
of the restorative powers naturally inherent in the system 
itself." 



268 Dr. Munro — The Scieiitijic Basis of Medicine. 

1. Ague and some forms of remittent fever ; cured by 
cinchona and its salts, and by arsenic. 

2. Syphilis ; curable by mercury. 

3. Scorbutus ; curable by fresh lemon-juice, more certainly 
by fresh animal and vegetable food. 

4. Bronchocele ; curable by iodine. 

5. Chlorotic aneemia ; curable by iron. 

6. Periosteal and other swellings on the surfaces of the 
bones, syphilitic, gouty, or strumous ; cured by the iodide of 
potassium. 

The general truth of these remarkable statements of Sir 
John Forbes cannot be denied by any physician of long 
experience, and, indeed, in more recent times, this meagre list 
of specifics is being questioned. On scientific grounds I do not 
think the claim of specific remedies to a place among the 
rational agencies of treatment should be entirely ignored. 
The first two diseases in the above list are now known to be 
due to the living action of specific organisms or germs, and it 
is not improbable that the specific remedies may be excellent 
germicides, or antidotes to poisonous compounds secreted by 
these organisms during their career in tlie human body. As 
long as the pathology of itch was unknown, sulphur might be 
well regarded as a specific remedy, but the moment research 
proved that its primary cause was a small cutaneous mite, the 
mystery of the specific action of this drug resolved itself 
into a substance that had the power of killing the parasite. 
Chance remedies, though not impossible, are extremely rare, 
especially when the nature of the disease is undetermined. 
The secondary evils which are said to follow the continued 
administration of mercury may also be explained on the 
supposition that the destructive properties of this drug are not 
only germicidal, but homicidal when given in large and re- 
peated doses. In scorbutus and chlorotic ancemia nutritive 
qualities are supplied by the lemon-juice, fresh meat, and 
iron, in which the blood was formerly deficient ; and in sup- 
plying these the treatment may be considered specific. The 
action of iodine and its compounds may have a stimulating- 
effect on the lymphatic and absorbent vessels, but otherwise 
there is no reason to look upon these drugs as specifics. At best 
they only assist the efforts of nature, as both syphilitic and 
strumous swellings disappear without any interference by 
medical art. The deobstruent powers of nature are well seen 
in the removal of extravasated blood and bloody tumours of 
the scalp by absorption. 

I have now a few words to say on the use of antipyretics. 



Dr. Munro — The Scientific Basis of Medicine. 269 

Many drugs possess tliis property, especially narcotics and 
sedatives, which depress the vital functions by diminishing the 
sensitiveness of the nervous system. Pain is relieved by 
opium, not because the drug removes or destroys the irritating 
cause, but because it stupities the nerve centres and renders 
them less cognisant of the morbid changes going on at the 
seat of pain. Hence, when the nervous sj^stem is in this con- 
dition, the entire metabolism of the body is disturbed and 
functional processes are arrested, the continued exercise of 
which is essential to the welfare of the organism. The main 
question then is, When, or in what circumstances, are these 
abnormal pyrogenous conditions to be attacked by antipyretic 
drugs ? 

The primary source of all energy in the animal economy 
is food which, in the shape of highly organised products, 
previously elaborated by solar heat and other constructive 
forces, contains this in a latent form. The total income of 
this potential energy is converted by the metabolism of the 
body into heat and mechanical labour — about four-tifths being 
expended in the production of the former. The long well- 
known theory propounded by Liebig — viz., that nitro- 
genous food went to build up the proteid tissues, while the 
non-nitrogenous or carbonaceous was exclusively used for 
calorific purposes, is no longer tenable, as it is now proved that 
heat is generated by the oxidation of all the tissues of the body, 
no matter what their composition may be. Heat is thus 
eliminated wherever ' metabolism of protoplasm ' is going on, as 
in muscular contraction, glandular secretions, molecular changes 
in brain substance, &c. Thermogenesis is, therefore, coextensive 
with the oxidation of food, wherever this takes place, whether 
in the digestive organs — where its organised products are 
prepared for their final distribution, or in the act of supplying 
the tissues themselves in situ. When molecular nutrition is 
completed, the heat set free is lost to the body, chiefly by 
means of conduction and radiation from its surface, and 
evaporation of the aqueous secretions from the skin and lungs. 
Although the production of heat thus varies, within certain 
limits, according to the functional activity of the body, and its 
dis.sipation is also variable and, to a certain extent, dependent 
on external circumstances, it is singular that in health the 
temperature of the body neither rises much above nor falls 
much below a fixed standard. This standard is so uniformly 
maintained that a change of even one degree above or below 
the mean or normal temperature is considered sufficient proof 
that some unusual influences are at work in the organism. 



270 Dr. Munro — The Scientific Basis of Medicine. 

Hence there must be some kind of compensating mechanism 
which equalises the quantity of heat retained in the body ; 
and the sensitiveness with which it acts may be estimated 
from the fact that the above hmits are hardly ever exceeded 
by active exercise, sudden changes of temperature in the 
external environments, or, indeed, by any combination of the 
ordinary conditions of life ; so that practically the temperature 
of the human body remains the same among all nations in all 
parts of the habitable globe. 

The ofreat reo-ulators of animal heat are the vaso-motor 
nerves, which act by increasing or diminishing the cutaneous 
vascular areas. By this means the blood, in greater or less 
quantity, is exposed to the surface, and the surplus heat is 
given off or retained according to the requirements of the 
system. When the increment of heat is due to muscular 
exercise, as in the act of running, the special nerves of per- 
spiration come into play, and the skin perspires freely. The 
evaporation of this water quickly absorbs heat, and so helps 
to neutralise its increased production. Under the influence of 
great external heat, the cutaneous vessels become quickly 
enlarged, blood flows freely to the surface ; and, hence, as long 
as perspiration goes on, the temperature remains nearly normal. 
But besides this peripheral mechanism which, so far, only acts 
like the safety valve of a steam boiler, there are various con- 
siderations which have led physiologists to believe in the 
existence of some central nervous mechanism which tends to 
regulate, not only the production of heat and the maintenance 
of the normal temperature in health, but its abnormal vari- 
ations in disease. 

As the high temperature in fevers and inflammatory diseases 
is proved to be due, not merely to a derangement of the com- 
pensating functions of the skin and vaso-motor nerves, but, in 
a still higher degree, to an increased production of heat (and 
of this there can be no doubt as there is a corresponding- 
increase in the consumption of oxygen and the production of 
carbonic acid), it becomes a question of the highest importance 
to the practitioner to determine its primary cause. And this 
production of heat is always a concomitant of inflammation what- 
ever its exciting causes may be, whether a mechanical, chemical, 
or physical irritant. It is well known that the injection of leucin, 
pus, or septic materials into the blood, produces inflammatory 
synqDtoms ; and it is now demonstrated, as I have already 
pointed out, that many epidemic diseases are entirel}^ due to 
micro-organisms, which live as parasites at the expense of the 
tissues- or blood of the unfortunate individuals afflicted. It 



Dr. MuNRO — TJiC Scientific Basis of Medicine. 271 

has also been shown by Pasteur and others, that many of these 
microbes can exist quite independently of a supply of free 
oxygen from the atmosphere, preferring, indeed, to decompose 
the tissues in which they live for the sake of their oxygen, 
Maj^ not the ammoniacal products thus set free become a 
secondary source of poisoning ? 

In further prosecuting this inquir}-, we are overwhelmed 
with difficulties. Does this high tenq^erature, which we have 
just seen to be an invariable symptom of so many diseases, 
proceed from irritation of the nerve centres, which are sup- 
posed to regulate the warmth of the body, or from actual 
accumulation of heat owing to a derangement of the cutaneous 
mechanism which prevents it escape ! Or is it due to a 
thermogenic poison in the blood? Or is it a concomitant of 
the life functions of these anaerobic microbes ? I am not 
aware that any physiologist has answered these questions in 
so full and satisfactory a manner as to assign to each of these 
probable factors its proper share in the elevation of temperature 
in disease. Until this is done I hold that antipyretics should 
be used with much greater caution than is now the fashion. 
Not only are we ignorant of the exact primary causes of the 
increased temperature, which may be different in the different 
diseases, but we are ignorant of nature's intent, so to speak, in 
so invariably resorting to it. That it is used in some way 
or other as a means of defence, and forms part of the general 
plan by which the disturbing elements are being eliminated, 
is quite probable. In epidemic diseases, where the disturbing 
element is some chemical compound — the result of the vital 
action of micro-organisms, which would poison the system unless 
quickly eliminated — we see a probable field for rational 
therapeutics, as well as an explanation of the injurious effects 
of administering drugs which have a tendency to diminish the 
function of the excretory organs. Granted that quinine has 
some special influence on ague, and that it both shortens the 
attack and mitigates the suffering of the patient, does it for 
this reason follow that it should be prescribed in every case 
of disease that shows a considerable rise of temperature? 
Further, to say that the dose must be increased in proportion 
to the increase of heat is both illogical and irrational. So far 
as scientific research has gone, it points to the conclusion that 
the functional activity of different species of microbes produces 
different kinds of chemical substances. Of this the different 
kinds of fermentations afford some striking illustrations. 
According to recent investigations, the microbe of yellow fever 
has been discovered, and its function proved to be the secre- 



272 Dr. Mvsro— The Scientific Basis of Medicine. 

tion of an "alkaloid of a special character which resembles 
ptomaines, and acts on the organism as a violent poison." 
(Brit. Med. Jour., 29th November, 1884.) 

The rapid circulation immediately following- increased 
muscular action, and the consequent additional pro<]uction of 
heat, is quickly followed by cutaneous perspiration which 
carries it off. If we, therefore, follow nature's indication, one 
method of lowering the temperature ought to be by facilitating 
perspiration. This is the special physiological action of 
salicin and its compounds, which act by causing a temporary 
paralysis of the vaso-motor nerves, and the special nerves 
which regulate the opening and shutting of the cutaneous 
pores. The physician rejoices when he finds the skin of a 
fever patient moist and soft ; and this change is always 
coincident with a fall in the temperature. As long as anti- 
pyretic medicines are confined to moderate limits, such as 
aiding the clearly defined indications of nature, I believe they 
are capal)le of doing good, but when they arc pushed to the 
extent of enfeebling, if not paralysing, the entire metabolism 
of the body — a result which I have often seen — I am equally 
satisfied that they do harm and greatly lessen the chance of 
recovery. On this subject I quote the following words from a 
speech of Professor Gairdner, at the last General Meeting of 
this Association. He said that " He could by no means admit 
that the one object of treatment in an acute disease wac to 
keep down the temperature by hook or by crook. It was 
impossible to regard the human body in an acute disease as a 
mere mass of overheated tissues, or to suppose that, by merely 
cooling it down outside, one could restore health and function 
when otherwise fatally disabled. When it was said that one 
must absolutely cool down the patient till it became necessary 
to give him stimulants to set him up again, he thought that 
the limits of safety in antipyretic practice had probably been 
exceeded. When it was said that, failing the cold bath, it 
was necessary to give enormous and repeated doses of quinine; 
and, failing these, enormous and certainly dangerous doses of 
digitalis, aconite, and even veratria, with the single object of 
getting down, and keeping down, the temperature, in diseases 
certainly admitting of fairly successful treatment without 
nearly so much interference, he confessed that he had thought 
that the practice of medicine was running in a wrong direction, 
that they were likely to have the story of the past repeated 
once more — a time of energetic and active practice (so-called) ; 
that is, of extremely powerful, and in some cases dangerous 
and eyen poisonous remedies, so advocated as to make them 



Dr. Muxro — Tlte Scientific Basis of Medicine. 273 

appear indispensable, and to place them, as such, in the hands 
oi every one all over the country. A system of that kind was 
very likely to run into abuse, and he could not, as a teacher of 
medicine, countenance it without considerable reservations." 
(Brit. Med. Jour., Oth December, 1884.) 

Having now exercised our critical privilege to the extent of 
dethroning medical art from the divine position assigned to it 
in the earlier ages of the world's history, and rejecting all 
its hereditary theories and empirical doctrines, as affording 
no rational grounds for the blind confidence placed in the 
curative powers of drugs, it remains to be asked, What are 
the principles, if there be any, which guide medical men in 
the treatment of disease ? What is the raison d'etre of the 
ars viedendl ! In the absence of positive indications from 
theories as to the nature of disease, must we consider each 
disease on its own merits, and, having dismembered it, as it 
were, treat its individual symptoms ? If there is no concensus 
of agreement on these preliminary points, there is still less 
about the means by which the proposed curative ends are to 
be attained. Are we, therefore, to conclude that medical prac- 
titioners of the present enlightened era are like the Israelites 
of old when, having sinned against God and forsaken the ways 
of their fathers, " every man did that which was right in his 
own eyes." Considering the diversity of opinion that may 
probably exist among my medical confrere>< on these problems, 
it may be advisable to lay some phases of their solution 
before you in other words than mine. I will, therefore, adduce 
written evidence from two distinguished authors and teachers 
of medicine, and I select these, not only because their opinions 
appear to me diametrically opposed, but because they both 
happen to have expressed them at the same time. The first 
extract is from the writings of the late Professor Niemeyer, 
whose text Viook on medicine is largely used in this country ; 
the other extracts are from medical addresses by Professor 
Gairdner, of Glasgow. 

" My outspoken assertions of ten years ago have come true. 
I then denounced the error of postponing all medical treatment 
of disease until our knowledge of the action of medicines, and 
our insight into pathological processes, should be so far 
advanced that means of cure would be self-evident. I pro- 
nounced this ideal goal to be unattainable, and declared it idle 
to hope for a time when a medical prescription should be the 
simple resultant of a computation of known quantities. I 
lamented that physicians, instead of striving to promote the 
healing art by their own efforts, should seek aid from the 

No. 4. T Vol. XXin. 



27-1 Dr. Munro — The Scientific Basis of Medicine. 

institutes of physiology and pathology, or from the laboratory 
of the chemist, obtaining now and then an incjenious suo-efestion, 
but never gaining an idea serviceable in the relief of an 
afflicted fellow-creature. I further showed that experiments 
made with medicaments upon the lower animals, or upon 
healthy human beings, with all their scientific value had, as 
yet, been of no direct service to our means of treating disease, 
and that a continuation of such experiments gave no prospect 
of such service. I finally declared, without reservation, that 
even the dazzling progress which pathology had made, had 
been of but little use to therapeutics ; that, in spite of new 
discoveries, our present success at the bedside is scarcely more 
favourable than that of .50 years ago ; nor in the future would 
pathological investigation promote therapeutic success, unless 
directed more in accordance with the requirements of general 
medicine than has been done hitherto." (Preface to Text Book 
on Practical Medicine, 7th edition, 1876.) 

On the other hand, Professor Gairdner writes as follows : — - 
" The art of medicine is at this moment in a peculiar position. 
The day of orthodoxies is over, the day of real science is only 
just dawning. It is no longer possible to condemn a man, even 
by implication, for having ceased to believe what our fathers 
believed ; but it is extremely difficult to state in general terms 
what we believe ourselves, and still more difficult to forecast 
the future, and to lay the foundations of the faith of our suc- 
cessors. . . . When we try to express in definite words 
the beliefs under which we act in our daily practice, how much 
there is of imperfect knowledge, how little of secure and 
clearly defined conviction ! Is blood-letting useful in pneu- 
monia or in apoplexy ; and if so, in what cases, and to what 
extent ? Are alcoholic liquors useful in fevers, under what 
circumstances, and to what extent ? What is the cause, and 
what is the preferable treatment of acute rheumatism ? Is 
mercury to be given in pericarditis, or other acute heart dis- 
ease ? Or in syphilis, and if so, when and how ? Are diuretics 
useful in Bright's disease, and when ? Is opium needful in 
delirium tremens, and when ? How would you treat acute 
dysentery? with calomel, or leeches, or ipecacuanha, or opium, 
or with none of these ? How would you treat cholera ? with 
opium, or with purgatives, or with neither ; and if with either, 
in what cases and under what conditions ? Who does not feel 
that in most of these instances questions have been started in 
which the old orthodoxies have been rudely shaken within the 
last twenty years, and in which nothing more definite or fixed 
can be alleged as having come in their place ? Who does not 



Dr. Munro — Tlie Scientific Basis of Medicine. 275 

feel that to set up a new creed in any of these particuhirs now 
woukl be to insult the dignity of science, and to do incalculable 
injury to the cause of truth ? For in almost every one of these 
instances the wise and skilled physician, of fully formed 
experience, has profited largely, and his patients have profited 
still more, by the destruction of authoritative beliefs involved 
in most of these questions." 

Professor Gairclner, writing subsequently witli reference to 
the address from which the above quotation is given, says — 
" The sixteen years since these words were written have been 
years of immense activity in research, and very much of what 
has been done in them tends, at least, to fulfil the promise of a 
medical art of the future founded not on mere hypothesis, still 
less on dogmatic statements fortified by authority, but on 
accurate, continuous, and patient demonstration of fact. In 
the first place, the art of diagnosis is constantly being improved 
by the introduction of new methods ; and the basis of all these 
methods consists in this, that diseases hitherto quite obscure, or 
called only by their conventional names corresponding to their 
most obvious symptoms, are being daily defined and rendered 
into much more exact conceptions in the light of an improved 
phj'siology and pathology, resting on observation and experi- 
ment. . . . Every day and every year removes us farther 
from the period when it is possible merely to make chance hits 
in therapeutics, and so, by an individual haj^py thought, or par- 
ticular prescription or nostrum, to compete with those who are 
investigating cautiously and experimentally the result of 
remedies in disease." (Medical Education, Character, and 
Conduct, p. 20, et seq.. Addresses 186G and 1882.) 

From whatever standpoint these authors contemplated the 
phenomena of diseases and the means of curing them, it is 
impossible, by any process of levelling up or levelling down, 
to reconcile their teaching. Professor Niemeyer actually 
laments that physicians should seek aid from the institutes of 
physiology, chemistry, pathology, and the results of experi- 
ments made on healthy man or the lower animals. By the 
most liberal interpretation of his doctrines, scientific medicine 
woulil l)e made to hang exclusively on accumulated experience 
and clinical observation, or, in other words, on rational empiri- 
cism. Ignorant and indolent physicians may take shelter 
under the cloak of an art that pretends to penetrate the secrets 
of nature without the trouble of understanding or investigating 
her methods of action, and gives scope for a belief in an 
acquired empirical skill to cure diseases and meet all their 
critical emergencies in the most satisfactoiy manner, with no 



276 Dr. Munro — The Scientific Basis of Medicine. 

higher philosophy than is involved in the oft-proved fallacies 
of the post hoc ergo propter hoc argument ; but, for my part, I can- 
not, and will not, endorse pretensions that are so contrary to 
the spirit of research which, in other departments of natural 
science, has so signalised this century by its marvellous dis- 
coveries. Nor must it be forgotten that empiricism, sometimes 
of the most rational kind, and clinical observation, have both 
been coeval with the earliest development of medical art ; and, 
in the hands of such acute philosophers as the Greek physicians, 
headed by the immortal Hippocrates, we have an example of 
the utmost they were capable of doing till a further expansion 
of natural knowledge took place. But whatever their value 
may be as means of investigating disease, they are not dis- 
carded by the methods of study and research advocated by 
the scientific school of progressive medicine. 

In summarising from these scattered thoughts with which 
I have attempted to delineate the scientific principles that 
underlie the medical art, and link its various instruments and 
appliances with the common substratum of the ascertained 
truths of natural science, the following are the categorical 
conclusions arrived at : — 

1. The keen, persevering, critical, and deep insight cultivated 
by trained observers in the study of natural phenomena and 
their bearing on the various phases of organic life is fast 
extending to medical science ; and already, not only have its 
methods of investigation been improved and extended, but 
many of its antiquated cobwebs have been brushed aside. 
Hence, many of the past medical landmarks, though profes- 
sedly founded on observation, confirmed by experience, and 
backed by the authority of great names, have been found, 
when subjected to the searching light of modern research, to 
have no foundation in fact, and are consequently rejected. 
All the phenomena of disease are connected with material 
causes ; and must, therefore, be referred to the same biological 
laws which regulate organic life in health. Diseases are as 
much the product of natural laws as health. 

2. One of the first fruits of this far-reaching philosophy is 
the foundation of the science of preventive medicine, which 
aims at the discovery and destruction of the physical causes of 
disease, as it were, in embryo; and the benefit already conferred 
on humanity by its legislative enactments, in the actual saving 
of life, is incalculably greater than all the other achievements 
of scientific medicine ; and yet it is the one department of the 
medical profession whose students are most neglected, and 
for whom there is no adequate remuneration. 



Dr. Munro — The Scientijic Basis of Medicine. 277 

3. The special province of the physician, however, is not the 
prevention of disease, but its treatment. This necessitates, as 
a mere preliminary step, not only an accurate knowledge of 
the normal phenomena of the human body, its cellular, 
nutritive, and chemico-vital processes, and the functions of its 
various organs, and how far the operation of one organ 
relieves that of another, but also a corresponding acquaintance 
with the abnormal symptoms excited by the various diseases, 
their primary causes, progress, duration, and natural termina- 
tion, the therapeutic and physiological action of drugs, and 
the processes by which poisonous and foreign elements are 
eliminated out of the system. The object of all treatment 
is to assist the curative efforts of nature ; and the prudent 
physician must be rationall}- satisfied, under the full light of 
scientific investigation, that his plan of interference is not 
opposed to that of nature or, if so, that it is superior to it, and 
will be for the ultimate good of the sufterer. Treatment may 
be directed towards a variety of objects, as the removal of 
causes, palliation of sufiering, establishment of favourable 
hygienic conditions, and the stimulation of the function of one 
organ, or the abatement of that of another, &c., according to 
circumstances. One poisonous element is removed through the 
skin, another through the lungs, kidneys, or bowels, and a third 
may be counteracted or destroyed by drugs. The discovery 
of remedial agents is greatly assisted by a knowledge of the 
nature and properties of the injurious substances to be removed; 
hence the trial of suo^crested remedies, within safe limits, is to 
be commended in proportion to their scientific reasonableness. 
As an illustration, we would say that experiments, directed 
towards the discovery of a remedy for small-pox, would be 
more likely to be successful now than when we were ignorant 
of the fact that this disease is due to a specific micro-organism. 
Without, therefore, altogether rejecting this suggested, or 
rational, form of empiricism, it must be acknowledged that, 
to whatever extent it may be carried, all treatment founded 
upon it should ultimately be explained by natural laws. 

4. If it be true that scientific medicine is dependent on our 
knowledge of the laws and phenomena of the immediate and 
collateral sciences which regulate human life, it follows, that 
the field of action for medical practitioners is almost illimitable. 
It not only affords abundant scope for all kinds of manipulative 
research in physiology, pathology, and therapeutics, but 
involves the consideration of logical deductions requiring the 
exercise of the highest intellectual faculties. To ascertain and 
describe the exact influence of a given drug on a highly 



278 Current Toincs. 

developed organism like the human body is, in my opinion, 
one of the most profound problems that can be submitted to 
the ingenuity of man. The power of observing correctly is a 
logical faculty which, when applied to the complex phenomena 
of life in health or disease, requires much training, knowledge, 
and experience. To a marked defect in medical education on 
this point, and the proverbial proneness on the part of the 
public to believe in sensational cures, must be ascribed most of 
the defects,, pretensions, impostures, and quackery still pre- 
valent in the medical profession. 



CURRENT TOPICS. 



The Outbreak of Scarlet Fever at Castlehead, Paisley. 
— The appearance of scarlet fever in five self-contained villas 
situated at Castlehead, Paisley, within the space of a fortnight, 
all of which were supplied with milk from one source, and 
none of which were subjected to any other influence in 
common, except the open air of the locality and the gravitation 
water supply, was a fact which could scarcely escape the 
attention of a physician in search of a cause. In view of the 
unconscious experimental proof supplied by the domestic 
habits of one of the infected families, the suspicion was raised 
to the position of demonstration. In this family two supplies 
of milk were received — the one from a farm in the country, 
the other from the Castle Street dairy which supplied the rest 
of the infected families. Three children used the farm milk 
and escaped ; two children used the Castle Street milk, but 
one used it raw, the other boiled. The child who drank the 
raw milk was infected ; the child who drank the boiled milk 
escaped. The state of matters in the daiiyman's family was 
found, on inquiry, to be this — the house and the dairy 
were en suite in one building ; and the business was conducted 
by the household so living. A child sickened at the close of 
November. The family doctor saw him on the 26th and 
diagnosed scarlet fever. He recognised the danger and 
advised removal to the Infirmary; but the tears of the mother 
shook his resolution. He assumed the part of arbiter between 
the demands of public safety and parental sentiment, and 
submitted to a so-called isolation, the character of which was 
demonstrated by the seizure of other two children on the 10th 



Current Topics. 279 

and iTtli December — an interval wliicli proves that the 
infection did not reach these children before the " isolation," 
but was the result of the distribution throughout the premises 
of the specific debris of the original case by the same personal 
intercourse and common atmosphere of the apartments, 
which poisoned the milk distributed therefrom to the five 
self-contained villas. So much for the proof afforded, by the 
activity of the poison both within and without the premises, 
of the reckless manner in which the dairyman must have 
conducted his business. A prosecution was instituted against 
the dairyman under the Dairies, Cow-sheds, and Milk-shops 
Order, issued by the Privy Council under the Contagious 
Diseases (Animals) Act, July, 1879. The cardinal facts 
brought out in evidence were these — (1) The dairyman 
admitted that he and his wife visited the patients morning 
and evening, but asserted that they did not " touch " them. 
(2) The servant stated that her mistress " attended " the 
patients and ndlked cows and gave out the milk for Castle- 
head. Her master also milked the cows. They both 
disappeared up the stair leading to the patients' room, but 
she could not say whether they " touched " them. (3) She 
also stated that the nature of the disease was concealed from 
her, and a neighbour testified that she was told it was 
" inflammation," and was ordered out of the house because she 
said " there was fever in accused's house." (4) The children 
gave evidence that their parents did not " touch " them. The 
verdict of the Magistrate was " not proven." 

It is impossible to comprehend such, a verdict, unless the 
clause of the Order under which the charge was drawn is 
before us, and accordingly we reproduce it. 

" 9. It shall not be lawful for any person following the trade 
of cow-keeper, or dairyman, or purveyor of milk, or being the 
occupier of a milk-store or milk-shop — 

"(1) To allow any person suffering from a dangerous in- 
fectious disorder, or having recently been in contact with a 
person so suffering, to milk cows or to handle vessels used for 
containing milk for sale, or in any way to take part or assist 
in the ccmduct of the trade or business of the cow-keeper or 
dairyman, pui-veyor of milk, or occupier of a milk-store or 
milk-shop, as far as regards the production, distribution, or 
storage of milk ; or 

"(2.) If himself so suffering, or having recently been in 
contact as aforesaid, to milk cows, or handle vessels used for 
containing milk for sale, or in any way take part in the 
conduct of his trade or business, as far as regards the pro- 



280 Current Topics. 

duction, distribution, or storage of milk — until in each case all 
danger therefrom of the communication of infection to the 
milk or of its contamination has ceased." 

It was necessary to prove either that some one actually 
suffering from scarlet fever had engaged in the business, or 
some one "having recently been in contact with a person so 
suffering." The dairyman was careful to say that he did not 
"touch tJie 'patients" and there was no evidence that his wife 
Avho " attended " the patients had " touched " them. No other 
verdict than that of "not proven" could have been given 
under a penal enactment so worded, and ^^"it]l such evidence in 
support of the charge. We have in this failure of justice a 
striking illustration of the result of entrusting the verbal 
expression of laws dealing with questions involving a minute 
acquaintance with the practical etiolog}^ of infectious disease 
to persons who have no such knowledge. This Order emanated 
from the Privy Council, who are the administrators of an Act 
dealing with the Contagious Diseases of Animals. Milk is the 
product of an " animal," but it would be quite as reasonable to 
ask the Water Commissioners, acting under the advice of civil 
engineers, to legislate regarding the distribution of enteric 
fever or cholera by water as to trust to the Privy Council, 
with the aid of veterinary surgeons, to legislate for the 
protection of milk from contamination with those diseases of 
human beings. Every clause of the Milk Shops Order is as 
defective as that recited above. They all break down through 
similar defects of expression, when brought to the test of a 
prosecution founded upon them. Until the whole subject of 
the regulation of the milk trade is divorced from its unnatural 
alliance with the Contagious Diseases (Animals) Act, and dealt 
with in a General Public Health Act, the public will continue 
to be, as they are now, deluded with a sense of protection 
w^hich is a mere sham. Between the inefficiency of the rural 
Sanitary Authorities who administer the present antiquated 
Public Health (Scotland) Act, and the helpless indifference 
of the County Authorities who administer the Contagious 
Diseases (Animals) Act in rural districts, the public are being 
daily poisoned with impunity. In Burghs again, where the 
same authority administers both Acts, though under a different 
name, the law is inoperative from the defective expression 
of its intention. 

The newspapers tell us that this verdict in the Castlehead 
case was "received with loud cheers by the audience in Court." 
We may be certain that those cheers did not proceed from the 
inhabitants of the villas, but from the same persons who had 



Cutn^ent Topics. 281 

the indecency, on the 9th of March, to meet in the Geoi'ge 
Hotel, Paisley, where the dairj'nian was "presented, by a 
number of his brother cowfeeders and friends, with a purse 
of sovereii^ns, marble timepiece and ornaments, and also a 
brooch and pair of earrings for his wife." There is not the 
slightest doubt, on evidence which meets the most rio-orous 
requirements of scientific induction, though it failed to satisfy 
the conditions of an indictment drawn under a slip-shod piece 
of legal phraseology, that this man inflicted a grievous injury 
upon his customers. Nay more, he spread disease among his 
customers by the same negligence with which he spread 
disease in his own family. The same is the course of events 
in the frequent case of epidemics of enteric fever established 
among the consumers of milk despatched from farms where 
enteric fever has already attacked the household of the farmer. 
The farmer is the co-partner in misfortune with his unhappy 
customers. The same measures which will protect the cus- 
tomers will save the farmer and his family. Paisley is, in 
many respects, an enlightened and intelligent community, but 
her cowfeeders and their friends are groping in gross darkness, 
otherwise such a scandalous ceremony as that in the George 
Hotel would not have been put on record against them. 
Dinners, suppers, and presentations have been got up upon 
many extraordinary occasions, but the occasion of a man 
poisoning his own children and those of his fellow-citizens 
with impunity is certainly the most extraordinary of all 
hitherto recorded. 

The ^Iembership of the Glasgow Pathological and 
Clinical Society. — The Glasgow Pathological and Clinical 
Society, though the youngest of the Medical Societies of the 
city, has, during the twelve years which have elapsed since its 
foundation, been one of the most active and successful. The 
evidences of its prosperity are not far to seek, and the 
following signs of it may be merely mentioned. During the 
whole period of its existence there has always been abundance 
of material brought forward and considered at its monthly 
meetings, and that too not alone by members of the Society 
but by numerous gentlemen outside of its ranks. And in 
proportion to the size of the roll the meetings have always 
been well attended. Further, several very successful discus- 
sions on important medical questions have been organised and 
carried through by the Society. The fact that many gentle- 
men from other important centres of medical teaching, such 
as London and Edinburgh, readily came forward to take part 



282 Current Topics. 

in the debates, is evidence of the widespread interest which 
they excited in the profession. Among such discussions may 
be mentioned that on Phthisis Pulmonalis which took place 
some years ago, and that on the Pathology and Clinical 
Significance of Albuminuria during last session. In connection 
with this we have had much pleasure in noticing in our 
contemporary, the Edinburgh Medical Journal, a very 
favourable review of the Society's Report of the Albuminuria 
Discussion, the closing sentence of which we may quote as 
illustrating medical opinion outside of our own city — " And in 
bringing this short notice to an end, we would express the 
hope that the Medico-Chirurgical Society of this city may, at 
no distant date, arrange for such a discussion as this of the 
Glasgow Pathological and Clinical Society." And lastly, as 
another evidence of the success which has attended the 
Society's labours, we would call attention to the first volume 
of Transactions which has been published during the present 
session, and which contains the record of a great deal of 
careful and good work. 

These facts in connection with the past history of the Society 
being remembered, it will easily be understood that any move- 
ments having for their object the alteration, either of the rules 
or the constitution of the Society, must be of considerable 
interest, not only to the members themselves, but also to the 
medical profession of Glasgow and neighbourhood. Under 
these circumstances we have thought it right to notice some 
recent discussions which have taken place with reference to 
the membership. The present state of the law in this matter 
is, that the membership is restricted to forty, any vacancies 
being filled by ballot from amongst gentlemen who have 
made communications to the Society ; that absence from three 
consecutive ordinary meetings incurs a fine of 5s ; and that 
absence from all the meetings of a session involves lapse of 
membership, the Council having the power to re-instate such 
a member for one session only, a second default being final. 

j^.mongst the business on the billet calling the meeting for 
the 9th February, 1885, was announced a motion by the 
Council to the efiect that the membership of the Society should 
be increased by five. The reason for this step was, that the 
Council thought it desirable that several gentlemen who had 
made important communication.s to the Society should be 
admitted as members. At the meeting indicated the question 
was very carefully discussed, and the motion of the Council 
almost unanimously set aside in favour of an amendment by 
Dr. Macphail that the membership be not increased, the 



Current Topics. 283 

same crentleman also e-ivinfj notice of motion for the next 
meetinor that the rule re^'ulatino; the attendance of members 
and lapse of membership be increased in stringency. At the 
March meeting, in the absence of Dr. Macphail, who was late 
of ari'iving, the President put the motion from the chair, and 
Dr. Renfrew moved an amendment that the rule be not altered, 
which was carried by a considerable majority. 

It will thus be seen that, for the present at least, no change 
will be made either in the membership or the rules of the 
Society, but how far this is an advantage, of course, remains 
an open question. We are decidedly of opinion that the 
resolution not to increase the membership was right. The 
object of the foundation of the Glasgow Pathological and 
Clinical Society was work, i. e., work as opposed to mere talk, 
and the founders thought that they could best accomplish this 
end by a limited but very carefully selected membership. The 
success of past years, to which we have briefly alluded, has 
shown that they were right ; and another result of this 
resolution of the founders is that membership of the "Path- 
oloofical" is regarded as valuable in a sense that cannot be 
applied to enrolment in any other medical society of the city. 
The members, too, by their vote at the February meeting, have 
shown that they regarded the limited membership as one of 
the elements of success not to be tampered with; and we know 
that the same opinion is held by some at least among the 
gentlemen who are well worthy of membership, and for whose 
sake we believe the Council brought forward its motion to 
increase the membership by five. Whilst objecting, therefore, 
to an increase of membership, it was probably thought by 
some that more stringent rules as to attendance should be 
enforced chiefly, we should imagine, with the object of stimu- 
lating such members, as are only so in name, to increased 
activity and interest in the work of the Society, or, failing 
this, of getting rid of them altogether. With this idea we 
are quite at one, notwithstanding the expressed opinion that 
the principle of compelling attendance is a bad one. It may 
be so for societies where finance is more an object than the 
advancement of medical science by united and earnest work ; 
but, as we have already indicated, it is and has been a good 
principle for the Glasgow Pathological and Clinical Society, 
and we are therefore very sorry, in its interests, that Dr. 
Macphail's motion was lost. We take it that the Society has 
no wish whatever to compel attendance (regular attendance 
being nothing more than the natural outcome of any interest 
whatever in the Society's work), and we think that the very 



284 Current Topics. 

moderate demand that to retain membership a gentleman 
must at least attend two out of the eight meetings held during 
the session is one that nobody need complain of. 

Peofessor Ogston, of Aberdeen, has gone to Suakim by per- 
mission of the Government. The War Office announced that no 
civilians are to be employed on the medical staff of the army ; 
but Dr. Ogston represented that, as his duty is to teach 
surgery to students — some of whom may enter the public 
service — it would be of advantage to him and them if he had 
the opportunity of seeing some military surgery, and becoming 
acquainted with the duties of medical officers in field service. 
The Government have therefore consented to his being present 
with the army at Suakim as a visitor. 

It may be interesting to our readers to recall the fact that 
the Professors of Surgery and Clinical Surger}^ in Glasgow 
University, Drs. Macleod and George Buchanan, had a similar 
opportunity, having been attached as Civil Surgeons to the 
army in camp before Sebastopol during the Crimean War. 

Professor Buchaxax has intimated to the War Office that, 
in the event of Civil Surgeons being required to be added 
to the medical staff for the autumn campaign, he will be pre- 
pared to recommend a number of young graduates for such 
appointments. The following is the reply : — 

" I have caused your request to be registered, and an official 
reply sent ; but I may add that, should we require volunteers, 
I shall not forget your kind offer of assistance. — Yours, &c., 

" T. Crawford, Director General." 

Glasgow University Medico-Chirurgical Society. — The 
closing meeting for the present session was held on the evening 
of Friday, the 20th March, in the Forensic Medicine Class 
Room, when the honorary president for the year. Professor 
W. T. Gairdner, delivered his valedictory address on " Modern 
Ideas as to Insanity, its Nature and Treatment." At the out- 
set Dr. Gairdner referred to the present unsatisfactory state 
of the teaching of insanity in our Scotch schools, and stated 
that, if the remarks he had to make had the effect of stirring 
up in any of his audience a deeper interest in this very impor- 
tant subject, their object w^ould be accomplished. The address 
dealt mainly with the great contrast between the present ideas 
with regard to insanity and those which prevailed during the 
Middle Ages, and even up to the end of the last century. Dr. 
Gairdner pointed out that the science of medicine had made 



Current Topics. 285 

no greater stride than tliat involvcil in the present mode of 
dealing with the insane, and showed that it was just the out- 
come of those modern doctrines now permeating medicine 
generally, which had replaced the dogmas of the Immoral 
and other old systems of pathology, which w^ere founded on 
a careful study of normal and abnormal structure and function, 
and which aimed at treating the man ratlier than the disease. 
The address was characterised by the Professor's well known 
careful and philosophical st3-le, and was listened to wnth 
evident interest and pleasure by a large audience of students. 
Mr. John A. Macdonald, secretar}- of the Society, moved a 
vote of thanks to the lecturer, and remarked that the influence 
of Dr. Gairdner's introductory address on the " Self-Education 
of the Medical Student " had been ver}^ material in bringing 
about the very successful session which they w^ere now bring- 
ing to a close. 

Notes from Yienxa. 

The so-called "Vagus-Pneumonia." — At a meeting of 
the Society of Physicians of Vienna, Dr. Gartner spoke on the 
so-called " Vagus-pneumonia." He said that a satisfactory 
answer to the question — Why in every case do animals whose 
vagi nerves have been divided die ? has never been oftered. 
The cause of death in many of these cases is inflammation of 
the lungs ; in others inanition ; in others, again, it is fatty 
degeneration of the heart ; while in still others it is an 
unknown, apparently mysterious disease. Traube has 
described tlie lung aflection as Broncho-pneumonia. 

Prof. Billroth found that 6 to 7 hours after the vagus 
nerve of a rabbit had been cut through, there were fully 
developed signs of inflammation present, the flrst traces of 
which could be seen two hours after the operation. After 
section of both vagi rabbits seldom live longer than 24 hours. 
Dogs, on the other hand, survive as much as 5 to 6 days, more 
especially when the sections take place at different times. A 
dog operated on by Nasse lived G2 days after the second 
section. The cut ends of the nerves have a strong tendency 
to unite again. When this occurs death is much delayed ; it 
always, however, finally takes place. One should therefore 
not merely cut the nerve across, but also remove a portion of 
the trunk, and in this way prevent union. 

In all cases, then, the simultaneous division of both vagi is 
followed ]jy death. On the other hand, if we cut one nerve 
only, there is scarcely any danger to life. One vagus is 
evidently sufficient for the purposes of life ; indeed, this has 



286 Current Topics. 

been seen in patients where a small piece of a vagus nerve 
has accidentallj^ been removed during an operation. 

As to the phenomena following section of a vagus, the 
respiration becomes slower ; the inspirations are lengthened, 
and require for their performance all the muscles of respira- 
tion; expiration is jerking, rapid, and is effected with the 
help of the expiratory muscles ; there is a distinct pause at 
the end both of in- and expiration. 

The inferior laryngeal nerves branch oft* as we know, from 
the vagus after that nerve has entered the cavity of the chest. 
The left nerve curves round the aorta ; the right passes round 
the subclavian artery of that side. They then ascend along 
the trachea to the larynx, the muscles of which they suppl3\ 
A section of the vagus in the neck thus divides the recurrent 
laryngeal nerve. As a result there is paralysis of the majority 
of the muscles of the larynx. The vocal cords are caused to 
lie close too;ether, and remain either motionless, or durincf 
inspiration approach a little nearer to each other. In the 
region of the orlottis there is observed a contraction of the 
trachea. In the case of dogs and rabbits this is not so extreme 
as to endanger life ; in cats and horses, on the other hand, 
suffocation follows. 

As a consequence of the section, the animal cannot phonate ; 
dogs, therefore, cannot bark, nor can they cough, that act 
requiring closure of the glottis. 

In regard to the circulation, changes also take place. The 
vagus contains the inhibitory nerves of the heart. Irritation 
of it causes stoppage of the heart in diastole, or at least slow- 
ing of the pulse. On the other hand, paralysis on section of 
this nerve increases the rapidity of the pulse. It has been 
supposed that this circumstance has some influence on the 
appearance of changes in the lung. But experiments by 
Genzmer and Frey have excluded this possibility. Eichhorst 
asserts that extirpation of the ffbres of the nerve leading to 
the heart causes fatty degeneration of that organ, and that 
this is the cause of death in those cases which do not go on to 
fatal pneumonia. 

In addition to these symptoms in animals whose vagus has 
been divided, there is also present difficulty of swallowing. 
The act of deglutition must be repeated several times before 
the ingested mass can be passed into the oesophagus. The 
vagus being the nerve that supplies the stomach, section also 
paralj'ses that viscus. Though swallowing is attended with 
difficulty, the food eventually reaches the stomach ; yet in 
spite of this the animals die of inanition, caused no doubt by 



Current Topics. 287 

the fact that constant vomiting is present. It was well 
known to Magendie that -section of the vagus caused vomiting, 
but hitherto no satisfactory explanation of the fact has been 
offered. Several of the animals operated on by us (says 
Gartner) vomited the food even before they had finished the 
meal, many of them only on imbibition of fluids as well as of 
solid food. It was discovered that vomiting could be induced 
by gently rubbing the anterior aspect of the neck. Move- 
ments of regurgitation were thus aroused, speedily ending in 
rejection of the entire contents of the stomach. To prove 
that the vomited matter proceeded from the stomach, and 
had not been merely lying in the oesophagus, a ^3as^-?no?'^e77i 
on a case of section of the vagi, followed by death, showed 
that violent attempts at vomiting had forced the greater part 
of the stomach itself into the oesophagus. The vomited 
masses have generallj' an alkaline or neutral reaction. This 
raises speculation as to the nature of the digestive juices 
after section of the vagi. It is certain that animals operated 
on in this way emaciate rapidly, whether because there is 
constant vomiting or imperfect assimilation is not determined. 

The fatal endino- follows in rabbits within 24 hours. Doo-s 
die 4 or 5 days after operation, or as long after as a few weeks. 

Can we now decide what is the cause of the pneumonia 
which is so constantly observed ? This question has been 
variously answered. Dupuytren supposed that the transform- 
ation of venous into arterial blood was effected by the vagus 
nerve, section consequently of this nerve suspended the process 
of change, and caused death. This theory explains the dark 
colour of the lungs after death of the animal. Emmert first 
suggested the presence of foreign bodies in the air passages as 
the cause of the phenomena. These no doubt play an im- 
portant part in the form of pneumonia observed. Legallois 
drew attention to the paralysis of the larynx. This observer 
was the first to carry out the experiment of dividing the 
recurrent nerve. 

Mendelssohn believed that the changes in the lung, after 
section of the vagus or recurrent nerve, were owing to the 
narrowing of the air passages through irritation of the glottis. 
His experiments in placing foreign bodies in the air passages, 
and in ligaturing the trachea were supposed to prove this, 
since he produced the same lung changes as follow section of 
the vagus nerve. 

This was the state of opinion on the subject on the appear- 
ance, in 1845, of Traubc's classical work — Tlte Cliamges in 
the Parenchyma of the Lungs after Section of the Vagi. 



288 Current Tojncs. 

Traube found mucus and fragments of food lying in the 
air passages of all animals whose vagi had been divided. 
He regarded the process as pneumonia, caused by foreign 
bodies. If he placed a canula in the trachea, preventing 
mucus from flowing into the lungs, no pneumonia followed. 
He concluded that it was not the removal of the lung from 
nervous influences, but paralysis of the larynx and oesophagus 
that caused the pneumonia. 

Schift" divided the vagus high up at the plexus ganglioformis, 
sparing the fibres that run to the larnyx and heart. But in 
spite of this, the charactei'istic changes in the lung appeared. 
He considered that paralysis of the branches to the lungs 
occasioned those changes in the lungs ; the vagus, he said, was 
the vaso-motor nerve of the lung, division of this nerve caused 
hyperemia, oedema, and inflammation. The presence of 
foreign bodies in the lung was merely an accessory part. 
In order to decide the matter, the vagi nerves must be divided 
below the point of departure of the recurrent nerves. 

Experiments in conjunction with Dr. Amrus were instituted. 
The recurrent nerve of a dog was searched for and divided. 
The upper division was passed through a slit in the vagus, 
ligatured there and allowed to unite ; the point of departure 
of the recurrent nerve from the vagus is thus artificially 
removed to a higher level. The operation was performed first 
on the risfht side, a few months later on the left. The dog 
died 16 days after the second operation. At the -post-mortem 
it was found that, on the right side, the recurrent nerve had 
not united with the vagus. With antiseptic precautions, the 
experimenters proceeded to carry out their aims without 
interfering with the recurrent nerves. They removed on the 
left side the fourth rib, on the right side the third rib. The 
vagus was then found, a part of its trunk removed, and 
the wound in the thorax sutured. The animals survived 
the first operation ; after the second, however, they died 
of pleurisy and pericarditis. After the second operation, 
slow respiration, difiiculty of swallowing and vomiting were 
observed. 

Post-mortem examination showed in one case no lung 
changes. In another, in which a fistula had been opened into 
the stomach in order to study the digestive juices, there was a 
large hemorrhagic infarction extending over the middle lobe 
of the riglit lung, there were also three small recent infarctions, 
otherwise the lungs were normal. In both cases it was seen 
that the operations had been correctly carried out. Without 
doubt, the hasmorrhagic infarctions had taken place shortly 



Current Topics. 289 

before death in consequence of increasing weakness of the 
heart, and were not due to division of the nerves. 

We are entitled, therefore, to consider that the lungs remain 
normal when, in section of the vagi, their recurrent branches 
are spared. The recurrents supply the trachea. Thus, to 
avert the lung changes, we have only to retain the trachea in 
a normal state. 

Thus the state of pneumonia, so constantl}^ observed in 
section of the vagi in the neck, is due to paralysis of the 
larj'nx, assisted, there can be no doubt, by the presence of 
mucus and foreign bodies in the air passages, because to avert 
the changes we have only to spare the recurrent nerves. — 
Wien. Med. Wochensck. 

Billroth ox (Esophagotomy. — At ameeting of the Society 
of Physicians in Vienna, on the 20th of February, Professor 
Billroth spoke on the subject of cesophagotomy. He said : — 
I exhibit before you here a woman on whom I have performed 
cesophagotomy. During sleep she had swallowed a set of arti- 
ficial teeth, for the removal o^ which unsuccessful attempts 
had been made before she came to the hospital. These appear 
to have slightly injured the oesophagus. On appearing before 
me the patient's breath was very foul, and there was to be 
observed a painful swelling in the neck. 

In general, I may say, we have no great fears as to the 
result of cases of cesophagotomy. Where, however, suppura- 
tion is present before the operation is performed, mediastinitis 
and pleuritis may arise subsequently to it. In regard to 
prognosis, such cases are not very favourable. 

In the present case Dr. Hacker performed the operation, and 
sutured the wound, having first inserted a drainage tube 
reaching to the stomach. The dressing was iodoform gauze. 

Although, with proper precautions, we can rely on maintain- 
ing aseptic cases which are so from the first, the prognosis 
should be guarded where there has been previous suppuration. 
Even cauterisation, with chloride of zinc or strong carbolic 
acid, may not have the desired effect. In regard to the dress- 
ing, iodoform gauze is very favourable for such cases. 

The drainage tube and the gauze were left in sitit for eight 
daj's. The wound was then found granulating. The patient 
progressed most favourably to recovery. An untoward result 
may, however, arise in the form of stricture of the oesophagus, 
even although examination by means of a bougie convinces us 
that such a state is not present at the time of examination. 

Immediately after this case, another of a similar nature 

No. 4. U Vol. XXnL 



290 Current Topics. 

presented itself at the clinic. A girl, aged 19, had swallowed 
a set of teeth during sleep. Energetic attempts at degh^tition 
had the effect of carrying it down to the cardiac opening of 
the stomach, from whence attempts to remove it were unsuc- 
cessful. On examination in the hospital no obstruction could 
be felt in the oesophagus to the passage of a bougie. It seemed, 
therefore, that the foreign body must be lying in the stomach. 
It is well known that tolerably large bodies can pass tlirough 
the cardiac opening which could pass only with difficulty 
through the pylorus — more especially if they are sharp 
cornered. 

On examination the patient did not complain of excessive 
pain, the stomach was, however, sensitive on pressure. Nothing 
could be discovered in this way. As she was very positive in 
her assertions that she had swallowed a foreign body, I per- 
formed gastrotomy over the left border of the stomach, two 
finger-breadths below the last rib. I then attempted to seize 
the foreign body by a pair of forceps. In this I was unsuccess- 
ful. I then proceeded to draw the stomach through the 
abdominal incision, and believed that I had drawn it all 
through in this way, but still found no foreign body. As I did 
not believe that it could have passed the pylorus I enlarged the 
abdominal incision, and passed my hand into the abdominal 
cavity. 

In regard to this step, I must remark that indications 
seldom arise for such an exploration. Until now, I had had 
no idea how soft the liver is ; so soft, indeed, that it can with 
difficulty be distinguished from the intestinal tube. In the 
dead body it is much harder. The gall bladder was felt 
moderately distended. Both kidneys were remarkably mov- 
able, and could be pushed downwards as much as an inch. 
The urinary bladder was distended. The uterus and both 
ovaries appeared firm. The foreign body could not be felt in 
any of these situations. There remained still to be examined 
the back part of the stomach. I introduced the left hand into 
the stomach, and searched in an upward direction. It is 
difficult to palpate this part of the stomach, because the 
gastro-splenic ligament interferes. Here, however, the teeth 
were found, and after a few attempts I w^as successful in 
removing them. The wound was then sutured. The patient 
made a good recovery, and has not in any way been injured 
by the examination. 

It is interestintr to note that the stomach cannot be alto- 
gether drawn out of the abdomen. I did not know of this 
before. The portion that lies above the incision made in 



I 



Reviews. 291 

operating cannot be drawn out, otherwise the diaphragm would 
be displaced. Owing to the position of the patient during the 
operation, a foreign body tends to be in this part when the 
other portion of the stomach is drawn forward. — Wien. Med. 
Wochent^ch. 



REVIEWS. 



The Transactions of the Edinburgh Obstetrical Society. Vol. 
IX. Session 1883-84. 1884. 

This v^olume is rather more than usually mteresting. Dr. A. 
Macdonald gives an account of two cases of extra-uterine 
fcetation, in one of which, after severe sjanptoms from bursting 
of the cyst, absorption of the resulting ha3matocele took place ; 
in the other, operative interference became necessary six months 
after rupture, owing to continued abdominal pain. In the 
cavity in which the foetal bones lay there was found a 
quantity of faecal matter and a fistulous opening into the 
bowel was observed. In the removal of the cyst, six inches of 
the small intestine which formed part of the cyst wall were 
cut out, and the ends carefully brought together by a con- 
tinuous catgut suture. The fistulous opening was treated in 
the same way ; a large drainage tube introduced, and the 
wound closed. The patient made a fairly rapid recovery, 
hindered somewhat by rawness of the edges of the abdominal 
wound, due to continuance of foetid discharge. 

Dr. Matthews Duncan crives the details of four cases of 
what are called htemorrhagic lupus. There were present in 
all the cases more or less lupus-like thickening and ulceration 
of the vagina, yet histologically, there was no evidence of 
lupus. Sudden and profuse bleeding was the striking 
symptom in all the cases. One of them was apparently 
permanently cured by the use of the actual cautery ; the 
results in the others are not given. 

Dr. Angus Macdonald gives three cases of lupus of the 
vulvo-anal region, one of which was also cured by the ap- 
plication of the actual cautery. In this paper the author 
gives a very careful account of the differential diagnosis, and 
points out that it is frequently confounded with malignant 
disease. 



292 Reviews. 

Dr. Freeland Barbour gives a long and painstaking account 
of the anatomy of the uterus during the Urst days of the 
puerperium. His observations are founded on the examination 
of six uteri from the bodies of women who had died soon 
after labour. The paper is interesting, although more purely 
scientitic than practical in its character. 

Dr. Leith Napier gives two cases of puerperal albuminuria, 
one ending in reflex paralysis ; the other in eclampsia. He 
believes that the one may be alternative to the other, and that 
fuschin will be found useful in the kidney diseases associated 
with pregnancy. The discussion on this paper gave Dr. 
Macdonald an opportunity of adverting to his special and 
carefully wrought-out view of the causation of puerperal 
eclampsia, wdiich is thus stated — " It will be remembered that 
I was led to believe that the essential pathology of the disease 
was traceable to irritation of the vaso-motor centres in the 
medulla oblongata. This irritation, whether originating in 
the effects of impure blood circulating in the vaso-motor 
centres, or reflexly from impure blood circulating throughout 
the tissues, I was inclined to hold, caused general contraction 
of the arteries. In the brain this led to extreme anaemia of 
the central parts, and engorgement of the peripheral portions. 
This central anaemia I regarded as the cause of the fits, the 
peripheral venous engorgement, which was of the nature of a 
compensating arrangement, being the source of the pain and 
coma. I was then, and I am still, inclined to believe that the 
commonest source of this irritation is of the nature of an 
accumulation in the blood of the excretory elements, which 
the kidneys, if healthy, remove. Hence the connection 
of eclampsia with kidney disease. But any powerful peri- 
pheral irritation, such as an extremely irritable lower uterine 
segment, might, in. consequence of the special nervous 
arrangements and susceptibilities of pregnancy, give rise to 
the same irritation of the vaso-motor centres. On this 
principle I explain those cases of puerperal albuminuria 
observed at times, in which there is no renal disease. On the 
same theory I would explain those cases, such as the two I 
have briefly referred to, in which the albumen is trifling and 
transitory. Onl}' it would almost appear that the uterus 
possessed a special power of sympathy with the kidney, 
whereby intense irritation of the former was liable to lead 
to disturbed function of the latter organ. I agree most 
thoroughly with the remarks of Dr. Napier to the effect that 
neither the purely toxa?mic theories, such as the urajmic or 
carbonate of ammonia theories, nor the purely mechanical, 



I 



Reviews. 293 

such as the Traube-Rosenstein — can be maintained. The 
beneficial effects of slight blood-letting upset the former 
entirely, whilst the latter theories can give no explanation 
of those eases that occur independently of dropsy and renal 
disease." 

Dr. Macdonald also gives the details of five cases of Emmet's 
operation, four of which were successful; the author however 
admitting, what is doubtless true, that complete relief from 
the symptoms does not usually follow for some little time 
after the mending of the cervix. Six other cases of the same 
operation are narrated by Dr. Skene Keith, four at least of 
which were followed by good results. 

This volume also contains the Quarterly Reports of the 
Royal Maternity Hospital, which are very carefully compiled, 
and at such length as to be both instructive and valuable 
for reference. 

The proofs have been badly corrected. Thus, on page 217, 
we have hand printed ior head, and connection for contraction, 
and such errors occur here and there throughout the book 
which, on the whole, is very readable and interesting. 



What to do in Cases of Poisoning. By Wm. Murrell, M.D. 
Fourth Edition. London: H.K.Lewis. 1884. 

This is a reliable work by a writer whose name is a guarantee 
of the extent and accuracy of the information here offered. 
Though in its fourth edition, the little book retains its handy 
form. In glancing through it many interesting points crop up. 
For example, it is instructive to notice how soon our " new 
drugs" come to find a place in the poison list ; not only 
have iodoform, pilocarpine, bichloride of methylene, ethidene 
dichloride, nitro-glycerinc, and others more or less familiar, 
been put in this list, but already we find there the abrus 
precatorius (jequirity seeds), convallaria, kairin, and several 
more. The author seems to have overlooked some recent 
researches which have made it clear that the action of the 
jequirity seeds is in no way dependent on or necessarily 
associated with the presence of any minute organism. In 
discussing the treatment of poisoning by such an irritant as 
.solution of ammonia, he neglects to mention the great value of 
ice, both Ijy the mouth and applied externally, as a means 
of checking the fierce pharyngitis and laryngitis set up ; 
in one case of ammonia poisoning which we had under treat- 



294 Revieivs. 

ment the necessity for performing tracheotomy, for which every 
preparation had been made, was obviated by the free use of 
ice. The obstinate gastritis which follows in such cases as 
recover from the acute condition is not referred to. Dr. 
Murrell has brought his little work well up to date, mentioning 
the comparatively recent case of poisoning by male fern, in 
which a dose of an ounce and a half of the liquid extract was 
given instead of a drachm and a half, on the strength of a 
misprint in Napheys' Modern Medical Therapeutics; he 
indicates an important error (also a misprint) in Quain's 
Dictionary, in which, in the article on phthisis, the dose of 
picrotoxine given for night-sweating is set down as I of a grain 
instead of /o- He informs us that in lead poisoning massage 
is of great service performed daily by a properly qualified 
" Masher ; " and makes a somewhat large demand on our 
credulity when he quotes a " good authority" to the effect that 
150,000 children are killed every year by soothing syrups and 
other similar preparations. The author evidently has little 
sympathy with the somewhat hysterical and overdrawn 
pictures often presented to us of the universally pernicious 
effects of opium smoking and opium eating ; he does not 
discuss the subject at length, but gives some useful references 
to the literature relating to it. 

• We have pleasure in most heartily recommending this 
valuable little handbook. 



Notes on Materia Meclica and Pharmacy. By Frederick T. 
Egberts, M.D. London: H. K. Lewis. 1884. 

The necessity for making some kind of separation between 
the two great departments connected with the study of drugs 
— pharmacy and materia medica on the one hand, and thera- 
peutics on the other — is one which has long been present to 
the minds of teachers of the subject. The field covered by the 
first of these divisions is a large one, including, as it does, 
a more or less extensive knowledge of botany, chemistry, and 
general phj-sics, while its importance to the practitioner admits 
of no question. How often, for example, does it happen that 
a most exhaustive inquiry into the circumstances of a case, a 
most elaborately considered diagnosis, and a well weighed 
prognosis, come to nought simply from a defective knowledge 
of the remedial agents proposed to be emplo^'^ed, from ignorance 
of their modes of combination, their general properties, or the 



Revieivs. 295 

properties of the special preparation used. "We Relieve, tlicre- 
t'ore, that they grievously err who would releg-ate to an 
altogetlier subordinate position, or even practically suppress, 
this most important brancli of study. On the other hand, the 
details of tlierapeutical knowledge have so accumulated during 
the past quarter of a century, more especially as regards the 
phj-sicilogical action of drugs, and the endeavour after a truly 
scientific system of therapeutics, one in which therapeutical 
use is distinctly' traced to the phj'siological action of the agent 
employed, has become a matter of so much solicitude to every 
conscientious teacher, that any attempt to combine the two 
branches in any ordinary course — say of one hundred lectures 
— must necessarily be futile. It is impossible to discuss 
satisfactorily in one course such subjects as materia medica 
and therapeutics. 

Considerations such as these seem to have induced Dr. 
Roberts to write this work for the benefit, in the first instance, 
of his own students, that he might devote the whole of his 
lecturing time to therapeutics. The work embodies the facts 
of the pharmacopoeia arranged in a systematic way, and so far 
as we have been able to observe is correct. More than absolute 
correctness as to details, and a systematic grouping of drugs 
and their preparations, is not to be looked for in a work of this 
kind. 



Tlie Elements of Physiological and Pathological Chemistry : a, 
Eaadhook for Medical Students and Practitioners. By T. 
Craxstoux Charles, M.D. London : Smith, Elder, & Co. 
1884. 

We have great pleasure in very favourably recommending this 
volume to the notice of our readers. The subject of Physio- 
logical and Pathological Chemistry is daily l)ecoming of greater 
importance in the study of medicine, and it has been felt that 
the number of works in English dealing efficiently with it has 
been somewhat limited. The appearance of Dr. Charles' book 
goes a long way to remove this defect in our medical literature, 
and the plan upon which it has been carried out is one which 
is likely to render it specially useful to the student and prac- 
titioner — viz., the very successful eftbrt which the author has 
made to combine the practical with the systematic, and so 
render the volume one which can be used for private study, 
and also be taken to the laboratory or ward for guidance in 
carrying out investigations. The volume is one of very con- 
siderable size, and thus does not present the objection, which may 



296 Revievjs. 

be so often urged against smaller works, of deficiency in detail. 
Its publication will, wq imagine, to a large extent save the 
practitioner from liaving laboriously to search through large 
German volumes for information on special processes and 
methods. 

The volume is divided into a series of books, which deal in 
great detail with the different subjects as follows — viz., Book 
I, Nutrition and Foods ; Book II, Digestion and the Secretions 
concerned ; Book III, The Tissues : Chemistry of the Tissues, 
Organs, and remaining Secretions ; Book IV, Excreta : the 
Faeces and Urine. If, in addition, we mention that the first 
two chapters give an excellent account of the reagents required 
for ordinary work, and the methods of preparing the more 
usual apjDaratus, &c., it will at once be seen that the scope of 
the book is large, and that its utility to any labouring in this 
particular field is likely to be very great. 

We have pleasure in congratulating Dr. Charles on the high 
character of the volume he has jDroduced, and heartily wish it 
success. 



West African Hygiene. By Charles Scovell Grant, M.D. 
Second Edition. London : Ed. Stanford. 1884. 

We regard this as quite an indispensable little handbook for 
those who intend visiting or staying on the West Coast of 
Africa, or indeed any other malarious region. It is intended 
partly for non-professional readers, and is therefore plainly 
and intelligibly written, with an avoidance of technical terms. 
We are able, from personal experience, to testify to the sound- 
ness of Dr. Grant's advice in regard to tropical hygiene and 
general medical matters as they call for attention in such 
climates as that of the West Coast. 



The Year-Booh of Treatment for 188^. Cassell & Company, 
Limited : London, Paris, and New York. 

The object kept in view in publishing this book is 
stated to be not only to record the advances made yearly 
in practical therapeutics, but to weed out the announcements 
so abundantly made in journals, and to secure a review of the 
same at the hands of competent authorities. This, on the 
whole, the "Year-Book" is successful in carrying out. That 
it has apparently met a " much-felt want" is obvious from the 
fact that this volume is already in its third edition. As a 
valuable, year-book it quite merits its popularity. 



Medico-GkiriLvglcal Society. 297 

The Pharmacopoeia of the British Hospital for Diseases of the 
Skin, London. third Edition. Edited by Balmanno 
Squire, Esq., M.B.Lond. London : J. & A. Churchill. 1884. 

The generally favourable notice which we gave to earlier 
editions of this work may be extended to this third edition 
also. The fact that it is already in its third edition says 
much for its usefulness. We would simply remark, by way 
of criticism, that the Latin of some of the prescription 
headings is not yet perfect, e. g., Pihda Podophylli cam Niice 
Vomicce. We notice that thymol and benzol are treated as 
declinable nouns ; and also, with some surprise, that the only 
oleates mentioned are those of zinc and mercury, and that 
these are directed to be made by the solution method and not 
by the double decomposition process. 



MEETINGS OF SOCIETIES. 



MEDICO-CHIRURGICAL SOCIETY. 



Session 1884-85. 

Meeting Y.—Gth Fehruarij, 1885. 

Professor Macleod, President, in the Chair. 

Dr. J. Wallace Anderson read a paper on the specific 
ORIGIN OF general DISEASE — i. e., of disease generally, in which 
he endeavoured to show the reasonableness of the opinion that 
many diseases (for we could never say how many) were 
caused by specific germs. Our position with regard to disease 
was one of antagonism ; we acted as if assailed by opposing 
forces. Disease, he thought, simply illustrated a law of 
response which was universal. A fever might 1)6 viewed 
as a form of resistance or defence, as a response to an evil 
necessarily is against some special influence or cause which, 
in common with others, was continually around us, but had 
for the time gained a certain degree of ascendancy. He then 
proceeded to consider the specificity of these influences or 
causes. Some of the distinctive features of the fevers usually 
accepted as specific were first noticed, and then diseases of 
more doubtful specificity, as erysipelas, pneumonia, dysentery, 



298 Meetings of Societies. 

and ordinary catarrh. He felt the difficulty of knowing 
where to draw the line, but had no doubt that even a common 
" cold " was a specific affection. The difficulty of the subject 
was increased by the fact that many of our terms included 
probably very different diseases. Pneumonia was one of these 
terms. Some think a fractured rib niuy cause a pneumonia. 
That cannot be the same disease as the ordinary idiopathic 
pneumonia, or still less the exceptional epidemic forms. No 
one would consider the first to be of specific origin, while he 
had no doubt the last variety was so ; indeed, its infectious 
character, of which there was good evidence, was sufficient in 
the oj^inion of many to fix its specificity. In considering the 
objections that might be urged, he said one instinctively hesi- 
tates to believe that erysipelas, diphtheria, dysentery, and such 
diseases have each a specific germ as its cause. This, however, 
was not to be considered unlikely from any idea of a limit to 
variety in Nature. Examples of endless forms were drawn 
from what, by contrast, might be called the visible world ; 
e.g., the infinite variety in the vegetable kingdom. We might 
still refuse to believe that such a vulgar thing as common 
catarrh could lay claim to any kind of descent. But the 
contrast between it and any uncommon disease was not 
greater than that between the ordinary chickweed and some 
rare flower or fern, and yet each had equally its specific origin. 
And lastly, it might be objected that while a rare plant always 
existed somewhere, some diseases were seen perhaps but a 
few times in a century ; e. g., true epidemic influenza. He 
believed that the germs were always present, however, in 
some less potent state, and that these years of special out- 
breaks were analogous to those special seasons of particular 
plants or flowers with which we are all familiar. 

Dr. Hugh. Thomson said that it would now be difficult to 
limit the kinds of diseases for which a germ origin might yet 
be found. The epidemic occurrence of pneumonia might have 
some such origin, as well as the inter-current pneumonia of 
typhus ; but it was rather too far-fetched to say that ordinary 
pneumonia could have a specific origin. The bearing of this 
germ theory on preventive medicine was its most important 
aspect to the ordinary practitioner. 

Br. Perry said that in diflerentiating the natural history of 
typhus from that of typhoid, Dr. Anderson had omitted one 
point. In enteric fever there was sometimes a relapse ; in 
typhus never. 

Dr. M'Vail said that the paper was interesting; but his 
objection to it was that its standpoint was simply speculative. 



Medico-Chirurgical Society. 299 

Now, at tliis period of tlie history of medicine what good was 
to be attained by speculating on the existence and life-activi- 
ties of organisms, the presence of which, in a number of 
diseases, had been absolutely demonstrated by experiment, 
and the life history of which had been carefully studied in 
the laboratory. These germs had not only been isolated, but 
had been cultivated outside the organism, and their character- 
istic effects been again produced on their reintroduction into 
animals. It had been shown that these bacilli of different 
kinds only produced each its own kind ; that they were 
dirierent in appearance and form, and could therefore be 
distinguished from each other. Considering the brief period 
that the germ pathology has been studied, the progress already 
made was marvellous. Dr. M'Vail adverted specially to the 
progress made in the identification and history of the germs 
of erysipelas, pneumonia, and leprosy, a case of which last 
named disease they had recently an opportunity of observing 
in the Western Infirmary. The result of these experiments 
was clearly, to his mind, to remove the germ theory of a 
number of diseases from the domain of speculative into that 
of scientific pathology. One of the most important and 
interesting circumstances in connection with these microbes 
was that under certain conditions they were innocuous, while 
under other conditions the same germs, or others not distin- 
guishable from them, were actively noxious. Thus, the bacilli 
of hay infusion, when introduced into the animal tissues, died; 
but under other conditions apparently the same bacillus might 
develop anthrax. 

Dr. Fleming said that he hardly agreed with Dr. M'Vail 
that no good could come from considering the question of the 
etiology of disease in the germ theory, apart from the stand- 
point of the natural history of these minute organisms. The 
paper, he thought, was a most suggestive one, and opened up 
not a few interesting questions. It would to him, a surgeon, 
be most interesting to watch the progress of the germ theory, 
now that it had passed from the surgical to the medical field 
of investigation. 

Dr. 2Iiddletoii said that it would have been interesting had 
Dr. Anderson shown how the facts of hei'edity in disease 
were to be read in the light of the new theory. It would 
have to be expressed in terms of an impaired power of resist- 
ance to some particular germ. The term "general disease," 
which occurred in the title of Dr. Anderson's paper, was not 
very clear ; it was usually used as antithetic to " local dis- 
eases," but he presumed that it was not so used by Dr.Anderson. 



300 Meetings of Societies. 

Dr. Macfie said that the fact that under different conditions 
the same germs might be injurious or innocuous had its 
parallel in the case of the tsetse fly, which in some districts 
of West Africa, he had been told by Dr. Christie, was most 
harmful to horses, while in other districts the same fly was 
absolutely harudess. 

The President said that in surgery they had certainly for 
many years had warm work of it in respect of these germs ; 
and now that the arena of investigation, and no doubt of 
controversy, had so vastly widened, it would be some time 
before the edifice of the germ pathology of disease could be 
firndy constructed. It was curious to speculate now, on the 
very threshold of the new age of inquiry, what form it would 
have assumed fifty years hence. Dr. Anderson's paper was 
one of great interest, and well expressed. 

Dr. Anderson said that he had no personal knowledge of 
the natural history of these minute organisms, and therefore 
from that side he had said nothing. His standpoint, as most 
of those who had spoken had seen, was that of the natural 
history of disease, and he had endeavoured to show how the 
phenomena met with there pointed in many cases to the 
existence and action of specific germs. He thanked the 
Society for the way in which his contribution had been 
received. 



GLASGOW PATHOLOGICAL AND CLINICAL SOCIETY. 



Session 1884-85. 
Meeting Y1.— 10th March, 1885. 



The President, Peofessor George Buchanan, in the Chair. 
Professor M'Call Anderson showed a case of supposed 

SYPHILITIC INTRA-CRANIAL TUMOUR, GREATLY BENEFITED BY 
MERCURIAL INUNCTION. 

D. M., aged 38, a blacksmith, was admitted to Ward II of 
the Western Infirmary, on 10th February, 1885. He com- 
plained chiefly of severe pain in the forehead and upper 



Pathological and Clinical Society. 301 

part of tlie head, which had been present for about 4 months. 
The family history was good. Twelve years ago he sutiered 
from an attack of gonorrhoea, which lasted about 3 or 4 
months, and did not appear to have left any bad results. 
About 8 years ago he had what he calls rheumatism, de- 
scribing it as constant pains in the bones and joints, becoming 
very bad on movement and markedly worse at night. Three 
years ago he had a painful affection of the throat, lasting for 
about a year. With the above exceptions, he had always 
been a healthy man previous to the onset of the present 
illness. 

About 4 months ago he was suddenly siezed, while sitting 
by the lire, with a violent pain in the forehead, above the 
left eye. It lasted several hours, and he was then free of it 
for about a fortnight. After that he had repeated attacks, 
and noticed that the intervals between them gradually became 
shorter, and since the beginning of the year they had been 
almost constantly present, although with occasional great 
exacerbations. It was not worse at night. The pain above 
described was often very intense, so much so as altogether to 
prevent sleep, and frequently to produce delirium. About 
the beginning of January his eyesight became somewhat 
impaired, so that he was unable to read as well as he used to 
do. On looking at anything steadily for a time, his vision 
became dim, as if a "scum" was before his eyes, and sometimes 
there was a feeling of pressure in them, especially on at- 
tempting to read. 

He professed never to have had any eruption on the skin, or 
falling out of the hair. During the 3 months previous to 
admission, he had lost flesh very much, having become, as he 
thought, about 3 stones lighter than formerly. A few scars 
were observed on the legs, which he said were due to the 
application of croton oil. The scar, on the right leg, a little 
above the outer malleolus, was distinctly coppery in tint. 
There was a rounded and depressed cicatrix on the glans 
penis a little above and to the left of the frenuni. This he 
attributed to a burn from a piece of live coal, although from 
the position of the scar this seemed a very unlikely cause. 
The foreskin was adherent to the glans at the sulcus. There 
were no scars at the angles of the mouth. There was no 
paralysis of the muscles of the face or eyelids, save a slight 
drooping of the left upper lid. The eyeballs were slightly 
prominent, especially the right, but this condition, he said, had 
been present from childhood. The tongue, on being protruded, 
appeared to be slightly drawn to the left side. On tapping 



302 Meetings of Societies. 

all over the head, two spots were found (one over the outer 
angle of each eye), which were distinctly tender. He could 
hear the ticking of a watch better when placed opposite the 
meatus auditorius than on the temple. The greatest distance 
he could hear the watch with the left ear was about 18 inches, 
with the right 24. The smallest type he could read on 
admission was a double small pica, whilst before the illness, 
he said he /yould read the ordinary type of a newspaper, which 
is only half the size of the above. (See Dr. Reid's Report). 

SmeVi and taste seemed to be normal, the dynamometer 
registered 105 with each hand. 

The symptoms were considered by Dr. Anderson to point 
t(o the presence of a tumour within the cranium, and -he 
further considered that there was sufficient evidence of 
its being syphilitic in its origin. The patient had been 
under medical treatment before admission, and had lately 
been taking iodide of potassium in 30 gr. doses. On February 
12th, he was ordered to rub into the skin daily, one drachm of 
Shoemaker's mercurous oleate ointment (the black variety), 
and to have 30 minims of paraldehyde at night, to procure 
sleep. 

In a few da^^s the pain had completely disappeared, and has 
remained away ever since. His sleep also has been perfect. 
He was dismissed on 27th February, feeling quite well, but he 
was advised to continue the treatment for some time longer, 
and to come back occasionally to report himself. 

The following is Dr. Reid's report on the examination of 
the eyes : — 

" Aided by 8 inch convex, he is able to see the smallest 
print at 12 inches with either eye. The area of the field 
of vision is complete in both eyes, there being no defects to be 
found in the lateral parts of the field. The power of dis- 
tinguishing colour is perfect, with the exception of deep purple, 
which he mistakes for black." 

Ophthalmoscopic examination : — " Hypermetropia of ^s" 
found. (Left pupil only dilated.) The left optic nerve seems 
rather prominent, tissue consolidated, and slight signs of eflfu- 
sion along the course of the vessels as they leave the optic 
disc ; but no distinct evidence of there having been choked 
disc or engorged optic nerve, the disturbance not being more 
than is sometimes found in a high degree of hypermetropia. 
The defect of vision which he complains of is to be referred to 
deficient power of accommodation, rather than to an actual loss 
of accommodation. This deficient power of accommodation is 
sometimes seen to follow a shock to the nervous system." 



Pathological and Clinical Society. 303 

D)'. Hugh Thomson remarked that, with regard to the ad- 
ministration of mercury, there was probably something in the 
fact that he had not previously been treated with that drug. 
He related a similar case which was largely treated with 
mercury without benefit, and wliich yielded almost at once to 
iodide of potassium. 

Professor M-Call Anderson also showed a case of 
TUBERCULAR LEPROSY, the clinical history of which was read 
by Dr. Duncan Love ; and Dr. J. Lindsay Steven showed, 
under the microscope, a section of skin showing the leprosy 
bacillus, which had been sent to Professor Gairdner by Dr. 
Thin, of London. 

J. W., a3t. 25, coal dealer, was admitted to the Western 
Infirmary, 4th February, 1885, complaining of a tubercular 
eruption of the face, arms, and legs of nine years', and of 
aphonia of one year's, duration. 

The family history, so far as is known, is satisfactory. 

The patient was born and brought up in India, where his 
present illness began. He had dysentery- about eleven years 
ago, which lasted for two months. Immediately after he had 
recovered from it he begun to suffer from swelling of his 
whole body, especially marked in the upper and lower limbs 
and in the face, which he attributed to drinking bad 
water. It lasted for several weeks and then gradually sub- 
sided. In about two months after it had gone, he noticed 
that his face was becoming swollen and of a dark colour. 
Dark red or brownish spots soon appeared on a level with the 
rest of the surface, not at all distinct at first, but afterwards 
becoming intensely red and inflamed, especially on exposure 
to the sun. The cheeks, nose, lips, and lobes of the ears were 
especially involved. The eruption next appeared on the hands 
and then on the legs. It never showed itself on the trunk of 
the body either in front or behind. The eruption continued 
as dark patches on the skin for two years, when .small lumps 
or tubercles, about the size of peas, made their appearance, 
which have come out in successive crops ever since, and are 
painful for a day or two at first. They appeared first on the 
face, then on the limbs, and were especially numerous on the 
inside of the thighs. These nodules have continued more or 
less ever since, occasionally becoming inflamed, but never 
suppurating. 

He came to this country about seven years ago, and felt 
much improved by the change. He was in the Infirmary on a 
previous occasion from 17th May to 13th November, 1879. He 



304 Meetings of Societies. 

was then treated by the internal administration of chaulmoogra 
oil, given at first in six minim doses three times a day, and 
gradually increased till, for the last two weeks of his stay in 
the Infirmary, the dose was 60 minims. On one or two occa- 
sions, however, before the maximum was reached, the medicine 
had to be discontinued, or the dose reduced, on account of 
sickness and want of appetite. During the last few weeks of 
his residence, 5 minims of ether were given with each dose, and 
seemed to make it agree better. On four occasions, during 
his stay in the Infirmary, fresh crops of tubercles appeared on 
his arms and legs, but the older ones became much less 
marked, and on dismissal he felt much better than he did on 
admission. He commenced business as a hawker of coals in 
the following March (1880,) and felt comparativelj^ well all 
summer, but when the winter came he was exposed to the cold 
and damp, and his face became a great deal worse, as it always 
did at that season. 

On admission, there were patches on the upper and lower 
extremities, rounded in form, and varying from the size of a 
cherry to that of a walnut. These patches have tended always 
to grow to a certain size, to remain so for an indefinite period, 
and then gradually to become less and disappear, leaving only 
a stainino- and slig-ht thickenina; of the skin. 

The features are greatly distorted, the tissues being in- 
filtrated and the natural lines of the surface much exao-o-erated. 
The skin of the forehead is thickened and corrugated, and 
the tissues above the eyelids projecting and hanging down so 
much as to interfere with vision, especially on the left side. 
The eyelashes and eyebrows are almost gone. The lips are 
enormously increased in size, and the superficial vessels 
distinctly visible. A year ago he fell oft' a cart, his face 
striking the ground, and since then tliere has been in the 
forehead and nose a tendency to ulceration, which is covered 
over with dryish crusts. The eruption is also seen on the 
back of the neck, where there is a large crust a little to the 
right of the middle line. The skin of the head, though 
yellowish, is of normal colour, and that of the unafiected 
parts of the body is of a dirty yellow tinge. 

On the arms the eruption is chiefly confined to the extensor 
surfaces, extending from the shoulders to the wrists, being 
macular over the shoulder, but elsewhere more tubercular 
in character. The hips, the front of the knees, and the 
posterior or flexor surfaces of legs and feet, are also involved. 
The toes are larger than formerl}^ but only within the last six 
months have the feet become swollen. The skin of the feet 



Pathological and Clinical Society. 305 

has a more or less white and silvery appearance. There is a 
tubercular condition of the scrotum and prepuce. 

About a year ago he began to have difficulty in speaking, 
which has gone on increasing until the voice has become little 
more than a whisper. The tongue, too, has become involved, 
presenting deep fissures. There is slight difficulty in swallow- 
ing. The eyes are inflamed, and there is a well marked 
opacity over the left cornea. He is of opinion that sensation 
is not affected, though perhaps a little more acute than 
fomierh' over the affected area. 

Since admission the treatment has been — Generous diet ; 
one drachm tincture of quinine before, and a pill of arsenious 
acid (gr. tjV) after food three times a day; every second day a 
warm bath, in which 4- oz. sulphuret of potassium is dissolved, 
and friction twice daily with equal parts of gurjun oil and 
lime water. 

On ^^fh Fehviiary, a painful swelling appeared in front of 
the left thigh, which disappeared in a day or two. 

Otlt March, 1885. — There has been a distinct diminution of 
the tubercular condition in general, but no improvement in 
speech. 

Dr. Knox asked how the bacilli were recognised. 

Dr. J. Lindsaii Stfcen replied that the leprosy bacillus was 
the only one, so far as he knew, which gave the same colour 
reaction as the tubercle bacillus, and that it might be re- 
cognised by this test. 

Dr. Ferry considered the specimen of an amputated limb, 
shown by Dr. Dunlop some time ago to the Society, as a case 
of leprosy. 

Dr. Xapier said that the condition of movement of the 
fresh leprosy bacillus was diagnostic as well as the colour 
reaction. 

Dr. Adanvi mentioned that the amputation case of Dr. 
Dunlop died with head symptoms. 

Note on the Bacillus Lepr.e, by Dr. J. Lindsay Steven. 

Since this patient was .shown to the Society I have, at the 
request of Professor M'Call Anderson, examined a portion of 
the skin for the leprosy bacillus. This organism is now well 
known, and has been carefully described by Hansen,* Neisser,-f- 

* Bacillus Leprae. Von Dr. G. A. Hansen, in Bergen, Virch. Arch., 
1880. B<1. Ixxix, p. 32. Also (Quarterly Journal of Microscopical Science. 
New Series. Vol. xx. 1880. 

t Weitere Beitriige zur ^Etiologie der Lepra. Von Dr. Albert Nei.sser, 
Yirch. Arch., 1881. Bd. Ixxxiv, p. 514. 

No. 4. X VoL XXin. 



306 Meetings of Societies. 

George Thin,* and others. The organism was easily discov^ered 
to be abundantly present in the tubercles in this case, and the 
following is a very brief note of the method pursued for its 
detection. The surface of a large, and not very old, tubercle 
on the left forearm was frozen with ice and salt, and then a 
small eliptical portion of the skin was excised. This was at 
once placed in absolute alcohol, in which it was kept for some 
days to harden. Sections were then made, and were stained 
according to the following methods. The dyes employed to 
colour the bacilli were fuchsin in some sections, and gentian 
violet in others. The tirst sections were treated in precisely 
the same way as is employed when searching for tubercle 
bacilli in lung or other tissue. The others were investigated 
by what is now known as Gram's method,-|- an account of 
which is given by Friedlander, ^ and also in English by 
Woodhead.§ This method is much to be recommended in 
the investigation of minute organisms, but space forbids 
further reference to it here. Some of the sections were also 
double-stained, the contrast dye being Bismarck brown, in 
order to permit of a more easy study of the relationship of the 
tissue elements to the bacilli. 

An examination after treatment in either of these ways 
showed that the bacilli were present in the skin in simply 
enormous numbers, so much so as at first sight to suggest the 
idea that the swelling was probably in some measure due to 
the aggregation of the organisms. They were situated in the 
rounded masses of granulation tissue as well as in the more 
diffuse infiltrations of round cells. With the D of Zeiss they 
could easily be recognised as minute rod-shaped bodies, occurring 
either singly, or for the most part, perhaps, in rounded masses 
or bunches. It was at first somewhat difficult to determine 
whether the appearance of masses of bacilli was due to the 
organisms being situated within cells, or to their being simply 
grouped together in bunches. A more careful examinatioUj 
especially after using Bismarck brown as a contrast stain, 
led to the conclusion that, for the most part, the appearance 
of rounded groups was due to their being situated in cells, a 
conclusion which agrees with the observations of most of the 
authorities who have investigated the subject. It should be 

* Medico-Chirurgical Transactions. Second Series. Vol. xlviii. London, 
1883. P. 315. 

t Fortschritt d. Med. 1884. P. 185. 

X Microxcopisrhe Technik. Von Dr. Carl Friedltender. Zweite Auflage. 
Berlin. Theodor Fischer. 1884. P. 49. 

§ Practical Pathology. Second Edition. Edinburgh : Young J. 
Pentland. 1885. P. 515. 



Pathological and Clinical Society. 307 

noted, however, that the cells which contained the bacilli 
diffei-ed from the other cells of the leprous tissue in retaining 
the violet colour, and not being in the least affected by the 
Bismarck brown, which dyed the other cells of a rich reddish- 
brown tint. It struck me that this peculiarity might possibly 
be due to the effects of the products of the organisms on the 
cells. Thoma* has shown that the leprous elements spread by 
the lymph channels in the tissues, and in one or two of my 
specimens this was well seen, the minute spaces in the 
trabecuhi3 of connective tissue beinsf filled with cells and 
bacilli. 

In order to study more particularly the appearances of the 
bacilli, they were subjected to examination by Zeiss' yV oil 
immersion lens, the system, by careful measurement, being 
found to magnify about 1,600 diameters. The bacilli were 
then seen to be fine minute rods of considerable length, 
occurring either singly or in bunches as already described. 
They were often sharply pointed at either extremity, and 






/ 






'v\ 



/ 



)i>r 



r 



J.L.S. 



# 



Leprosy Bacilli. — The illustration shows the individual organism, and 
also the appearance they present when in groups or in the interior of cells. 
The spores are also shown, x 1600. 

almost all of them contained small rounded spores, which 
varied considerably in size in some instances, the larger spores 
being in the centre. Ziegler in his text-book, quoting chiefly 
from Neisser, states that the bacilli may contain from 2 to 3 
of these spores, but in more than one instance I found 5, as 
may be seen in the woodcut. So far as I have yet had an 
opportunity of measuring the bacilli, my results agree with 
those recorded by other observers — viz., from 4 to 6 micro- 
* Virch. Arch., Bd. Ivii. 



308 Meetings of Societies. 

millimetres (about 50V0 of an inch). I have been unable to 
make out that the rods are enveloped in a mucoid covering 
as has been described by Neisser. In the illustration, in 
addition to representing free bacilli, an attempt has also been 
made to show the appearance presented when the organisms 
were grouped into masses or in the interior of cells. 

Dr. Knox asked for a Report on the histological nature of 
the tumour shown by him at the January Meeting. (See 
Journal for February, page 13G.) 

Dr. Newman said that the tumour was a cancerous one. 
Dr. Coats thought it an endothelioma. The great bulk of the 
tumour was fibrous, but at the margin there are alveoli filled 
with cancer cells. 

Dr. Knox thought it was important to look at macroscopic 
characters. It was growing from under surface of true skin, 
and was adherent to the omentum. He thought that the 
true nature of the tumour was fibrous, the fibrous bands 
enclosing the endothelial elements of the omentum. He did 
not know of any true cancer which was encapsuled as this 
one was, and endothelioma can only be classed among 
sarcomata. 

Professor George Buchanan showed a preparation of 

DISLOCATION OF THE SEMI-LUNAR BONE OF THE CARPUS. The 
patient from whom the specimem was obtained was admitted 
to Professor Buchanan's Ward, on the 12th December, 1884, 
with an open wound in front of the right wrist, in which 
one of the carpal bones was found lying. This was replaced 
and the wound dressed. On 17th December, Dr. Buchanan 
removed the bone, which was found to be the semilunar, and 
discovered that the styloid process of the radius had been 
chipped off. On 2Gth December it was found necessary to 
amputate the hand, and on 6th February the patient was 
dismissed well. 

Dr. Knox said — some years ago a man was brought into the 
Western Infirmary who had his hand crushed sideways. The 
palm was split open, and the trapezoid bone was forced out 
from dorsum of the wrist. 

Dr. Wm. L. Reid showed a uterus removed from a case 
where Porro's operation was performed by Dr. Wm. Muir, 
assisted by Dr. Knox and himself. It was interesting, inas- 
much as she had one child born naturally. The patient was 
32 years of age, and- this was her fourth pregnancy. The first 



Pathological and Clinical Society. 309 

child was born naturally 10 years ago, the second and third 
were delivered by craniotomy, the third six years ago. At 
that time the pelvic bones bent, and she had to walk with 
sticks (and during the delivery of the placenta the bones were 
felt to yield under the pressure of the hand). There had been 
no previous disease. Now the bones are hard, and she can 
walk quite well, but there is little more than an inch of 
conjugate diameter. This, her fourth labour, occurred to-day 
at full time. The pains came on at noon, but fluid had been 
draining away during the night. She was taken to the 
Training Home early in the afternoon, and Porro's operation 
was performed. In opening the uterus the child was found 
in the third cranial position, and after removal breathed almost 
at once. The spray was used in the room for some time 
before, but not during the operation. The abdominal wall 
was very thin, the uterus having projected forwards to a great 
degree. The uterus was opened in the middle line, cutting 
through the placenta, which was removed with the foetus. 
There was no great loss of blood. Lawson Tait's clamp was 
used after the wire of an ecraseur had been applied and 
tightened. One wire of the clamp having been accidentally 
cut through Koeberle's serre-nreud was applied and the 
uterus cut off. The stump was pierced by a needle carrying 
strong silk, with which it was firmly secured. The abdomen 
was closed in the usual way and an antiseptic dressing applied. 
An hour afterwards the patient was fairly well. 

Dr. Fraser, of Paisley, showed an impacted fracture of 
the right femur which had taken place 4 years ago. The 
patient was a woman aged 04, and recovery was good. 

Dr. Hector C. Ca^ieron showed two small sequestra 
which he had removed from the tibi.e after an attack of 
TYPHOID FEVER, and which illustrated well the affection of 
these bones described by Paget, as apt to occur during con- 
valescence from this disease. The patient was a servant in 
the Western Infirmary during the late epidemic, and when 
convalescent she was transferred to his wards on account of 
localised attacks of acute periostitis in front of both tibise and 
one femur. That in the femur resolved, but the disease in 
the tibiae passed on into suppuration, and in order to hasten 
recovery. Dr. Cameron removed the sequestra which he now 
showed. As Paget had pointed out, the amount of suffering 
on the part of the patient was out of all proportion to the 
extent of the disease. Dr. Cameron also showed other 



310 ,/ of Societies. 

sequestra whicli he l^^j^d j:^^^^^^ ^^^^^ ^^^^^ ^^^^^ ^^^ 

tibise of a gentleman afte,^^ ^^ ^^^^^^ ^^ ^^^^^^^.^^ 

Dr. JAMEb ^ oP showed a mamma which had been 

removed on accoui^^ ^^ ^^^^ presence of a small tumour 
supposed to be scu-^^^^ 



^^ASGOW SOUTHERN MEDICAL SOCIETY. 



Session 1884-85. 
Meeting VIII — 19th February, 1885. 



The President, Dr. Napier, in the Chair. 

Mr. Alex. Miller read notes of an unusual case occur- 
ring IN obstetric practice. 

It was the case of a lady who, on the 24th December, 1882, 
was suddenly seized while in church with a considerable 
discharge per vaginam of a clear viscous fluid. She had felt 
perfectly well previously. Dr. M. was not asked to see her 
for 12 days after this event, when patient told him she had 
considered herself about five months pregnant. Her last 
menstruation took place in May 1880, and she was delivered 
of a healthy child in March 1881. On 18th May, 1883, Dr. 
M. made a careful examination of the patient, when he 
ascertained that she was not pregnant, as -she had supposed ; 
and two days afterwards a consultant confirmed his decision, 
and having passed the sound 3j inches, hypertrophied uterus 
was diagnosed, for which acid nitrate of mercury was applied. 
Ten days after tinct. iodi was applied to the os, and injections 
of sulphate of zinc and alum were used twice daily. Tonics were 
administered, and she was afterwards sent to the coast, appa- 
rently well. She was seen again in September, when she 
appeared to be about seven months pregnant; and on 13th 
December she was delivered of a large, healthy male child, 
and made a good recovery. The question was raised as to 
what was wrong in December, when the sudden discharge 
took place, and the peculiarity that, at the date of the intro- 
duction of the sound and the application of the caustic, she 
must have been ten weeks pregnant. 



Glasgow Southern Medical Society. 311 

Dr. W. L. Be id felt tliat he would like to read the ease 
more carefully before coining to a definite conclusion regarding 
its nature. It did not seem to him like a case of abortion 
preceding the successful pregnancy, but he thought a possible 
explanation of all the symptoms might be found if it were 
considered a case of that somewhat rare affection called 
secondary atresia of the cervix — vvhei'e the canal becomes 
blocked apparently by an eroded condition previously exist- 
ing, causing union of the walls of the cervix. This has the 
power of preventing menstruation for a time at least. He 
fancied Dr. Miller's case must have been something like that, 
and that the primary discharge was a bursting forth of the 
pent up material. He had seen three such cases within the 
past year. In one of them the patient suffered from con- 
siderable " bearing down," and this condition of atresia was 
diagnosed from the fact that when the sound was passed it 
was followed by a gush of grumous material coloured with 
blood. The woman, within a few weeks after this occurrence, 
became pregnant. Remarking upon the fact of the sound 
being passed in Dr. Miller's case during the pregnancy with- 
out any apparent mischief. Dr. Reid said he had occasionally 
done this in pregnant women, abortion, of course, following 
in most cases, but no harm resulting in others. He did not, 
however, recommend the practice. 

Mr. Gilmoiir scarcely thought that atresia of the cervix 
explained the whole facts of the case, and would be more 
inclined to consider it a case of prolonged gestation. 

Mr. Miller, in reply, declared himself in a difficulty to 
accept any of the above theories. The primary discharge 
in his case scarcely corresponded to Dr. Reid's cases of atresia, 
as it was said to be a clear, watery discharge. 

Dr. Alex. Patterson related the history of a case in which 
he had successfully performed utero-ovarian amputatiox 
for a fibroma combined witli pregnancy. This paper will be 
found at p. 241. 

TliC President, in introducing the discussion which followed, 
said that the Society had to be congratulated in having such 
an important and successful case Ijrought before it by one of 
its members. 

Dr. JarncH Ckaliner.'< had seen the case from the beginning,^ 
and was highl}' gratified when Dr. Patterson undertook to 
perform the operation, up to which time there was nothing 
looked forward to but death. 

Dr. W. L. Reid saw the patient prior to the operation, 



312 Meetings of Societies. 

when he diagnosed the tumour as ov^arian. He thought it could 
not simply be a fibroid, as he discovered fluctuation behind 
a comparatively tliin wall, and he knew tliat, except under 
extremely rare circumstances, the early history of the case 
scarcely admitted the diagnosis to be fibi'oid ; and further 
he excluded pregnancy, from the fact that the woman had 
been married for so many years without such an occurrence. 
He therefore consoled himself that altliough his diagnosis 
turned out not to be entirely right, there was some justification 
for it. 

Br. Knox said the point which struck him most in these 
recent advances in abdominal surgery, \^^as that surgeons were 
obtaining success just in proportion as they were getting 
clearer views in the matter of details. He strongl}'- advocated 
the eucalj'ptus spray, which Dr. Patterson had used on this 
occasion. 

2Ir. Stuart Nairne remarked that it did not seem to him 
that any of the gentlemen who had seen the case had provided 
for such a contingency as pregnancy. He would like to ask 
Dr. Patterson if there were awj efforts, •before operation, 
made to lift the mass up that was impacted in the pelvis. 
He thought that if this had been done, tliere Avas nothing to 
prevent the pregnane}^ 8'oiiig on ; and he was aware that such 
had been done previously in similar instances. A push up 
from the vagina, he considered, was much more efficient than 
pulling from above. 

Dr. Fork said it also occurred to him as rather curious that 
no attempt had been made to get the tumour dislodged from 
its position in Douglas' pouch, especially as there Avere no 
adhesions. He knew, of course, that even if pregnancy had 
gone on to completion, the operation would have been eventu- 
ally necessary. 

I)r. Patterson, in reply, thought that the gentlemen who 
had spoken had not fully comprehended the unusual nature 
of the case. He did not think the tumour could have been 
pushed up ; but suppose it had been possible, he would have 
been afraid, from the relation of the tumour to the uterine 
wall, that the uterus would not have expanded to the required 
extent. 



Medical Items. 313 

MEDICAL ITEMS. 

UNDER THE DIRECTION OF 

ALEX. napip:r, m.d. 

A Permanent Solution of Hydrochlorate of Cocaine. 
— In discussing the pluirnuicy of this new drug, Dr. Squibb 
(Ejihemeris, January, 1885) states that its solutions, like those 
of most alkaloids, are all liable to deteriorate by the growth 
of microscopic plants, which are nourished by the alkaloid, 
and therefore destroy it. These growths commence usually 
within a week, and when once started they increase rather 
rapidly. As the salt will always be used in solution, and as 
many persons wall not take the time and trouble for even so 
small a matter as the making of accurate solutions, it becomes 
highly important to fix upon a definite standard strength of 
solution for ordinary uses, and to have this securely protected 
against change in keeping. There are several agents which 
prevent these growths in alkaloid solutions, and among the 
most effective are carbolic acid, salicylic acid, boric acid and 
the aromatic series. A small proportion of ether often pre- 
vents the growths, and as this seemed least objectionable here, 
it was tried, but failed, until the proportion was so large as to 
be irritating to mucous membranes. 

All the protective agents tried were found somewhat irritant, 
even in dilute solution, and in selecting the one which seemed 
least irritant, and which was effective in the smallest pro- 
portion, salicj'lic acid w^as adopted. An incidental objection 
to this acid is its extreme sensitiveness to the presence of very 
minute traces of iron. j\lmost all filtering paper contains iron 
enough to react with salicylic acid, and in handling extracts, 
alkaloids, &c., it is not easy to avoid the use of steel spatulas, 
tinned iron funnels, &;c. Hence it is, that a very nearly or 
quite colourless solution of hydrochlorate of cocaine, when 
mixed wnth a very dilute solution of salicylic acid, will, either 
at once or in a few hours, in proportion to the amount of iron 
present, become very sensibly deeper in tint, and of a i-eddish- 
brow^i tint. As no possible hai-m can come from this tint, and 
as a tinted solution is just as good as a colourless one, this 
objection to salicylic acid was not considered of sufficient 
weight to cause it to be rejected. Boric acid seemed to be a 
much better protective agent, in that its effects upon mucous 
membranes — of the eye, for example, — are not at all irritant, 
but, on the contrary, are sedative. But it is a much less certain 



314 Medical Items. 

protective, and is required in so much larger a proportion than 
salicylic acid that it was not thought safe to adopt it. 

At ordinary temperatures 1 part of salicylic acid is held in 
solution by about 300 parts of water, and it is good practice 
to keep such a solution standing upon some undissolved crystals 
for use in protecting solutions of the alkaloids for hypodermic 
and general use. In making up the solutions of alkaloids, a 
good rule is to take one-half water and the remainder of the 
solution of salicylic acid, as the solvent. This gives to the 
solution of the alkaloid salt about one six-hundredth part of 
salicylic acid, — a proportion that can hardly be objectionable 
in any way, and yet is sufficient to protect the solutions 
indefinitely. — Pharmiaceihtical Journal. 28th March, 1885. 

[A recent writer on this same subject states that camphor 
water is an excellent solvent of cocaine, and also makes a 
permanent solution. He also found that solutions of this drug 
are most active when neutral or slightly basic, and that an 
acid hydrochlorate of cocaine, though more soluble, is less 
effective.] 

The Therapeutic Use of Sodium Nitrite. — R. M. 
Simon (Blniiinyham Mediad Review, 5th January, 1885) 
gives some interesting notes upon the use of the above agent, 
as follows : — All the combinations of nitrous acid have in 
common the properties of dilating the smaller blood-vessels 
and lowering of the blood tension, and it is probable that they 
will prove useful in all conditions where symptoms can be 
attributed to, or are associated with, increase of tension. I 
used the nitrite of sodium freely a year or so ago in epilepsy, 
on the strong recommendation of Dr. Rolfe, but was greatly 
disappointed with the results. Latterly, I have used the 
nitrite in over twenty cases of different diseases, and with 
gratifying results in many instances. Amongst these were 
five cases of aortic disease, with regurgitation through the 
valves, four of these were greatly advantaged by its use, but 
in one there was no good found to result. 

Of sixteen cases, five of aortic, five of mitral, and five of 
renal disease, and one an old man of 72, suffering from vertigo 
without organic disease, two only derived no benefit from the 
nitrite, whilst all the others were very much improved. The 
result was most striking in a case of angina, but was almost 
equally so in each of the cases of heart disease, more especially 
those in which the aortic orifice was affected. The dose given 
was one grain three or four times, and I think it possible that 
in any cases of total or partial failure it might have been wise 



Medical Items. 315 

to have increased the dose, as Avith the doubtful exception of 
one case of purging, no ill etlects followed the use of the drug. 
— R. S. T. 

The Increase in the Number of the Insane. — 
In tlie Anudlcs Medico-Psi/cJtologiqucs, September, 1884, Dr. 
Lunier gives a continuation of his paper on the progressive 
increase in the number of the insane and its causes, which 
was published in the same periodical in Jan. 1870. He finds 
that tlie same increase which has been observed in all other 
civilised countries also holds ofood with France. In fact, the 
number of lunatics, 16,538 in 1835, had risen to 87,968 in 
1872 ; that is, it had increased five times, allowing for the 
corresponding increase of the population. Tliis apparent 
augmentation could in great part be accounted for by the 
increased number in the asylums, and the greater exactness of 
the census returns. He finds that, as a rule, for every 100 men 
in an asylum there are 110 women, from which one might 
readily conclude that insanity is commoner with women than 
with men. Dr. Lunier shows that it is a simple fallacy : 

In 184:2, for 100 women admitted there were 116 men. 
„ 1852, „ 100 „ „ „ 115 „ 

„ 1862, „ 100 „ „ „ 111 „ 

„ 1872, „ 100 „ „ „ 117 „ 

„ 1880, „ 100 „ „ „ 112 „ 

Yearly average „ 100 „ „ „ lU „ 

Nervous insanit}', which is the commonest form with women, 
is rarely cured, and does not notably shorten the life of those 
who are affected with it ; on the contrary, general paralysis, 
whicli is most frequently observed in men, is almost 
always fatal in a few years; and alcoholic insanity, from 
which they generally recover, causes a great number of 
admissions and discharges in the asylums. At the end of the 
year there remain a comparatively small number of general 
paralytics and alcoholics, while a large number of chronic and 
incurable cases sufi'ering from ner\ous insanity accumulate in 
the asylums. The true measure of the frequency of insanity 
is given by the admissions ; and, on the average, tliere are 
admitted every year into the asylums 114 men for 100 women. 
Therefore, argues Dr. Lunier, men are more liable to become 
insane than women in the proportion of 114 to 100; but here 
again it might be objected that more men are sent to asylums 
than women, because a male patient is more difficult to manage 
out of an asylum. Dr. Lunier observes that, where facilities 



316 Medical Items. 

are given by the Government for the gratuitous admission of 
lunatics, they send into asylums, as insane, harmless imbeciles, 
hemiplegia dements, and weak-minded people, who formerly 
went and still should go to the hospitals for the incurable. 
Dr. Lunier believes that the increase in the number of the 
insane is much less considerable than is generally thought. 
Forty years ago the admissions increased at the rate of 12'5 
percent yearly; now they only increase at the rate of 1'70 
per cent. He considers it certain that the number of those 
affected with general paralysis, alcoholic insanity, and maniacal 
excitation, has become greater, especially in the towns. On 
the contrary, the number of idiots is diminishing; as for 
cretins, of whom there were from fifteen to twenty thousand, 
it will be difficult to meet any of them, even in the gorges of 
the Alps and Pyrenees. — The London Medical Record. 16th 
March, 1885. 

Bacteria Two Hundred Years ago.- -The Amsterdam 
AUgemeen Handelshlad publishes a communication from 
Professor E. Cohn, of the University of Breslau, who recapitu- 
lates the substance of a correspondence of the celebrated 
naturalist Leeuwenhoek with Francis Aston, of London, a 
member of the RoA^al Society. Leeuwenhoek, writing from 
Delft, in 1683, reports that among the debris of food remaining 
between his teeth he had discovered, with the aid of the 
microscope, living organisms moving with great activity. He 
distinguishes various kinds among them, which he describes 
so precisely that they would be easily recognisable. One, 
which occurs less frequently, resembles a rod, the bacillus ; 
others, twisting in curves, are bacteria ; a third kind, creeping 
in snake fashion, is the vibrio ugula; another kind, of extreme 
minuteness, resembles a swarm of flies rolled up in a ball, and 
is evidently the micrococcus. Its movements cannot be 
traced with certainty. He says that this species seems to be 
made up of parallel threads, varying in length, and remaining 
immovaljle, while other specks move in and out through the 
web. Leeuwenhoek marvels that these things could live in 
his mouth, notwithstanding his systematic habit of cleansing 
it. He instituted observations which showed that they were 
also to be found in the mouths of other persons. Some years 
later he could not discover any traces of those minute 
organisms, and he was led to attribute their disappearance to 
the use of hot coffee. But shortly afterwards he rediscovered 
them as lively as ever. In September 1692 he sent some 
sketches of them to the Royal Society. Professor Cohn 



Medical Items. 317 

observes that it would seem from this correspondence that the 
knowledge concerning tliose minute entities made no advance 
for nearly two centuries, and he remarks on the wonderful 
skill with which Leeuwenhoek used the imperfect instruments 
of his time.— The London Medical Record. IGth March, 1885. 



The Treatment of Epididymitis. — In the 3Ied. Prihavl. 
k'Morsk. Shorn., December 1884, p. 20, Dr. M. Smirnoff, 
surgeon on board the Plastron (with 163 men) writes that 
during her cruising from 1880 to 1883, not fewer than 
sixty-nine cases of acute gonorrhoea came under his obser- 
vation, fifteen of them (in twelve patients) being complicated 
with epididymitis of the right testis in six cases, of the 
left in nine. The duration of epididymitis varied between 
ten and thirtj'-four days, with an average of eighteen days. 
With the disappearance of acute symptoms (in three to five 
days) the patients resumed their full active work. The 
treatment in the acute stage consisted in inunction of a 
mixture of equal parts of grey mercurial and belladonna 
ointments ; later on, warming compresses were applied. The 
patients wore a suspensory during the whole course of the 
disease. Except the omission of vodka (aquavitas), no changes 
in the usual dietary (of the Russian sailor) were made. The 
same treatment was practised with identical results also by 
Dr. Gubareff, on board the Africa, and by Dr. Bogoslovsky, on 
board the Vestnik. — The London Medical Record. IGth 
March, 1885. 

The Internal Eruption of Varicella. — That chicken-pox, 
like the other febrile cutaneous disorders, may affect the 
mucous lining of the mouth and throat is a clinically estab- 
lished fact, of which, however, no mention is made by the 
majority of writers. In most cases this internal eruption is 
either unnoticed or altogether absent ; sometimes, on the other 
hand, it is (piite troublesome and of more importance than the 
outward sjinptoms. 

According to recent authorities, the interior workings of 
varicella are not confined to the buccal and pharyngeal 
membranes ; thus, four cases of albuminuria following the 
disease have been reported in one journal, and a case of 
nephritis in another. These scattered instances, however, are 
insufficient to warrant a change in our general estimate of this 
transient and essentially benign affection. 

From a somewhat extensive observation of vai-icella — 



318 Medical Items. 

especially as met with in a children's dispensary — I am enabled 
to present the t'ollowing conclusions : 

Varicellous eruptions of the mucous membrane are not of rare 
occurrence. They are generally found inside the mouth, 
especially on the dorsum of the tongue and on the palate. 
Here the vesicles take their rise at an early stage in the 
disorder, probably sooner than the cutaneous exanthem, but 
we have never been able to observe them in this situation, 
owing to their speedy development and rupture, which leaves 
rounded erosions in their stead. Usually this buccal eruption 
is of a trivial character, causing but little trouble on masti- 
cation. Exceptionally, however, it may set up a severe 
inflammation, actual stomatitis, wdiich is quickly subdued by 
chlorate of potassa. In rare cases, the pustular invasion may 
extend to the mucous membrane of the conjunctiva or of the 
vulva, but even then it is annoying rather than serious in its 
manifestations. — (J. Comby, Le Fi'ogres Me'dicul, 27th Sept., 
1884.) Journal of Cutaneous and Venereal Diseases, March, 
1885. 

A SuccessftQ Case of Porro's Operation.. — Dr. Halbrun 
of Breslau gives the details of a case of Porro's operation 
performed by Prof. Fritsch. The patient was a primiparous 
woman, 27 years of age, who had as a child suffered so 
severely from rickets that she had to move about on crutches 
until she was twelve years of age. Her legs and pelvis were 
badly distorted. The conjugate diameter at the brim was 
three inches, the transverse at the outlet two and a half 
inches ; but the kyphotic deformity was so marked as to make 
the pelvis, as regards parturition, worse than these measure- 
ments might lead one to believe. It was determined to 
operate before labour set in, in order to avoid damage to the 
cervix uteri — Mliller's method of removing the fundus from 
the abdomen before extracting the child was adopted. A bit 
of elastic tubing was thrown round the cervix, and tied just 
as the uterus was opened, and the child removed. The latter 
cried immediately. The knot of the elastic ligature was tied 
with silk thread, and fixed to the stump by two or three fine 
stitches. The tissues of the stump were then hollowed out, 
and the peritoneal edges carefully stitched together after 
treatment by strong carbolic acid. Tiie peritoneum was 
wiped out, the stump sunk into the pelvis, and the abdomen 
closed. The patient made an excellent recovery, her tem- 
perature never rising above 100°, and she and her child were 
dismissed from the hospital on the loth day after the 



Medical Items. 319 

operation. We recommend those interested in the subject to 
consult the original communication. Centrulbl filr Gyn., 3rd 
January, 1885.— W. L. R. 

Treatment of OzcBna.— The following is the formula 
employed by M. Vidal at the Hopital St. Louis, in the treat- 
ment of ozoena. Solution of chloride of zinc (5 per cent), 1 
ounce; boracic acid, 14 grains; water, 28 ounces; ammonia, 
q. s. to neutralise the fluid. A little of this solution is snuffed 
up into the nostrils several times a day. M. Gorecki employs 
for the same purpose, and in the same way, a warm saturated 
solution of boracic acid. By means of one or other of these 
preparations the foetid odour may be destroyed, in most cases, 
within a few days. — (Journal de Medecine et de Chirurgie 
pratiques, August, 1884.)— TAe Practitioner, February, 1885. 

Viburnum Prunifolium as a Uterine Sedative. — 
Attention was first called to this drug in 18U0, by Dr. Phares 
of Newtonia, Miss., who regarded it as a " Nervous antispas- 
modic, tonic, astringent, and diuretic," and as "particularly 
valuable in preventing abortion or miscarriage, whether 
habitual or otherwise." Further trial has been made by Dr. 
J. H. Wilson, Liverpool, of its influence in cases of threatened 
abortion, and several are detailed in which its administration 
was vmiformly successful. In the cases cited, abortion 
threatened at periods varying from the earlier weeks of 
pregnancy to the seventh month, and Dr. Wilson found it act 
as a " sedative and tonic to the uterine nervous system." He 
believes that, if given early, and before the ovum is thrown 
off, most cases of abortion may be prevented. 

The drug may be given as a liquid extract in 3j doses, but 
in this form is apt to induce nausea. An extract in doses of 
2 to 4 grains in pill is more palatable. Only in one case was 
" throbbing of the temples " complained of as due to its 
administration. 

Dr. Wilson admits that several of his cases might have done 
well under ordinary treatment, but is disposed to believe that 
"convalescence would not have been so speedy or satisfactory." 
— {Liverpool Med. Chir. Jour., January, 1885.) — A. K. C. 

Plovers' Eggs. — Every one has remarked the difference 
between the white in plovers' eggs and in hens' eggs. Tarchnoff 
has investigated this difference.' He finds that in all birds 
which are hatched fledged, the albumen in the egg is much 
thinner and more watery when fresh, and more transparent 



320 Books, d'c, Received. 

when boiled, than in hens' eggs. The eggs in birds which are 
hatched unfledged resemble those of the hen. Pitreons' eo'ffs 
are intermediate between the two kinds. To this transparent 
albumen the author gives the name of " tata " albumen. It 
contains about 2 per cent more of water than ordinary- 
albumen, and requires a higher temperature to coagulate it. 
The point about it which is important in practice, however, is 
that when coagulated it is digested and peptonised eight or ten 
times more readily than ordinary white of egg. In cases 
where the digestion is very feeble and where it is important 
to sustain the strength of the patient, it is possible that by 
using plovers' eggs instead of hens' eggs considerable ad- 
vantage may be gained. — (PJiilger's Archiv, Vol. xxxiii.) — The 
Practitioner. March, 1885. 



Books, PampJilets, &c.. Received. 

Bodily Deformities and their Treatment : a Handbook of Practical 

Orthopaedics. By Henry Albert Reeves, F.R.C.S. With 228 

Illustrations. London : H. K. Lewis. 1885. 
Dental Surgery for General Practitioners and Students of Medicine. 

By Ashley W. Barrett, M.B. London : H. K. Lewis. 1885. 
A Practical Treatise on Urinary and Renal Diseases, including 

Urinary Deposits. By William Roberts, M.D,, F.R.S. Fourth 

edition. Assisted by Robert Maguire, M.D. London : Smith, 

Elder k Co. 1885. 
Selected Memoirs, comprising Albuminuria in Health and Disease. 

By Dr. H. Senator. Some Considerations on the Nature and 

Pathology of Typhus and Typhoid Fever. By the late A. P. 

Stewart, M.D. Movable Kidney in Women. By Dr. Leopold 

Landau. London : The New Sydenham Society. 1884. 
Clinical Lectures. By Richard Quain, F.R.S. With forty plates. 

London : Smith, Elder k Co. 1884. 
Transactions of the College of Physicians of Philadelphia, 3rd series, 

Vol. VII. Philadelphia: Printed for the College. 1884. 
Electricity and its Manner of Working in the Treatment of Disease. 

By W. E. Steavenson, M.D. To which is appended an 

Inaugural Medical Dissertation on Electricity for the Degree of 

M.D. of the University of Edinburgh, written in Latin. By Dr. 

Robert Steavenson, 1778. With a Translation by Rev. F. R. 

Steavenson, M.A. London : J. & A. Churchill. 1884. 
A Manual of Dermatology. By A. R. Robinson, M.B., L.R.C.P. k S. 

Ed. New York : D. Appleton k Co. 1885. 
A System of Practical Medicine by American Authors. Edited by 

Wm. Pepper, M.D., LL.D. Assisted by Louis Starr, M.D. 

Vol. I : Pathology and General Diseases. Philadelphia : Lea 

Brothers k Co. 1885. 



THE 



GLASGOW MEDICAL JOURNAL. 



No. Y. May, 1885. 



ORIGINAL ARTICLES. 



CASES OF CALCULUS. 

By GEORGE BUCHANAN, 
Professor of Clinical Surgery in the University of Glasgow. 

{Communicated to Glasgow Pathological and Clinical Society^ April 14,1885.) 

Since my report of cases in Glasgoiu Medical Journal, 1882, 
I have had seven cases of calculus in the bladder, all in the 
adult ; all removed by lithotomy ; all recovered. In each, I 
preferred lithotomy for special reasons belonging to the 
IndiNddual case. 

I." — R. C, aged 57, a patient of Dr. Brown, of Crossbill. He 
suffered from chronic cystitis and severe irritation of the 
bladder. He was most anxious to have lithotrity performed, 
having heard of its greater safety, and only consented to the 
cutting operation on my assuring him that he was not in a 
favourable state for the other. 

The calculus was a curious combination of oxalates and 
urates. The nucleus, oxalate ; the bulk of the stone, mixed 
urates and phosphates ; the external shell an eighth of an 
inch thick ; again oxalates, a thin layer on the exterior. 

II. — John W., aged 36, at Bridge of Weir, a patient of Dr. 
Campbell Syme, of Kilmalcolm, suffered from symptoms for 
many years, but always neglected to apply for relief till 1st 
July, 1882. He also was anxious for lithotrity, a well known 
ofentleman in his neijxhbourhood havinfj been cured in that 
way formerly ; but when I pointed out the difficulty arising 
from the state of his bladder, and especially when he learned 

No. 5. y Vol. XXIII. 



322 Professor Buchanan — Cases of Calculus. 

I could not operate on him in his own house, but he must 
come and reside near me in Glasgow, he consented to be cut. 

The stone has a peculiar long oval shape, with alternate layers, 
and the outside is quite black, probably coated with altered 
blood. 

III. — John R., aged 20, suffered from symptoms for 10 
years — lithotomy in Western Infirmary, 11th July, 1882. 

Nothing remarkable in this case, except the stone, which 
has in its centre, instead of a nucleus, a little cavity containing 
a particle of shrivelled clot. Hollow stones are not common, 
only two existing in the Museum of the Royal College of 
Surgeons, London. 

IV, — This is probably the most remarkable calculus to be 
seen in any collection. 

James L., aged 27, had lithotrity performed in an English 
hospital in May, 1882, by Bigelow's method at one sitting. 
The fragments, when dried, weighed two ounces and two 
drachms. The patient was dismissed as cured, thirty-two 
days after the operation. 

Some months after, the symptoms were as bad as before 
the operation, and in November, 1883, he was admitted to my 
ward with chronic cystitis, and a large stone in his bladder. 
Lithotomy was performed. 

A section of the stone showed that the concretion had 
formed round three large fragments of the orioinal stone 
which had been left in the bladder. The largest is about an 
inch long, and quarter of an inch thick. 

A year after my lithotomy, on the 10th November, 1883, he 
called to report himself as quite well, and free from all his 
former symptoms. 

V. — B. W., aged 36, has suffered from symptoms of stone for 
six months only ; but they are now urgent. The urine is 
alkaline, foul, purulent, putrid, and causes excessive irritability 
of bladder. For these reasons I chose lithotomy. 

The result was favourable. 

VI. — David J., aged 32, suffered from symptoms for five 
years, but at intervals was quite well. Being very nervous 
and afraid of anything being done, he did not mention his 
complaint till a fortnight before his admission to my wards in 
October, 1884. Knowing it was a large hard calculus, I pre- 
ferred lithotomy. 

The stone was a much nodulated oxalate of lime calculus of 
dark colour, with a pale brown uric acid nucleus. 

VIL— W. G., aged 2.5, sent by Dr. M'Kerrow, of Ayr. Two 
years aga he noticed a little blood in his urine. Soon after he 



Professor Buchanan — Gases of Calculus. 323 

passed a small calculus whicli he gave me. It proved to be 
oxalate of lime. Since then the symptoms have given rise to 
little trouble till lately. Now the urine is acid -with pus — no 
crj'stals can be seen. The stone is large and smooth, but feels 
very dense and hard with the sound. For these reasons I 
selected lithotomy. The result was favourable. 

Resume. — In all these cases I selected lithotomy because 
I believed that, in my hands, it was the safest operation in 
the particular circumstances. For more than twenty years I 
have been a strong advocate for lithotrity in suitable cases ; 
but I am equally certain that for me the stone must be 
moderate in size, and the bladder fairly healthy, and the urine 
not purulent and putrid. In this latter case a free drainage 
from the perineum is of itself an important element in the 
treatment. 

Another case I shall relate in consequence of the curious 
sensations it sjave rise to. It was a renal calculus discharged 
Iter uretkram,. 

A. F., aged 19, a senior medical student, suffered intense 
agony along the course of the ureter, down which he could 
trace the passage of a calculus by the alteration in the seat of 
pain. At length the pain ceased for a time, and he believed it 
had dropped into the bladder, and shortly after the well 
known stinging pain in the point of the penis, in the perineum, 
and in the region of the bladder, convinced him he was correct 
in his judgment. 

At this juncture he sent for me and pointed out the 
particular spot in the bladder where he asserted I should 
find the stone. I put him under chloroform and most carefully 
searched with a sound, but failed to detect any calculus. 

Next day the pain in the point was even more severe. 
Large opiates and hot sitz baths I'clieved him for a few hours ; 
but the following day his agony was so great that I again, 
under chloroform, made a minute search with a smooth scoop 
lithotrite, directing most care to the spot he had indicated 
on the left of the fundus. Still no stone could be found, and 
I informed him that the calculus must be arrested at the 
mouth of the ureter. His agony was, however, so great that 
he declared he would be willing to undergo lithotomy, so that 
I might search for and, if possible, scoop away the stone. He 
again declared that his feeling was such that the stone must 
be now in the bladder, for the pain was now out of the left 
fundus, but most distinctly behind the pubes as well as in the 
point of tlie urethra. I accordingly again sounded him tliis 
time with the same result, and I could only assure him 



324 Mr. Knox — Notes of a Case of Rupture of the Bladder. 

that all these pains from which he suffered so acutely, and 
often so as to cause rigors and profuse sweating, were 
reflected from a rough calculus as yet impacted near the 
orifice of the ureter, and that relief would come in due course ; 
and so it did, for one day, instead of my visit to him in bed, 
he walked into my consulting room telling me the pain was 
gone. A few days after he called with the calculus, about the 
size of a grain of wheat, rough and sharp. 

I have not met with a case where a calculus passing along 
and temporarily impeded in the ureter had caused symptoms 
so identical with those of a stone in the bladder. 



NOTES OF A CASE OF RUPTURE OF THE BLADDER. 

By D. N. KNOX, M.A., M.B., Surgeon, Royal Infirmary. 
(Read before the Pathological and Clinical Society, ll^th April, 1885.) 

The case I have to bring before you to-night is interesting, 
both from the comparative rarity of the injury and also from 
the puzzling character of the symptoms. The patient was a 
man aged 30, who, on 27th December last, got drunk with 
some friends, and in a quarrel was knocked down and kicked 
on the abdomen. He lay on the floor all night in a drunken 
stupor. Next morning he found he could not make water, 
and was seized with severe vomiting. No assistance, however, 
was called in till the morning of the 29th, when a surgeon 
was sent for, and removed, according to patient's statement, 
about two pints of urine by the catheter. The inability to 
pass water still continuing, he was admitted to the Royal 
Infirmary on the 30th as a case of retention. The patient 
then complained of pain over the whole abdomen, especially 
in the umbilical region, with total inability to pass water. 
He also stated that he had suflfered from stricture some years 
before. He was in a state of collapse, face pale and anxious, 
surface of body and extremities cold, and pulse very weak 
and irregular. On examination of body no trace of bruising 
or swelling could be detected. The abdomen was normally 
tympanitic, and the bladder was not distended, The catheter 
was passed by the house surgeon, and about six ounces of 
bloody urine were drawn ofl'. There was no tenderness of 



Mr. Knox — Notes of a Case of Rupture of the Bladder. 325 

abdomen, nor were the legs drawn up. About an hour after 
admission, severe vomiting came on, and lasted during the 
evening. Next day patient was weaker, his pulse feebler, 
his face very pinched and anxious ; but the vomiting had 
stopped, and the pain in the abdomen was less. During the 
course of the daj' the patient four times passed a small 
quantity of urine voluntarily. At the house surgeon's visit 
in the evening the catheter was passed, and about 20 ounces 
of urine removed. All the urine contained blood. At mid- 
night the patient died quietly, and shortly before death a 
small quantity of urine was passed involuntarily. 

I confess I did not recognise the full extent of the injury in 
this case. I supposed him to be suffering from the common 
effects of an excessive dose of alcohol on a patient with a 
stricture, with injury to the bladder from over-distension, with 
further injury to some of the abdominal viscera and slight 
peritonitis. Owing to the state of collapse, and the absence of 
physical signs, I could make nothing further of tlie case, and I 
therefore confined my treatment to restoratives and anodynes, 
with hot bottles to the extremities and poultices to the 
abdomen. 

On jjost-raortem examination by Dr. Newman, a large intra- 
peritoneal rupture was found on the posterior surface of the 
apex of the bladder. It measures \h inch in length, and is 
vertical in direction. Surrounding this opening, and extend- 
ing even to the sides of the bladder, there was a quantity of 
blood-clot, by which the opening seemed to be closed and the 
small intestines to be loosely glued to the bladder. The 
bladder was not contracted, but rather distended and contain- 
ing urine, and it will now be seen to be rather larger than 
normal. Careful examination of the peritoneal cavity failed 
to show any trace of urine. The peritoneum generally was 
slightly congested, and some small patches of Ijanph were 
seen. The peritonitis, however, was not altogether new, for 
the peritoneum was in places much roughened, and the liver 
and spleen were firmly adherent by fibrous bands to the 
diaphragm. A small rupture with a considerable superficial 
haemorrhage was also found in the liver. The other abdominal 
organs were normal. 

The explanation of this case, then, would seem to be that 
the bladder, largely distended, was ruptured by a kick, and 
urine escaped into the peritoneal cavity causing the pain, 
vomiting, and other symptoms. This extravasated urine may 
have been drawn off' by the surgeon, the catheter having 
passed through the rupture. Thereafter the kidnej^s for a 



326 Mr. Knox — JS^otes of a Case of Rupture of the Bladder. 

time suffered from shock, and there was partial suppression 
of urine, as only about six ounces were secreted in the twenty- 
four hours preceding- admission to the Infirmary, while the 
inflammatory action and the blood-clots caused the blocking 
up of the rupture and prevented further escape. This block- 
ing up of the rupture explains also, I think, the large amount 
of control this patient gained over his bladder by the third 
day after the injury. 

On comparing this case with others recorded so carefully 
and analysed so exhaustively by Rivington,* I find that it 
resembles in some points and differs in others from what may 
be called typical cases of intra-peritoneal rupture of the 
bladder. Thus, while most recorded cases agree with it in 
the maimer of production by blows or falls upon a distended 
bladder, there is generally evidence of fluid in the peritoneal 
cavity either free and difiused, as in ascites, or bound down so 
as to form a tumour dull and fluctuant, or the patient is 
conscious of a snap and sudden sense of relief to his distended 
bladder. Thus, Rivington says (p. 35), " The surgeon will find 
most probably that the abdomen is swollen or prominent in 
front, yielding perhaps the sense of fluctuation, tender on the 
slightest pressure, and tympanitic ; but in the hypogastric 
region, for a variable distance, and sometimes extending 
towards one or both of the iliac fossae, the percussion note is 
likely to be dull, more especially in the erect position." While 
this state of matters may have been present in my case before, 
it was not observed after his admission to the Royal In- 
firmary, nor was any fluid observed in the peritoneal cavity 
after death. As regards this latter point, I may say 
that in many recorded cases no mention is made of fluid 
being found in the peritoneal cavity after death ; but 
whether this is merely an omission in the record or not, 
I cannot tell. It is open for us to suppose that some urine 
may have been removed by absorption, though Rivington 
and others think that this is always slight. My own case, 
however, leads me to the conclusion that a considerable 
amount of urine may have been absorbed by the peritoneum 
both because the rent had obviously been occluded for some 
time previous to death, so that the bladder could contain a 
considerable quantity of urine, and also because of the slight 
evidences of recent peritonitis without the presence of 
extravasated urine either immediately before or after death. 
Moreover, this absorption may explain the extreme depres- 

* Rupture of tlie Urinary Bladder^ based on the records of more than 300 
cases of the affection. 



Mr. Knox — Notes of a Case of Rupture of the Bladder. 327 

sion from which this patient suffered by increasing the amount 
of urea, &:c., in the blood. I do not think this case gives any 
support to the tlieory that the peritoneum is tolerant of the 
presence of healthy urine, for here the amount of extravasated 
urine was not large, and was removed comparatively early, 
and there was no evidence of the presence of decomposed 
urine, to the absorption of which Harrison * would attribute 
the fatal peritonitis of such cases. On a careful study of 
the evidence brought forward by Kivington and others on this 
point, I have come to the conclusion that the peritoneum, even 
though it may absorb urine, is still most intolerant of it, and 
that contact for even a few hours is sufficient to set up acute 
inflammation, and by absorption to produce the most serious 
general depression. In consequence mainl}' of this, the 
prognosis in all these cases is the worst possible. Rivington 
only admits one genuine case of recovery after intra-peritoneal 
rupture, that of Dr. Walter (p. 58), where abdominal section 
was performed ; all the other reported cases are dismissed as 
unproved for want of evidence. My own case, however, shows 
that some of the so-called typical symptoms may be absent, 
and hence that perhaps a larger number of genuine recoveries 
may have taken place than are at present admitted. 

As regards the treatment of such cases, I think it obvious 
that heroic measures should be adopted at the earliest possible 
moment. A delay of a few hours, by increasing the peritonitis 
and further poisoning the system, may prove fatal. Abdominal 
section above the pubis should at once be performed, the peri- 
toneal cavity carefully cleaned out, the wound in the bladder 
stitched with catgut, and efficient drainage from the bladder 
e.stablished by a median urethrotomy. 

The suturing of the rent in the bladder is, I think, of some 
importance. In Dr. Walter's case it was not done, and yet the 
patient recovered. In a case operated on by Mr. Willett,-f* the 
rent was sutured but imperfectl}', and urine again escaped, so 
that after an interval of rest and apparent relief, the symp- 
toms returned and the patient died. It might be well to adopt 
Rivington's suggestion, and test the sutures by distending the 
bladder with water before closing the abdominal wound. In 
Mr. Heath's case,:J: the stitches in the bladder gave way, partly 
from sloughing of the edge of the rent and partly from softening 
of the catgut. It would be well, therefore, to prevent such an 
accident in future, to bring the rent together by sutures, so 

* Lectures on the Surgical Disorders of the Urinary Organs, p. 318. 
t *S'^. Bartholomew's Hosp. Reports, 1876, p. 209. 
% Med. Chir. Trans., 1879, Vol. Ixii, p. 335. 



328 Dr. Paton — Calcareous Masses 

inserted as to bring not the edges but the peritoneal surface 
together, as is done with the parietal peritoneum after abdo- 
minal section. Such careful suturing, besides preventing 
escape of urine, would have the further advantage of prevent- 
ing adhesion of a coil of intestine. Rivington recommends 
carbolized silk as better than catgut for sutures. Our ex- 
perience in Glasgow would indicate chromic catgut as the best 
material. 

With sufficient attention paid to the toilet of the peritoneum, 
the suturing of the vesical and abdominal wounds and the 
perfect drainage of the bladder — and, of course, with perfect 
antiseptic precautions throughout — if only the cases could be 
seen at once, I have no doubt a certain measure of success 
would yet be obtained in the treatment of this most desperate 
injury. 



CALCAREOUS MASSES FOUND IN THE PLEURAL 

CAVITY. 

By JAMES PATON, M.D., Greenock. 
{Communicated to the Pathological and Clinical Society, IJfth April, 1885.) 

The case wliich I have the pleasure of bringing before you 
to-nioht for your consideration is evidently one of extreme 
rarity, and the only case, so far as I know, in which calcareous 
matter has been taken out of the pleural cavity during life. 

J. M'G., aged 70 years, formerly a farmer, but during the 
last 20 years has been chiefly engaged as a cattle dealer. 
Never had any illness requiring medical attendance previous 
to November, 1883. His father died at the age of 84 years, 
from the effects of a thorn piercing his thumb — evidently, from 
his description of the case, producing some form of blood- 
poisoning. His mother died at the age of 32 years, from 
lumbar abscess. Has one brother living, aged 78 years, and 
in good health. Two brothers and three sisters died after 
reaching manhood and womanhood; but he can give no 
account of the causes of death. His son informs me, however, 
that two or three of them died from disease of the chest. 

In November, 1883, he travelled from Oban to Edinburgh 
and caught cold. For a short time before this he had been 
troubled with a slight tickling cough, which caused him 



Found in the Pleural Cavity. 329 

no anxiety. In a few days he returned to Oban. The cough 
became somewliat more troublesome, and after a short time 
he felt a pain in his left side ; but this pain was never, at any 
time, what he would characterise as severe. He never has 
had any expectoration during the progress of his illness. 
Felt tired and breathless after any exertion. Never had any 
rigor, so far as he can remember. Finding that he was 
getting no better, but remaining very much in the same 
uncomfortable condition, he applied for admission into the 
Greenock Hospital, and remained there from the 5th to the 
27th of May, 1884. On the 27th of May, he was admitted 
into the Greenock Medical Aid Home, where he came under 
my care. 

He states that he never was a teetotaller, but never indulged 
in anything like excessive drinking. Never had syphilis, and 
there are no traces of such. He has a florid complexion, and 
says he has always had a high colour ; tall, and very spare. 
Has cataract of the left eye, but no arcus senilis. The tongue 
is clean, and the appetite has always been fairly good. 

On exposing the chest, the walls have the appearance of 
having contracted considerably, the contour of the ribs being- 
very distinct, with depressed intercostal spaces. At the left 
apex there is slight fattening, made more perceptible by what 
will be immediately stated. On the left side, in the fifth 
intercostal space, there is a distinct bulging, about the size of 
the palm of the hand, external to the nipple, distinctly fluctu- 
ating, and can be considerably reduced by pressure. His 
breathing is somewhat hurried, but not laboured. His vessels 
are decidedly atheromatous, the radials feeling tortuous and 
hard, and the heart's action is very irregular, as will be seen 
from the sphygmographic tracing, averaging about 80 per 
minute. A systematic temperature chart was not kept, as the 
constitutional disturbance never seemed at all great, and any 
time the temperature was taken it was generally about normal. 

A few days after his admission to the " Home," I aspirated 
the tumour, withdrawing scarcely 1 oz. of pus, mixed with air 
cells. I may mention it was also aspirated in the Hospital, 
when only about a teaspoonful of pus, mixed with air cells, 
was removed. This did not seem to benefit him to any 
appreciable extent, and in a day or two the bulging was as 
large as before. The superficial structures now became red 
and inflamed, and the swelling seemed on the point of bursting. 
On the 15th June I opened it aseptically, and drained with an 
ordinary rubber drainage tube. For some time after this he 
seemed to improve considerably. The amount of discharge 



330 Dr. Paton — Calcareous Masses 

gradually lessened for some time, the dressings being allowed 
to remain on a week or so without beingr changed. Althoug-h 
never entirely confined to his room, he could now enjoy a walk 
of two or three miles without discomfort or undue fatigue. 
This seeming improvement continued for some months. Of 
course this was during the summer months, which, no doubt, 
had a beneficial influence. Unfortunately, about the middle 
of October, on removing the dressings, another small opening 
was found, about Ih inch upwards and outwards from the 
primary incision, with which it communicated, forming a sinus, 
and from which issued a small quantity of pus. The sinus 
was slit open. The discharge now became more profuse, 
necessitating more frequent dressings. 

At this time the couo-h became exceeding-ly troublesome, 
causing a considerable amount of pain at the wound, but he was 
still able to be up and move about, and took his food remark- 
ably well. He was also very much inclined to lie and sleep. 
The position he was in the habit of assuming, when lying on 
the sofa, was on his belly. Previous to the opening of the chest, 
he could lie equally well on either side, but afterwards lay on 
his rio;ht side. The discharo-e still continuino-, and mischief 
evidently existing at least within the pleural cavity, I advised 
him to allow me to take out a bit of his rib, for the purpose of 
getting freer drainage. To this he would not consent for some 
considerable time. However, he at last acceded, and on the 
20th February, 188.5, assisted by my friend Dr. Marshall, who 
administered a combination of ether and chloroform, I cut out 
a small portion of rib. On putting my finger into the pleural 
cavity, it came against a quantity of irregularly shaped, hard 
material, which I lifted out, most of it being comparatively 
free. After clearing away as much as was lying free I could 
still feel small hard particles of debris, as if adhering to 
the walls ; but the position in which these small particles 
were most distinctly felt was where there were distinct 
adhesions, as if between the pleura and pericardium. After 
removing as much of this calcareous material as practicable, 
the internal covering of the ribs was found to be perfectly 
smooth, thus dispelling my first impression that I had to do 
with carious ribs. On closer examination it M^as evident they 
were calcareous plates, resembling bone. The interval between 
the chest wall and the pleura, as felt through the opening, was 
considerable; judging roughly, I should say about li inch. 
The thickened pleura could be distinctly felt. For the first 
two days after this operation he expressed himself as feeling 
much easier, the cough not so troublesome, and the breathing 



Found in the Pleural Cavity. 331 

easier. But on the third day after it, he coniplainod of a 
strange feeling in his head ; this was followed by blindness, 
drawing of the mouth to the right side, and imperfect articu- 
lation. These symptoms however gradually passed off within a 
few hours, and did not return. On the 27th, or seventh day 
after the operation, he had a rigor, after which he gradually 
sank, and died on the 1st Mai-cli, or ninth day after the 
operation, apparently from exhaustion. 

I got liberty to make a post-mortem examination, but 
restricted, if possible, to the chest alone. 

On opening the chest wall in the usual way, a large cavity 
was found, in which was some pus, with a large qviantity of 
calcareous debris lying at the bottom. This cavity was 
situated at the base of the lung, extending much farther 
upwards anteriorly than posteriorly. The hand could be 
placed into it, and felt it to be distinctly bounded by the 
thickened adherent pleurae, forming quite an enclosed sac. 
The pleurae were so firmly adherent to the chest wall that 
considerable force was required to separate them, so much so, 
that it was found necessary to cut a window through some 
of the ribs to get at the posterior surface. On detaching the 
pleurae from the chest wall posteriorly, another small cavity 
was found, corresponding to a position a little above the angle 
of the scapula. In this isolated cavity, which would be about 
the size of a small orange, this one calcareous piece was found, 
together with a small quantity of pus. With the exception 
of these two cavities, the pleurae were so firmly adherent and 
thickened that it was impossible to separate them. Where 
these cavities existed, the pulmonary pleura was thickened, 
with shrinking of the pulmonary structure, constituting a 
true pleuritis deformans, as was apparent from the space 
which intervened between it and the chest wall. The heart 
was soft, somewhat large, and coated with a considerable 
quantity of fat. The valves were apparently quite competent, 
with the exception of the aorta, on one of the segments of 
which was found a small, hard, atheromatous plate. The lung 
structure cut with difficulty, and from the cut surface exuded a 
quantity of greyish-white, cheesy material, resembling tubercle. 
Remarks. — This is a case of so-called ossification of the 
pleura. The generally accepted theory regarding the develop- 
ment of these calcareous plates in the pleural cavity is that, 
from what may be termed a chronic empyema, the pleura gets 
into that condition that it is unable to absorb the more solid 
constituents of the pus cells, these become dried up, and the 
formation of these calcareous plates ensues. 



332 Mr. M'Millan — On the Rearing of Hand Fed Infants. 

The only other case which I can find, in which the full 
details of the symptoms during life are given, is that given 
in the Lancet of 4th April of this year, by Sir A. Clark in 
his admirable Lectures on Primitive Dry Pleurisies. In his 
case the atheromatous state of the circulatory system was 
found after death. 

If the above explanation be a correct one, the question 
naturally suggests itself. How is it that, out of the numerous 
cases of empyema, so few give rise to the formation of these 
calcareous masses ? The pleurae are affected, and disturbed 
in their natural physiological function in all cases of effusion. 
Must we not look, then, a little beyond the mere fact of the 
pleurae losing their absorbent power for a clearer and truer 
explanation of the development of these calcareous plates ? 
I cannot dissociate in my own mind the connection which 
seems to me to exist between the atheromatous condition of 
the circulatory system and these calcareous formations, and 
it would be interesting to note, so far as can be done, if any 
cases in which these formations have been found have been 
recorded where atheroma was not present. 



ON THE REARING OF HAND FED INFANTS. 

By EDWARD M'MILLAN, L.R. C.S.Ed. 

{Introductory to a discussion on the subject at the Southern Medical Society, 

2nd April, 18S5.) 

The rearing of hand fed infants is a subject of so much im- 
portance that I make no apology for introducing it at this 
time. 

When we find so much ignorance displayed in regard to 
the proper dieting of the children of educated people, need 
we be astonished at the serious results arising from the same 
cause amongst the children of the poor ? Every old woman, 
or pretentious monthly nurse, has her favourite method of 
feeding — or stuffing — the unfortunate infant under her care ; 
she is at all times ready to feed it, but especially so when it 
cries ; she gives it sugar and water, castor oil, rusks, porridge, 
or arrowroot without rule, save that when an infant cries it 
must be fed. 

We all know well that many infants thrive in spite of the 



Mr. I'Millan — On the Bearing of Hand Fed Infants. 333 

mode of 'eeding, but we know equally well that the high 
death-rat of infants under one year, may be traced to the 
same cav.e. In answer to an inquiry, our esteemed sanitary 
medical dicer, Dr. Russell, tells me that during the years 
1880-81-2 the per centage of deaths amongst infants under 
one year:o births amounted to 14 '8. Many years ago, Sir 
Hans Slone noted that the mortality of those suckled, com- 
pared wit those hand fed, was as 19"2 to 53"9. In Paris, and 
in other u-ge centres of population in France, the mortality, 
in the cae of hand fed infants, has been noted respectively, as 
high as 5 '3, 63"9 and 80 per cent. 

In comdering this subject, the senior members of this 
Society mst have been struck with the great change in the 
habits of the people during the last twenty or twenty-five 
years. 1 'enty-five years ago it was comparatively a rare 
thing to se a feeding bottle. In fact, women were ashamed 
to show tat they were unable to suckle their infants ; and, 
when it ^as necessary to employ artificial means, usually 
there wasa good reason for so doing. At the present time, 
what is S( common as the feeding bottle ? One can scarcely 
enter trai or car without seeing a specimen of the universal 
"Maw" 0- Mather." 

What i the cause of this change in the habits of the 
people ? ,'urely it is to be found in the mode of living. 
"Want of tiercise, improper diet, inattention to the skin — in 
a word gei;rally defective hygiene — are all important factors 
in lessenin the secretion of what is best for infant life — 
mother's nik. Then, too, we find that modern society makes 
such great lemands on some mothers, that they very readily 
adopt the ,se of the feeding bottle to free them from what 
ought to bi their first care. 

I freely admit that there are many mothers, however 
willing au' anxious to suckle their infants, who cannot do 
so, either :'om deficiency of quantity, or deterioration in 
quality of tie milk. 

In comin to the important point, viz. — what to give the 
infant depived of its natural sustenance — it is necessary to 
remember tat the stomach of the infant is different from that 
of the adtt. The former may be compared to a vertical 
tube, with i slight dilatation in the centre, lying almost 
parallel to he body, which, as the child grows, gradually 
assumes almst a horizontal position ; and it was most certainly 
never interied to receive, much less digest pap, and the 
numberless :oncoctions, with which the genus " Gamp " con- 
trives to stif the poor innocents. 



334 Mr. M'Millan — On the Rearing of Hand Fed Infants. 

When we consider the ahnost entire absence of the two 
important ferments from the stomach and duodenum, viz., — 
salivary and pancreatic diastase, in the early months of infancy, 
we must be careful not to order farinaceous foods, until the 
natural secretions are formed to convert the starch into sugar. 

Ass's, goat's, and cow's milk are always considered to be the 
best substitutes for human milk. I need not dwell on the 
comparative analyses of the three vai'ieties of milk, but pass 
on to consider what is most used in this country — cov/'s milk. 
Cow's milk, properly prepared, as I shall subsequently note, I 
consider the best substitute for human milk ; in quantity and 
quality it varies very much, but this depends on the kind of 
cow, the feeding, the time of year, and the time of day. 
Hence the discrepancies we find in the different analyses. 

Taking the most important constituent in cow' smilk, casein, 
I find that the mean of ten results by different analysts is 
about 55 per 1,000 parts, varying from 34-0 to 72. Dr. Play- 
fair a^ivino; it as 41 "6. 

In one table human milk stands at 39'24. 

The milk of cows, stall fed, in towns, is usually acid; human 
milk, as you know, being alkaline. 

During this month I got four specimens of milk, obtained 
from stall fed cows, from different dairies on the South Side. 
On the application of the test paper they all gave an acid 
reaction. 

Leaving the subject of milk in the meantime, I wish to say 
a few words on some of the other infant foods, which are used 
to so great an extent and which are often over lauded. 

In 1865 Liebig's Food was first introduced. It consists of 
second's flour, malt, bicarbonate of potash, skimmed milk, and 
water. The malt converts the starch of the flour into sugar 
and dextrine. This food is sold in a dry state, under the 
well known name of " Savory & Moore's Food for Infants." 
I think this an admirable preparation, and although it sometimes 
disagrees, I am confident that to it many infants owe their 
lives. In ordering it I always recommend that it should, if 
possible, be made at home, as by so doing it will be fresher, 
better, and less costly than if bought in tins. 

Another preparation, based on Liebig's process, is Mellin's 
Food. My experience of it is not great, but I believe that in 
many cases it is an admirable substitute for human milk. 

Nestle's Milk Food, a preparation of concentrated milk, 
baked flour, and sugar, is much used on the Continent ; it is 
looked upon with great favour in the Parisian Foundling Hos- 
pitals. My own experience has not been favourable to its use. 



Mr. M'Millax — On the Bearing of Hand Fed Infants. 335 

Swiss milk, condensed, in my opinion, is useful as a stop 
gap in summer weather, on board ship, or under circumstances 
wdiere a proper supply of cow's milk cannot be obtained ; but 
I should advise that it be used sparingl3^ At a meeting of the 
Acad»^mie de jNIedecine, M. Tarnier, in a paper on the feeding 
of infants, declared that, in his opinion, preserved milk, of 
whatever brand, is of no value for new-born infants. 

For further information on these points, I would refer you 
to an essay by Dr. Thos. Barlow, published in vol. Ixvi of the 
Med. Chir. Tn(ns., London, where a series of cases of rickets 
are graphically described. Dr. Barlow states that in nine 
cases absolutely no fresh food Avas given. The diet consisted 
of — Nestle's food, made with water, Ridge's food, made with 
water, mealy foods, Anglo-Swass food. Savory & Moore's and 
Neave's foods. I would also refer you to an article in the 
Lancet of 12th January, 1884, p. 60, b}- Rickman J. Godlee, 
F.R.C.S., in which is detailed a very severe case of so-called 
scurvy rickets. The diet for the first six weeks was con- 
densed milk, then cow's milk. When three months old, sago ; 
when six months, nursery biscuit thrice daily. Again, I 
would refer you to a short article in the Lancet of 9th 
February, 1884, p. 247, by Edmund Owen, F.R.C.S., and to a 
letter in the Lancet of 22nd March, 1884, p. 553, by Geo. R. 
Lake, M.R.C.S. These two articles show clearly how im- 
portant a factor ineJfBcient feeding is in the production of 
serious disease. 

Dr. Routh praises Revalenta Arabica or lentil powder : 
amongst vegetable substances it is said to come closest in 
composition to milk: it contains phosphoric acid in abundance, 
chloride of potassium, and casein. Its nuti'itive matter is, 
to its calorifiant matter, in the proportion of one to two and 
a half, milk being in that of one to two. Lentil powder is 
slightly laxative. To prepare it, mix one part with ten parts 
of cold water, and boil for ten minutes. In my opinion it 
ought not to be used for infants under two months. I w^ould 
observe the same caution in regard to the use of oat flour. 
Peptonised foods are much used, but my experience of them is 
limited. 

Returning again to the subject of cow's milk. I wish to 
<lirect your attention to artificial human milk. Dr. Frankland's 
Experimental Researches in Chemistry, p. 843, gives a for- 
mula for its preparation, and from a comparative table shows 
that by the removal of one-third of the casein from cow's 
milk, and the addition of about one-third more of sugar of 
milk, a liquid is obtained which closely approaches human 



336 Mr. M'Millax — On the Rearing of Hand Fed Infancs. 

milk in composition, the percentage amounts of the chief 
constituents being as follows : 

Casein, ------- 2-8 

Butter, ------- 3-8 

Milk Sugar, - - - - - - 5-0 

Salts, ------ ^ -7 

Dr. Frankland further states that " this preparation saved 
the life and thoroughly nourished one of his children for the 
year he consumed it." 

In the Lancet of August, 1884, Mr. Walker, Spondon, 
Derby, in an admirable letter on the hand rearing of infants, 
refers to Dr. Frankland's method of preparing artificial 
human milk, and corroborates his opinion regarding the value 
of this preparation. 

Since September, 1884, I have had many opportunities of 
testing this preparation. In every case in which I have 
ordered it the infant has done well, care being taken that the 
bottle and the fittings belonging to it were kept clean. 

On two occasions I found it necessary to reduce the quantity 
of casein still further by curdling one-half of the milk instead 
of one-third. 

Frankland's Artificial Human Milk — Sbiplified. 

Total quantity of milk required — a pint and a half. — A 
piece of rennet about an inch square (about half a teaspoonful 
of essence of rennet will do as well) ; 160 grains of powdered 
lump sugar. 

The following simple process enables any unskilled person 
to prepare artificial hiiman milk : — 

Allow half a pint of new milk to stand for twelve hours; at 
the end of this time remove the cream and add to it one pint 
of fresh new milk. Into the half pint of skim milk put a 
piece of rennet about an inch square, to be obtained from the 
butcher. Set the vessel in warm water till the milk is fully 
curdled, which requires from five to fifteen minutes, the 
rennet being removed as soon as the curdling commences, and 
put into an egg cup for future use, as it can be employed 
daily for a month or two. 

About half a teaspoonful essence of rennet may be used 
instead. 

Break up the curd thoroughly and separate the whole of 
the whey by passing it through thin cloth or muslin — bring 
the whey rapidly to the boiling point. Add the sugar to the 
boiled whey. 



Current Topics. 387 

The sweetened whey is added to the pint of new milk (and 
cream). It is then ready for use. 

Note. — Two breakfastcupfuls equal to a pint. Two tea- 
spoonfuls of sugar equal to 160 grains. 

In this formula for sugar of milk I have substituted 
powdered loaf sugar, and have found the result quite satis- 
factory. 

If this sliort paper be the means of directing increased 
attention to this important subject — the Hand Rearing of 
Infants — it will afford me the greatest satisfaction. 



CURRENT TOPICS. 



Closing of the Winter Medical Session in the Glas- 
gow Medical Schools. — At the end of March and the 
beginning of April the winter session of the various medical 
schools of the city was brought to a close, and in all of them 
it seems to have been a most successful one. 

At the University the work of the Medical Faculty was 
formally brought to a close on Friday, the 3rd of April, but 
the delivery of the Lord Rector's address on Thursday, the 
26th of March, with the holiday on the following day, in 
reality, practically terminated the labours of the students, 
who, after the break, were not inclined seriously to settle to 
work again during the following week. The professors, how- 
ever, continued to lecture until Friday the 3rd, when the 
amiouncement of the honour lists in the different classes set 
the students free, some to put the finishing touches to their 
work for the professional examinations, others to recruit by a 
month's holiday for the work of the summer. The numbers 
attending the anatomy classes have been so large that it has 
been found absolutely necessary to provide increased dissecting 
room accommodation. This has been accomplished by the 
erection, at the north-east extremity of the University, close 
to the anatomical rooms, of an iron building somewliat 
resembling an impoverished mission church, which is certainly 
anything but an ornament to the splendid pile which remains 
as a monument of the labours of Sir Gilbert Scott. It is to 
be hoped that the presence of this unsightly edifice — a blot 
as it is on the fair face of our University — will excite in 

No. 5. Z \'ol. XXIII. 



338 Current Topics. 

generous and benevolent individuals a desire to contribute 
the necessary funds for enlarging and improving the Medical 
School. The only change in the teaching arrrangenients 
which calls for remark is that which has taken place during 
the past year in the course of Pathology. As there is no 
chair in the University, instruction in this subject has, for 
many years, been given to the students by Dr. Joseph Coats 
at the Western Infirmary. Formerly there were two courses 
— a winter course of 100 lectures on general pathology, and 
a summer class of practical pathological histology. In future 
these classes will be combined, and will consist of a winter 
course of 50 lectures, with a weekly demonstration on post- 
mortern examinations, and a summer course of practical 
instruction, for which a single certificate will be given. 
Some chansfes have also been made in the ordinance reg^u- 
lating the medical examinations, &c., but of these we hope 
to give some account in a future issue. 

The Andersonian Medical School has this winter completed 
one of the most successful sessions it has had for many years. 
The anatomical classes were particularly large, there having 
been 30 students in the junior classes. The other classes 
have been proportionally successful, and we have no doubt 
that when the school is removed west its success will be still 
greater. The session was closed on the 27th of March, when 
Dr. Fergus presided at a general meeting of the teachers and 
students, at which the prizes and certificates were awarded 
to the successful competitors. 

Western Medical School. — The year just closed has been by 
far the most prosperous in the history of this School. In the 
summer session 83 students attended, and in the winter 
session 125 students. The School is entirely on the model of 
the great Extramural School of Edinburgh. It is a voluntary 
association of teachers : and in this respect it is quite differ- 
ent from any other in Glasgow since the close of the Portland 
Street School about forty years ago. The lecturers are in 
direct competition with the University professors ; and that 
the students appreciate such rivalry is shown by the figures 
mentioned. Success did not attend all the classes that four 
years ago were begun in the School ; and, singularly, this is 
not due to the circumstance of the professors in these subjects 
in the College being more illustrious than their colleagues, in 
competition with whom the teachers of the Western School 
have been more or less successful. 

Glasgoiu Royal lnfirr)iary School of Medicine. — There 
was no formal closing at the end of the session at this School, 



Current Topics. 339 

and in view ot" what such meetings have become elsewhere 
this deficiency is scarcely to be regretted. The number of 
students attending the classes has been rather less than in 
previous years, which shows how little the School has become 
known. It possesses advantages in regard to its excellent 
buildings, free supply and admirable preparations of anatomical 
material, and large clinical field, such as should ensure a large 
and increjisino- number of students, if these advantaoes were 
widely known. We are informed that the students have been 
so successful in passing their examinations that scarcely any of 
their number remain as " chronics " to swell the total numbers 
of the School, and that in the recent examinations at the 
Faculty Hall not a single student of this School failed to 
satisfy the examiners. 

It is exceedingly difficult to arrive at any trustworthy facts 
as to the relative attendance at the classes of the two eastern 
Schools, but we have it on reliable authority that the clinical 
rolls of the Royal Infirmary give the following figures : — 
Andersonian students, 44 ; Royal Infirmary School students, 
38 ; not attached to either school, 6 — total, 88. 

In connection with the Royal Infirmary School too, it may 
be mentioned that during the past session a course of lectures 
and demonstrations on diseases of the throat has been 
instituted by Dr. Newman. The course was largely attended 
by students, 106 names having been given in, and there 
having been an average attendance of 78. We understand 
that a similar course on diseases of the nose and pharynx will 
be given during the summer session. 

The preceding paragraphs will give some idea as to what 
has been done in the different schools during the past session. 
The information contained in them has been furnished by 
gentlemen connected with each, and it will be seen that a fair 
amount of success has been experienced b}- all. As regards 
numbers, the Western Medical School would seem to have 
been as prosperous as — proportionally perhaps more so than — 
any of the others, but we have no information as to how the 
figures given have been made up — i. r., whether the 125 
represents simply the slump totals of the different class rolls, 
or the actual numbers of individual students attending the 
School. It will easily be understood that these two things 
are not identical, for the same student may be enrolled in two 
or three classes. 

The April Medical Examinations at the University. 
— The following figures may be of interest to our readers, as 



340 Current Topics. 

showing the numbers who took part in these examinations, 
and also the proportion of passes and rejections : — 

Examinations in General Education for Degrees in Medi- 
cine. — At the examinations just concluded, 299 candidates 
appeared. Of these, 81 passed in English, 73 in Latin, 87 
in arithmetic, 95 in mathematics, 101 in mechanics, 39 in 
Greek, 87 in logic, 46 in French, 1 in German, 6 in higher 
mathematics, 38 in natural philosophy, and 6 in moral 
philosophy. 

Professional Examinations for Degrees in Medicine. — 
The annexed table will show at a glance the numbers taking 
part in and the results of these examinations : — 

Passed. Reiected. , Total. 

•* drew. 

First Professional — 

Chemistry, Zoology, Botany, . 42 27 12 81 

Second Professional — 

Anatomy and Physiology, .47 12 5 64 

Third Professional — 

Regional Anatomy, Materia 

Medica and Pathology, . .53 13 6 72 



142 52 23 217 

University of Glasgow. — Degrees of M.B. and CM. — 
Pass Lists, April, 1885. 

First Professional Examination. — Henry N. Bird ; Thomas 
Cameron ; Archd. Campbell ; Daniel Craig ; John Crawford ; 
John Dewar ; Richard G. Dick ; William Dinsmore ; Robert J. 
Freebairn ; Robert Halliday ; Wm. T. Hannah ; Thomas W. 
Hay ; Thos. W. Jenkins, M.A. ; John W. Jordan ; Thomas 
Laird ; George Lowson ; John R. Marshall ; John Melville ; 
Alex. C. Morrison ; Wm. H. Murray ; James M'l. M'Call ; J. S. 
M'Conville, M.A. ; John M'Corkindale ; John M'Kendrick ; 
Alex. Park ; Thomas L. Paterson ; Wm. F. Paton, M.A. ; David 
J. Penney ; John W. W. Penney ; David Pryde ; Dugald Revie ; 
William Russell ; Alexander Shanks ; Hugh R. Sloan ; J. 
Mitchell Stewart ; David Stone ; Andrew Tannahill ; George 
Thomson ; Joseph B. Wallace ; William Wallace, M.A. ; James 
D. Wilson ; Richard J. Wylie.— (42.) 

Second Professional Examination. — James Bruce ; Alex- 
ander Butler ; James G. Connal ; Saxon S. Dale ; Thomas T. 
Downie ; Jas. K. DufF, M.A. ; Alex. Duncan ; David Elliot ; 
Arch. G. Faulds ; Wm. R. Forrester ; Andrew Gray ; Harry 
Gray ; R. C. Highet ; G. F. Hilliard ; Robert Hogg ; Arthur D. 
Hughes ; John A. Jackson ; Josias Jago ; Hugh W. Kilpatrick ; 



Current Topics. 341 

Thomas Kirkland ; Jolm Love ; Jaines Marshall ; William 
Millar ; Robert C. Miller ; John K. Morton ; James Muirhead ; 
Charles M'Bryde ; James M'Donald ; Thos. L. Macfarlane ; 
Thomas M'Geoch ; Alex. H. M'Lean ; Wm. T. Nicholson ; Hugh 
Rhodes ; Harry W. Robinson ; Wm. P. Sandilands ; Charles E. 
Scanlan ; Aurung Shah ; Wm. Snodgrass, M.A. ; J. Barclay 
Stewart ; J. Stewart (Lochgilphead) ; Robert Stirling ; Edward 
B. Tant ; James A. Ure ; Thomas Watt, M.A. ; Evan Williams ; 
George Wills ; Donald Wingate.— (47.) 

Third Professional Examination. — Basil J. Adam ; Alex. W. 
Aird ; W. M. Alexander, M.A., B.Sc. ; Robert M'G. Beattie ; 
James A. Brown ; Walter F. Brown ; Arch. T. Campbell ; Alex. 
Carmichael ; Robt. K. B. Crawfurd ; John R. F. Cullen ; John 
Currie ; James F. Davidson ; George W. Davis ; Daniel M'K. 
Dewar ; James K. Duff, M.A. ; Wm. Henry Fergus ; R. Irvin 
Gardner; Bruce E. Goff; R. W. T. Haddow; Robt. Hamilton; 
Walter Hay ; Robert Henry ; Herbert Hickin ; Wm. H. Man- 
ners ; John Marshall ; William Marshall ; Alex. L. Mathieson 
Alfred E. Miller ; Henry W. B. Monteagle ; Donald S. MacColl 
James M'Conechy; Hugh M. M'Houl ; C. A. MacKechnie 
Alex. A. MacKeith ; John MacKeith ; James M'Lachlan ; David 
T. MacLeod ; John A. Macquarie ; William Pjde ; Robert 
Ramsay ; John Ritchie ; Robert Robertson ; Wm. Robertson ; 
John Rowat ; Alex. Roxburgh ; H. W. Sinclair ; John Stewart 
(Renfrew) ; James W. H. Steil ; John Thorburn ; Wm. Wallace 
(Glasgow) ; Wm. Wallace (Greenock) ; James Watson ; James 
Wyllie.— (53.) 

Glasgow University Medico-Chirurgical Society. — At 
the Annual Business Meeting of this Society, the following 
were elected Office-bearers for next session, viz.: — 

Honorary President., . . Professor Leisiiman, M.D. 

President, John Macphail. 

-IT- n -J ^ ( Senior, . . John H. Carslaw, M.A. 

Vice-Presidents, -It- tj.^.. t a^..,, 

' (Junior, . . . B^\siL J. Adam. 

o f ■ i Corresjwnding, . William H. Fergus. 

^secretaries, ^ j^i^^^^g^ Henry J. Younger, M.A. 

Treasurer, Arthur D. Hughes. 

Librarian, . . . . . William B. Leishman. 

The Faculty Certificate in Public Health. — We 
have just been favoured with copies of the four papers set at 
the recent examination for a certificate in Public Health, 
held in the Faculty Hall, on 10th and 20th of April, 
respectively. The papers are of a searching character, and 
the examiners are Drs. James M. Milne, Eben. Duncan, James 



342 Current Tojyics. 

Christie, and J. B. Russell. We have received no information 
as to the number of candidates who presented themselves; 
but we hope that many students will avail themselves of the 
opportunity now granted them by the Faculty of obtaining a 
qualification in Public Health. 

International Medical Congress, 1887. — We have re- 
ceived a copy of the rules and preliminary organisation of 
the ninth session of the International Medical Congress, to be 
held in Washington in 1887. The first rule is to the effect 
that — 

"The Congress will be composed of members of the 
regular medical profession, and of such persons as may be 
specially designated by the Executive Committee, who shall 
have inscribed their names on the Register of the Congress, 
and shall have taken out their tickets of admission. As 
regards foreign members, the above conditions are the only 
ones which it seems, at present, expedient to impose." 

The work of the Congress is divided into nineteen sections, 
as follows : — 

" 1. Medical Education, Legislation, and Registration, in- 
cluding methods of teaching, and buildings, apparatus, &c., 
connected therewith. 
" 2. Anatomy. 
"3. Physiology. 
"4. Pathology. 
" 5. Medicine. 
"6. Surgery. 
"7. Obstetrics. 
"8. Gynaecology. 
" 9. Ophthalmology. 
"10. Otology. 

" 11. Dermatology and Syphilis. 
" 12. Nervous diseases and Psychiatry. 
" 13. Laryngology. 

" 14. Public and International Hygiene. 
" 15. Collective Investigation, Nomenclature, and Vital 
Statistics. 

" 16. Military and Naval Surgery and Medicine. 
" 17. Practical and Experimental Therapeutics. 
" 18. Diseases of Children. 
"19. Dental and Oral Surgery." 

" Notices of papers to be read in any of the sections, 
together with abstracts of the same, must be sent to the 
Secretary of that section before 30th April, 1887. These 



Current Toincs. 343 

abstracts will be regarded as confidential communications, and 
will not be published until the meeting of the Congress. 
Papers relating to questions not included in the list of subjects 
suggested by the officers of the various sections will be 
received. Any member, after 30th April, wishing to bring- 
forward a subject not upon the programme, must give notice 
of his intention to the Secretaiy-General at least twenty-one 
da3^s before the opening of the Congress. The officers of each 
section shall decide as to the acceptance of any communication 
offered to their section, and shall fix the time of its presenta- 
tion. No communication will be received which has been 
alread}' published, or read before a society. 

"All addresses and papers, read either at general meet- 
ings or in the sections, are to be immediately handed to the 
Secretaries. The Executive Committee, after the conclusion 
of the Congress, shall proceed with the publication of the 
Transactions, and shall have full power to decide which papers 
shall be published, and whether in whole or in part. 

" The official languages are English, French, and German. 

" In the sections no speaker will be allowed more than ten 
minutes, with the exception of. readers of papers and those 
who introduce debates, who may occupy twenty minutes. 

"The rules, programmes, and abstracts of papers will be 
published in English, French, and German. 

" Each paper or address will appear in the Transactions in 
the language in which it was delivered by the author. The 
debates will be printed in English." 

The president selected is Dr. Austin Flint, Sen., of New 
York. 

Our Army in Egypt. — Some time ago we received a Govern- 
ment document entitled " Sanitar}-, Medical, and other Notes 
and Memoranda for the information of the Principal Medical, 
Sanitary, and other Officers of the Medical Staff of the Suakin 
Expeditionary Force," and, as there can be no doubt that it 
will prove highly interesting to our readers to have some 
idea of the arrangements made for the comfort of our soldiers, 
and of the dangers to which they are subjected, we propose 
giving some extracts from it. 

" Hospitals. — The proposed Hospital provision to be provided 
for the Suakin portion of the force will include, in addition to 
that already there — 

" The Peninsular and Oriental s.s. " Ganges " as a floating 
hospital, capable of accommodating about 200, distributed as 
follows : — 23 sick or wounded officers, 79 iron cots for the 



344 Current Topics. 

more seriously sick and wounded cases ; the balance for 
ordinary cases of sickness or wounds. Punkahs are pro- 
vided. 

" One base or general hospital, 300 beds, at Suakin, or at 
such place contiguous as may be deemed advisable. 

" This hospital will be composed of huts sent from England. 
Each hut wall hold 12 men at 800 cubic feet; they are well 
ventilated, and have been, in several respects, specially adapted 
for a hot climate. Provision will be made locally for an 
Officers' hospital, if required. Punkahs will be provided. 
There wall be two corrugated iron cook-houses, each supplied 
with three American kitcheners. 

" Two large tents (Toilet's system) similar to those used in 
the Tonquin expedition have also been provided. 

" Four field hospitals, new establishment, 100 beds each ; in 
addition to stationary hospital for the lines of communication 
— that is, one hospital of 200 beds, divided into four sections 
if necessary. 

" The hospital at Suez, 200 beds, will be available, and can 
be utilised for the reception of cases. A staff of nurses for the 
base hospital, hospital ship, and Suez hospital — four to each 
respectively. Two Bearer Companies will also be available." 

" Climate. — The rainy season, generally speaking, may be 
said to commence early in May, and continue off and on up to 
the end of October." 

" In March the summer begins with drought, sultry nights, 
and verv hot days. In May the afternoon temperature is 
105-8° Fahrenheit. 

" Much inefficiency may fairly be anticipated to arise from 
the heat. It may be practicable to devise means for diminishing 
the intensity of the direct rays of the sun by increasing the 
thickness of tents or huts by a thatched roof made of any 
vegetable coarse fibre." 

" Diseases. — Experience has fully borne out the anticipations 
as to the character of the diseases to be encountered by an 
army constituted like our own. Diarrhoea and dysentery, 
enteric fever, heat fevers, heat exhaustion, and sunstroke, are 
the principal general diseases ; ophthalmia is the local disease, 
to w^hich must, of course, be added the wounds and injuries 
incidental to warfare. 

" So-called Egyptian ophthalmia is a form of disease mainly 
attributable for its specificity to dirt, overcrowding, and 
flies ; it is characterised by slight subjective symptoms in its 
initial stage, but is often preceded by the presence of raised 
vesicles or granules, called ' sago-grain granules,' on the inside 



Current Topics. 345 

of the ej'elids. In such cases exposure to dust, glare, or 
catarrh will induce an acute or even a purulent ophthalmia. 

" There are, however, two great factors in the production of 
sickness in an army in the field ; one is fatigue, the other is 
insufficient nourishment. Climatic conditions are so far 
secondary to these tliat they may, to a greater or less extent, 
be overcome b}' avoidance of one, and ample provision for the 
other." 

" Water. — How far it may be practicable to sink wells, or to 
obtain good water through Norton's tubular wells, must be 
determined locally, 

" There will be two vessels at Suakin for distilling water, 
each capable of condensing 150 tons a day. 

" Troops marching from Suakin can be supplied with water 
from the shipping, which would be pure. Soldiers should be 
directed to fill their water bottles with cold tea, with the 
addition of some lime-juice and sugar, by which boiled water 
would be to some extent secured for them. 

"A large supply of alum has been sent out and specially 
marked for the purification of water, in view of its being 
practicable to serve out a fragment of it to the men ; it is a 
very efficacious agent for ridding the water of suspended 
impurities, and its method of use is so simple as to put it 
within the reach of every one. The soldier should be instructed 
how to use it. Six grains of powdered alum to a gallon of 
water, Nile water for example, allowed to stand for 10 or 12 
hours, will cause a subsidence of all suspended matters. 

" It is extremely difficult, if not impracticable, to overcome 
the taste and properties of brackish water, and its injurious 
effects. To some extent this may be done by using it exclusively 
for cooking or, at any rate, as a vehicle for oatmeal, milk, and 
other articles of food requiring salt ; reserving tlio distilled 
water for drinking purposes. Freezing or distillation are, of 
course, out of the question in the field." 

" Sanitarij Police. — A sanitary police should be organised 
by the medical and other authorities of the I'cspective divisions 
concerned, and native labour will be required for hospital 
conservancy at the base." 

" InfectioiiH Disease.'^. — For all infectious diseases, or disea.ses 
ordinarily so designated, the grand rules are : — separate the 
sick, largely increase the superficial area for (that is, spread 
out) the remainder, and change the site ; this will be specially 
required in the case of cholera. 

" There is no hygienic limit for the occupation of a camp, 
because so much must depend upon local conditions, but tern- 



346 Current Topics. 

porary camps on loose soil soon become fouled unless extreme 
care be taken. The practical rule is^when in doubt, move." 

"Men employed early or late, and on early morning 
inarches. — In the event of an early morning march, or of men 
being employed late at night, a ration of hot cocoa and milk, 
coffee, or tea, should be issued — cocoa and milk for choice. 

" It is obviously important to have the troops supplied with 
food regularly, and always before marching ; and, if possible, 
at a halt. 

"The Medical Officers attached to regiments, and the 
Sanitary Officers of brigades or divisions will exercise a 
careful supervision over everything connected with hygiene in 
the field, and will personally satisfy themselves as to the 
cooking, the sufficiency and quality of the supplies, &c. The 
returns and reports required from Medical Officers serving in 
the field by the Army Medical Department Kegulations, for 
the information of the Sanitary Officer, will be invariably 
furnished." 

"Medical Inspections. — Medical inspections of troops should 
be made as frequently as practicable, and daily in the event 
of the appearance of any infectious disease, and a vigilant 
attention should be given to the early detection of disease ; 
these inspections need not, of course, be parades, or of a formal 
character, 

" It is better to march in the daytime (in as open order as 
possible) than to lie in the sun all day and have broken nights. 
Either early morning, or from 4 to 8 or 10 p.m., so long as it 
is moonlight, will do for marching. 

" In the event of troops occupying towns or villages, native 
grog shops should be put under military police regulations or 
altogether closed." 

The above extracts will give some idea of the medical and 
sanitary provisions made for our troops in the East, and will 
show the highly interesting nature of this document issued by 
the War Office. It also contains full instructions for the 
dietino^ and clothing; of the soldiers as well as for the treatment 
of the wounded in action. 

Notes from Vienna. 

NoTHNAGEL ON Addison's DISEASE. — At a meeting of the 
Society of Physicians of Vienna, on the 6th March, Professor 
Nothnacjel communicated the followino^ remarks on Addison's 
disease :-^He said, " It is now 30 years since Addison collected 
and published the numerous symptoms of this disease with 



Gwn^ent Topics. 347 

which his name is so closely associated. Addison pointed out 
that a certain form of an^^mia and asthenia, along- with a 
peculiar discoloration of the skin, occurred simultaneously, 
with changes in the suprarenal bodies. Over this assertion there 
arose a livel}' discussion. Brown-Sequard, in 18.56, published 
a report on experimental investigations, in which he confirmed 
the truth of what Addison had asserted. Since that time it 
has been much debated whether the affection of the suprarenal 
bodies is an essential or an accidental occurrence; and also 
whether the creliac plexus or the splanchnic nerve is affected, 
I mj'self jDerformed a number of experiments, many years 
ago, with a view to determine these points. I destroyed one 
or both suprarenal bodies in 153 rabbits, without producing 
the symptoms of Addison's disease. Last year I had the 
opportunity of observing a patient who had suffered from 
Addison's disease for 3| years. In this case I took the 
opportunity of examining the point, which is the most 
interesting to us — viz., what is the origin of the pigmentation 
of the skin ? 

"As you know, a patient with tins disease has a dark bronze 
coloured skin, marked here and there with patches of black. 
He has also greyish coloured spots on the mucous membrane 
of the mouth, lips, and throat. In one case I saw such a 
discoloration on one of the vocal cords. The conjunctiva is 
always free of colour, thus contrasting w^ith what we see in 
icterus. The palms of the hands are but slightly discoloured, 
the roots of the nails not at all. In only one or two cases 
have the latter been seen affected. 

"As regards the exact situation of pigment in the skin, it is 
definitely ascertained that it is seated in the deepest laj-ers of 
the rete Malpighii. In saying this I exclude all pigmentation 
arising from skin diseases with itching, and that form seen in 
reduced systems. How then, we may ask, does the pigmen- 
tation arise ? There are, a priori, two suppositions possible — 
1st, That it is formed locally by a morbid metabolic activity of 
the cells ; 2nd, That it is brought from some other locality. 
The first view has obtained the greatest number of supporters, 
among them Burdach, Risel, and Averbeck. It is thus assumed 
that under some occult influence pigment arises from the 
unpigraented protoplasm of the rete cells. As proof of this it 
is mentioned that this pigment does not contain iron. It was 
shown long ago, and I can confirm it, that, treated with 
ferrocyanide of potassium, it does not give the peculiar Berlin 
blue reaction. This, however, proves nothing. We know 
that pigment that actually does contain iron gives, with this 



■348 Current Topics. 

coarse chemical test, negative results. One must be content 
to believe that iron may be present, but in such combination 
with the protoplasm that it cannot be detected. There is no 
proof for the supposition that the pigment arises through 
metabolic activity of the rete cells, though it has, by some, 
been considered sufficiently probable to warrant belief. 

"We must now consider from what source the pigment 
arises. Our knowledge on this point is but small. Some 
years ago Dr. Ehrmann, in Vienna, proved that in amphibious 
animals the pigment does not arise in the epidermis cells, but 
by means of movable connective tissue cells, travels from 
the cutis cells into the epidermis cells. These do not them- 
selves enter into the epidermis, but, as it were, serve as 
carriers of pigment. Riehl has proved that the hair also 
obtains pigment from the cutis, which is carried to them by 
means of cells. This observer has further proved that in 
leukoderma syphilitica the pigment cells are absent from the 
deepest layers of the rete, and that many ot them lie in the 
upper layers of the cutis — viz., in the papillary bodies. Riehl 
has also pointed out that in inflammatory processes in which, 
owing to great hyperaemia, extravasation has taken place 
into the upper layers of the rete, cells can be seen in the 
neighbourhood of the blood-vessels. He believes that pigment 
is carried by these cells to the epidermis. Virchow proved, 
many years ago, that in Addison's disease pigment exists, not 
onl}' in the deepest layers of the rete, but also here and there 
in the upper layers of the cutis, i. <?., in the papillary bodies. 
I believe that this is always the case; only in soine cases the 
pigment in the upper layers of the cutis is more abundant, in 
others it is less so. In the plates in Greenhow's monograph 
we see pigment cells represented, and in Risel's three cases of 
Addison's disease, on all of which a post-mortenu was per- 
formed — the invariable ending of this disease is death — 
pigment cells in the corium are described. These latter 
have exactly the same constitution as those which Riehl has 
represented in the corium of the white spots of leukoderma 
syphilitica. According to the number of cells the colour is 
deeper or lighter. Occasionally the discoloration takes the 
form of broad stripes. This is best seen on the skin of the 
•scrotum, which is, as a rule, strongly pigmented, and less so 
on the skin of the arms, though here also it is present. 

"In accordance with their observations, Riehl and Ehrmann 
consider it very probable that in a way similar to what we 
see in the normal skin and in hairs, the pigment cells are 
carried to the epidermis. I have been able to convince 



Current Topics. 34^^ 

myself that the pioment cells are most richly aggregated 
together around the hlood-vessels. Where there are pigment 
cells to be seen, one can always find a blood-vessel. 

"It is noteworthy that the same pigment cells are present in 
the skin of phthisical and carcinomatous patients. In these 
cases the cells lie in the uppermost layers of the cutis. We 
also see brown pigment in the linea alba, and elsewhere, of 
pregnant women. In many cases that I myself have 
examined, pigment cells have been found lying in the corium. 
Finall}-, pigment cells are found in the corium of the skin of 
the scrotum of a healthy white man. In the skin of a negro 
they are present in enormous quantities. 

"The object of the preceding remarks has been to show that 
in the pigment of Addison's disease, in the linea alba of 
pregnant women, and in cachectic persons, there is nothing 
special or distinctive, Ijut that each closely corresponds 
anatomically with the skin of the negro, and with the most 
pigmented parts of the skin of a white man. 

"From what I have said we must then conclude that in all 
of these cases the pigment is not produced in the deepest 
layers of the rete, but that it is carried thither by cells con- 
taining pigment. 

"From what source do these cells obtain the pigment? 

"This question can be answered only if we examine the 
origin of pigment in normal skin. It would probably be a 
profitable task thus to examine the skin of a negro. I believe 
that children of dark races are at birth without colour, and 
that the pigment appears during early infancy. It would 
thus be advantageous to examine the skin of young negro 
children. We might thus better understand the course of 
formation of the pigment. 

" We will now examine a hypothesis which appears to have a 
certain basis to support it — viz., that the pigment can be pro- 
duced in the cells of the corium. It is, however, far more 
probable that the cells of the corium do not produce the 
pigment, but that they obtain it from the blood. All obser- 
vations tend to show that in every case the colouring matter 
of the blood takes part in the formation of any pigment that 
is produced in the organism. Recklinghausen has pointed out 
that the pigment in a neevus is characterised by a brown 
colour. In general the pigment arising from the blood colour- 
ing matter has a brownish tint, while that arising from matter 
introduced from without — e.g., the salts of silver — is of a 
darker sepia colour. The hypothesis that pigment may arise 
in the corium is not quite sufficient, because the colour of the 



350 Current Topics. 

skin covering ntevi and melanotic tumours is a dark brown, 
while the corium cells, of which we have been speaking, are 
of a beautiful yellowish-brown tint. As we find the pigment 
cells Ij'ing in greatest abundance around the blood-vessels, it 
is extremely probable that they obtain the pigment from what 
is in their immediate vicinity — viz., from the blood. As a fact, 
this has not actually been proved, but to me it appears very 
probable. 

" How, then, we may a,sk, does the pigment get out of the 
blood ? 

" Extravasation of blood in Addison's disease has not hitherto 
been observed. It is possible that the pigment escapes from 
the vessels already in a state of solution. In general, we 
observe that the pigment is chiefly lodged in the internal 
organs of the body — it is seldom seen in the skin ; oftener, 
however, in the brain. Occasionally those suflering from 
severe intermittent fever have a dark coloured skin. In 
Addison's disease we have never hitherto been able to find 
pigment of this kind in the blood. Several observers assert 
that the blood corpuscles present peculiar deviations from the 
normal. But these observations are quite isolated and always 
have reference to cases in which complications, such as disease 
of the spleen, were present. We have, therefore, no reason 
for assuming that the pigment is already in the blood, and 
exudes through the capillaries. Rouget has observed, under 
the microscope, that in the larvae of the frog red blood cor- 
puscles escape from the capillaries, and are taken up by the 
connective tissue cells. They then lie around the vessels, and 
are afterwards transformed into pigment. Something similar 
may take place in Addison's disease. I cannot, however, 
prove it. Still it appears undoubted that in Addison's disease 
the pigment comes from the blood. 

" The further question now arises, What causes the pigment 
to leave the blood-vessels ? 

" This question cannot be answered, so long as we have no 
certain knowledge as to the history of the disease. My own 
view, with which those of most observers agree, is, that the 
affection is a disease of the sympathetic nervous system. All 
observations tend to show that the sympathetic system stands 
connected in some way with the disease, 

" Looked at from this point of view, we are able in a measure 
to examine the other pigmentations of a pathological nature. 
In phthisis and carcinoma the pigmentation is only occasion- 
ally seen. In carcinoma it occurs chiefly in the abdominal 
organs. Perhaps in these cases there is carcinoma of the 
retroperitoneal tissues, by which these nerves could be easily 



Current Topics. 351 

affected. It ix further to be considered whether also in cases 
of phtliisis, witli pigmentation of the skin, there is not present 
retroperitonitis, and att'ection of the adjoining segment of the 
sympathetic nervous system. In pregnant women, and in 
those sutiering from disease of the uterus — in whom also pig- 
mentation of the skin occurs — we have to do with affections 
of an organ b}" which, in some hitherto unknown way, very 
various segments of nerves have been drawn into sympathy. 
From tliis point of view we can bring as much of these 
pathological processes as is known to us under one category. 
This is, however, certain — that the pigment does not arise 
from metabolic activity of the cells in the deepest layers of the 
rete, but that it is conveyed thither, and most probably from 
the blood. 

" As you know, the clinical picture of Addison's disease is 
constituted by three groups of symptoms — viz., by anaemia, 
by asthenia, and by the dark colour of the skin. In very 
many cases there are also symptoms of disorder of the digestive 
system, vomiting, and diarrhoea. For diagnosis the discolora- 
tion of the skin is decisive. The other symptoms are, however, 
very important. Next in importance to the discoloration of 
the skin, is asthenia. In the history of every case, the patient 
complains of extraordinary exhaustion and feebleness. These 
symptoms remain during the Avhole disease. Addison himself 
states that he has seen obscure forms of anaemia — which we 
now describe as progressive pernicious anaemia — and that he 
has thus stumbled across cases of Addison's disease. It has 
happened in some cases that the anaemia in Addison's disease 
is veiy striking ; I must, however, say that it is not so striking 
as is seen after loss of blood, or in chlorosis and leucaemia. 
In the history of cases of Addison's disease the anaemia is not 
specially mentioned. Griesinger and Traube assert that the 
patient does not become strikingly pale, that anaemia is not a 
very prominent symptom. Oedema is not present, there are 
no heart murmurs, or only occasionally, when a complication 
is present, there is no 'bruit de diable.' The symptoms 
therefore which accompany anaemic changes in the blood are 
awanting in Addison's disease. The clinical appearances of anae- 
mia are not sharply marked. I would prefer, therefore, to con- 
sider this symptom as not essential to the course of the disease. 

" The last case that I observed, in which, in contradistinction 
to an assertion of Jiirgensen, the splanchnic nerve was normal, 
died with brain complications and coma. Dr. v. Jaksch 
examined the urine of the deceased and discovered in it a 
quantity of acetone. Perhaps we should consider acetonia one 
of the symptoms of the disease." 



352 Revieivs. 



CORRESPONDENCE. 



To the Editors of the Glasgow Medical Jo^irnal. 

16th Aj^ril, 1885. 

Gentlemen, — In the report of a case which I brought before 
the Glasgow Southern Medical Society recently, and which 
appears in a condensed form in the Journal for April, it is 
stated that " hypertrophied uterus was diagnosed, for which 
acid nitrate of mercury was applied." This is a little mis- 
leading, and no doubt to many would seem very unusual 
treatment. The decision arrived at was, that we had to deal 
with a hj'pertrophied uterus, due probably to sub-involution. 
There was also a granular eroded condition of the os and cervix 
uteri, and it was for this that the acid nitrate of mercury was 
used, and, I may say, effectually, though it brought on severe 
downbearing pains twelve hours after its application, but these, 
very fortunately, were entirely relieved by the use of a 
morphia suppository of two-thirds of a grain. 

By inserting this in the next number of the Journal you 
will greatly oblige. 

Yours faithfully, 

ALEX. MILLER. 



REVIEWS. 



Practical Manual of Diseases of Wo7)ien, and Uterine 
Therapeutics. By H. Macnaughton Jones, M.D., &c., 
Examiner in Midwifery, Royal University of Ireland, 
formerly Professor of Obstetrics in the Queen's University, 
Ireland, &c. London: Bailliere, Tindall, & Cox. 1885. 
Pp. 472. 

The second edition of this work has followed the first at an 
interval of a few months, so that it would appear to have 
taken well with the professional public. The subjects are 
taken up in much the usual order, and in short chapters, 
having on an average fourteen pages in each, beginning with 
one on what may be called the clinical anatomy of the female 
pelvic organs. In the one on the Examination of a Case which 



Revieivs. 353 

follows, we are struck by the fact that there is no mention of 
the use of antiseptics for the hands or instruments before 
makinof an examination, althouirh the after cleansinof with 
Condy's tiuid is recommended. We should not care to use 
the sound freely in certain cases where it is very useful, 
unless it were covered with some antiseptic material. The 
various methods of passing the uterine sound are referred to 
in detail, but the author does not know, or at least fails to 
mention, two of the most useful in cases of difficulty. These 
are straightening the canal by means of a tenaculum inserted 
into the anterior lip, and changing the position of the patient 
from the lateral to the dorsal, while the point of the sound is 
kept pressing gently on the obstructing portion of the canal. 

In speaking of depletion of the cervix uteri, one is recom- 
mended to deplete shortly before the advent of a period. We 
think it is generally believed that, however suitable it may 
appear, this is not good practice, experience showing that the 
ordinary menstrual tlux is thereby lessened in quantity, if not 
staved off altosfether for that time. So far as relievino^ chronic 
congestion goes, it is better to deplete a week or ten days 
after a period than before it. 

The author ranofes himself on the side of those Avho believe 
in the mechanical theory of dysmenorrhoea as giving rise to 
painful spasm. " Every practitioner will meet with cases of 
<lysmenorrhoea in which he can find no satisfactory reason for 
the pain in any abnormal state either of uterus or ovary. 
Even if there is a version or flexion, he finds that the uterine 
canal is pervious; he rectifies the displacement, and still the 
pain recurs. There may be some congestion of the uterus and 
ovarian tenderness, or hypersensitiveness of the internal os on 
passing the sound, yet not sufficient to explain the violent 
spasmodic pains that precede or accompany the earlier 
appearance of the menstrual discharge. At times we notice, 
as characteristic of this form of pain, that the patient states 
that some clots have passed, and that on the appearance of 
these the pain has been relieved. The passage of these clots 
is occasionally followed by a profuse, or rather prolonged. 
How. Dr. Matthews Duncan has drawn attention to the 
clgnic contractions of the uterus which occur in the unim- 
pregnated state during menstruation, and he attributes to these 
contractions, when exaggerated and painful, the fits of spasm 
which occur in this form of dysmenorrhfea. Dr. Duncan 
rather doubts the truth of the mechanical theory as a cause of 
the pain. He regards it as the result of muscular spasm, and 
finds an analogy in the attack of spasmodic asthma in the 
No. :>. ' 2 A Vol. XXIII. 



•354 Reviews. 

lung. Still, he associates with it as an exciting cause, 
catarrhal states of the nmcous lining of the canal, congenital 
defects, and also flexions and versions, and he treats the 
spasm by mechanical dilatation. It has always seemed to me 
that those obstetricians are right who see in spasm of the 
urethra, occurring in gouty constitutions, in old gouty states, 
or with attacks of gonorrhoeal urethritis, and with lesser 
degrees of stricture, or following occasionally on some slight 
excess, a counterpart (though by no means an exact one) of the 
spasm which occurs in the cervical canal. In both, I believe, 
there is swelling and congestion, or some old contraction or 
flexion sufficient to excite spasmodic contraction of the 
sphincter fibres. We know that in the case of the urethra 
the flow of urine is arrested by the spasm, and that it is re- 
established by the passage of a bougie. Here the cause of 
the spasm is to be sought for in the morbid condition of the 
blood or urethra, gouty or gonorrhoeal. Pain occurs when 
the obstruction to the flow of urine prevents the escape of 
water, and with the efforts to expel it. No doubt, after the 
bladder has been emptied, in some cases of vesical and 
prostatic congestion there is irritation and pain; but it is 
doubtful if this is due to ' spasm.' As Dr. Duncan rightlj^ 
says, painful contractions of the uterus occur. But those that 
we are familiar with, as after pains, have for their object the 
expulsion of clots in utero, acting as foreign bodies, and there 
is the powerful and exceptional physiological effort of con- 
traction of the uterine fibres to restrain haemorrhage, and 
bring about reduction in bulk. 

" We must remember that all through pregnancy we have 
uterine contractions occurring which are not painful, and 
which can be felt with the hand placed on the abdominal 
wall. Contractions become painful when there is blood to 
expel, or clots, as in after pains. The therapeutic means 
we adopt, such as dilatation, in order to cure the dys- 
menorrhcea, and the actions of such medicines as apiol 
in relieving the pain, also incline me to think that in 
the case of spasmodic dysmenorrhoea we must still seek for 
the source of pain in the mechanical interfei'ence which is the 
consequence, partly, of the morbid or abnormal uterine con- 
dition, and partly of the spasm which that condition induces." 

In speaking of the treatment of dysmenorrhoea, Dr. Jones 
says, he has " no doubt that good is also effected by wearing 
one of the many varieties of electrical apparatus now so 
elegantly contrived for female use." We have had some 
experience of them, and have a great deal of doubt. We are 



. 



HevicicK. 35.5 

afraid that tliese " eleg-ant " appliances are chiefly of use in 
brino;iniJ- i^rist to tlio mill of the contrivers. 

The sequence of the pathological changes taking j^lace in 
prolapse of the uterus is given thus — "(1) relaxation of, or 
deficiency in, the uterine supports ; (2) retroversion of the 
uterus ; (3) descent of the uterus ; (4) partial prolapse of the 
vagina; (5) incipient inversion of the vagina; (6) incomplete 
prolapse of the uterus, with descent of the bladder, and 
possibly of rectum ; (7) during the occurrence of the processes, 
4, 5, 0, enlargement of the uterus, with hypertrophy of the 
supra- and infra-vaginal portions of the cervix, and eversion 
of the lips of the os uteri ; (8) further inversion of the vagina, 
with protrusion of its anterior wall, and thickening of the 
mucous membrane, which gradually becomes hard, anrl, it may 
be, eroded in parts ; (9) complete prolapse of the entire uterus 
and inverted vagina, both now altered by exposure and 
friction." 

We agree with this enumeration, except that we think it is 
a mi.stake to put retroversion before descent of the uterus, 
because it is its descent which causes the cervix to be guided 
forward by the curve of the posterior vaginal wall, and the 
fundus is thus thrown backwards. 

The author's description of trachelorraphy is neither full 
nor exact. He does not even mention the most difficult step 
in the operation, that of the introduction of the sutures, and 
he says, " A stout rubber watch-spring ring is slipped on to 
the base of the cervix to control bleeding." We presume this 
is a mistake, and that he is mixing up a simple rubber ring, 
and a simple piece of watch-spring used with the ecraseur, 
either of which would serve the purpose, while a rubber 
watch-spring ring has no comjyressing, but only expanding 
power. It is also a fact that experienced operators now use 
nothing but hot water, as no kind of ring can be used with 
advantage where the scar runs high up, and no ring is 
necessary where it does not. 

In dealing with the subject of cancer of the uterus, the 
author refers to the question of the origin of malignant 
disease. " The most distinguished pathologists have been 
divided in their opinion as to whether cancer is primarily a 
local disease — one of the peculiar characteristics of which is 
to rapidly invade the system through the blood and lym- 
phatics — or if it is but the local manifestation of a constitu- 
tional or general blood-state. The weight of evidence, both 
clinical and pathological, appears to me on the side of those 
who hold the former view." Again, a few pages farther on, 



356 Revie^va. 

" I have yet to see the case in which pre-existing- cervicitis, 
whether catarrhal or granular, has led up to malignant 
disease of the uterus. The presence of lacerations of the 
cervix in some cases may be fairly looked on as a mere 
coincidence of the multiparous uterus ; the strongest predis- 
posing cause unquestionably being repeated pregnancies." 

It is somewhat difficult to reconcile these two statements, 
and we think the author is (juite wrong in the conclusion to 
which he has come. We cannot believe, unless it were clearly 
proved by facts, that repeated pregnancy causes cancerous 
disease of the uterus, aside from the diseases resulting from 
labour, and w^e firmly believe that a badly split and ectropic 
cervix rubbing for years against the posterior vaginal wall, 
with all the weight of a largely hypertrophied uterus behind 
it, and constantly soaked in profuse muco-purulent discharge, 
is very likely indeed to suffer malignant degeneration of its 
tissues. 

Some of our surgeons operate on ovarian tumours often, 
we are afraid, without making a very exhaustive differential 
diagnosis. Does not the following passage strike terror to 
their hearts ? — "That practitioner will have the least chance 
of committing' an error in the diaonosis of an abdominal 
tumour who commences his examination of the case, recol- 
lecting the many possible and likely sources of error which he 
has to avoid. I have been in the habit of directing the 
attention of my class to the carefully collated list of forty- 
three diseased conditions which Dr. Gaillard Thomas shows 
may be mistaken for ovarian cystoma." Dr. Jones contents 
himself in this volume with giving twenty-nine conditions 
which may be confounded with ovarian cystic disease, and 
then goes on to give the chief positive and negative signs and 
symptoms of ovarian cysts. In the enumeration of these 
signs the author falls into an error which we know to be a 
very common one. He says that if the tumour be ovarian, 
" the uterus does not move with the tumour, nor is the uterus 
found to be continuous with it." We have often had occasion 
to point out that an ovarian tumour having extensive attach- 
ments to the tissues in the pelvis, when moved, so disturbs 
these tissues as to move the uterus freely, without being in 
the least degree adherent to, or continuous with it. But the 
converse is true, and is the right way to put the sign — viz., that 
the tumour does not move with the uterus ; the latter being 
comparatively small, can be gently and independently moved 
by the- sound, except where both it and the ovarian tumour 
are jammed together in the pelvis, or are actually adherent. 



Reviews. 3.57 

There are once and again, what appear to us, inconsistent 
statements. Thus, vaginismus is properly enough described 
as a disease in which the slightest touching of the vaginal 
orifice gives intense pain ; and on the next page there is 
mentioned as treatment, " warm alkaline baths of soda and 
starch, used with a speculum inserted into the vagina while in 
the bath." In none of the cases of vaginismus we ever saw- 
was it possible to introduce a speculum, either in a bath or out 
of it, without the aid of pretty profound anaesthesia. 

Four-and-twenty afiections of the rectum are mentioned, 
and some of them are described; amongst others the operation 
considered most suitable for the removal of piles by scissors 
and ligature, which, we are sorry to say, after having read 
three or four times over, we do not understand. There are 
two chapters on The Diseases of the Mamma, followed by 
four appendices on Health Resorts, Dysmenorrhoea, Alexander's 
Operation, and the author's Demonstrating Vaginal Speculum. 

There are some misprints. Thus, on page 18, "schirrus" 
for scirrhus ; on page 103, " hydraminos " for hydranniios ; on 
page 103, " the recto- vaginal suture " for recto-vaginal septum ; 
and on page 355, "artesia" for atresia. There are 203 wood- 
cuts, mostly obtained from various instrument makers, and 
mostly good. The author sometimes becomes virtuously and 
amusingly indignant at certain parties — now those who uphold 
specialities, and again those wdio presume to do certain things 
without special knowledge. " Unfortunately, many students 
look on the treatment of women's affections as a ' specialty.' 
This 'is but one of the many disastrous consequences which 
have followed that modern parcelling out of the body into 
segments, and the handing over of a small piece of it to this 
or that specialist to exercise his speculative ingenuity in the 
discovery of some diseased condition beyond the ken of the 
ordinary physician. A mushroom-like brood of specialists and 
specialties appear daily to be sprouting into existence." "Over- 
weening self-confidence and ignorant assurance, which we 
frequently meet with as weedy growths springing from the 
uncultivated soil of what some are pleased to call their ' ex- 
perience,' and which, when we come to inquire into its claims 
on attention, we find means nothing more than the accumu- 
lated heaping of ignorance on ignorance in the mental ashpit, 
where the fungus of empirical experience is the only product 
that remains to assert itself amidst the stagnant debris of 
an uneducated and routine obsei'vation — will nowhere mon; 
startlingly meet the rebuff they merit than in the case of 
over-confident diaj^nosis of abdominal tumours." 



358 Beviews. 

We hardly know whether to commend this volume or not. 
There is a fair exhibition of the medical aspect of the subject 
of which it treats, but the surgical is passed over in a cursory 
style. It is very much the kind of work which may be 
produced, as indeed the author admits this one has, at the 
request of the publishers, as opposed to that written by a 
man who is pressed into print by having something original 
to say. 

The second edition differs from the first only in the addition 
of the chapters on the Rectum, Mamma, and Alexander's 
Operation. 

Glaucoma and its Treatment. By G. L. Johnson, M.A.. M.B., 
B.C. Cantab. London : H. K. Lewis. 1884. 

The author of this little brochure starts with the proposition, 
the truth of which he wishes to establish by a process of 
inductive reasoning : — " That the ordinary method of treat- 
ment for glaucoma by iridectomy, though highly successful in 
acute forms of the disease, is nevertheless both uncertain and 
unsatisfactory in the chronic condition of glaucoma." All 
who have large experience in the performance of operations 
on the eye will freely admit the truth of that proposition ; but 
why is an iridectomy so wonderfully successful in some cases 
of glaucoma and so signal a failure in others ? Our author 
professes to find an answer to this question in the study of 
the lymphatic system of the eye, and in the nature of the 
pathological processes associated with glaucoma. 

Defining glaucoma as "the sum of the pathological con- 
ditions dependent upon increased tension of the eyeball, from 
whatever cause arising," evidence is adduced to show that the 
aqueous humour and the nutrient fluids of the vitreous are 
secreted mainly by the ciliary processes, and drawn off by the 
canal of Fontana, and the meshwork of the irido-corneal 
region, so that any circumstance tending to obliterate this 
angle, by disturbing the balance of secretion and excretion, is 
apt to induce glaucomatous tension. From various considera- 
tions, Dr. Johnson thinks that in acute glaucoma the primary 
obstruction may be referred to inflammation and engorgement 
of the ciliary processes, and a suddenly increased secretion 
into the vitreous of an otherwise fairly healthy eye, with 
retarded elimination from narrowing of the external angle, or 
Fontana's space, by the pressure exerted upon the iris and 
ciliary processes from the increased volume of the vitreous ; 
whilst in chronic slaucoraa there are slow and orradual 



Revieivs. 359 

structural changes in the ciliary body and in the tissues 
around the angle of the anterior chamber, by which the 
connective tissue becomes increased, and its subsequent 
contraction tends to narrow and obliterate the lymph spaces, 
and finally to tie down the iris against the contiguous cornea. 
This, according to the author, explains the very different 
effects of an iridectomy in cases of acute and in chronic 
glaucoma, for in the former the operation relieves the con- 
gested iris and ciliary processes, so that these parts resume 
their normal position, and the lymphatic circulation being* 
restored, the tension of the eyeball falls to the normal. In 
chronic glaucoma, however, the case is different, for here the 
structural changes in the ciliary body and iris, with the 
blocking up of the lymphatic channels, permanently obstruct 
the normal outflow, so that an iridectomy, however carefully 
performed, cannot be expected to restore those parts to their 
normal condition. A careful study of the drainage system 
of the other parts of the eye convinced the author that the 
vitreous chamber offered a greater chance of success to the 
operator by opening up a free communication between this 
cavity and the Tenonian and the supra-choroidal spaces, and 
through these with the exterior. Dr. Johnson then proceeds 
to describe an operation which he terms " scleral paracentesis," 
which he performs by thrusting a lancet-shaped knife through 
the sclerotic into the vitreous towards the centre of the globe, 
at about 4 mm. from the margin of the cornea, and on with- 
drawing the knife slowly, the fluid contents of the vitreous 
are allowed to escape, thus producing an instant reduction in 
the tension of the eyeball. The wound heals without any 
inflammatory reaction, and should there be any return of 
increased tension, which rarely happens, a second paracentesis 
suffices to produce a permanent effect. This operation at once 
commends itself by its simplicity and by the ease with which 
it can be performed, and, as the author is careful to point out, 
it differs from other forms of scleral paracentesis which have 
been formerly tried with only partial success. It yet remains 
to be seen, however, whether the promises of this operation 
will be fulfilled after more extended trials; but meanAvhile 
Dr. Johnson deserves credit for the manner in which he has 
thought out this method of procedure, which, though it may 
not supersede iridectomy in all cases of chronic glaucoma, 
nor arrest those degenerative changes which too frequently 
go on even in spite of the most successfully performed opera- 
tion, will certainly take its place as a perfectly safe method of 
dealing with many difficult ca.ses. 



3G0 Revieius. 

The Bradshaiv Lecture on the Pathology of Cancer, delivered 
at the Royal College of Surgeons of England, 1884. By 
W. S. Savory, F.R.S. London : J. & A. Churchill. 

Mr. Savory's address is full of material for reflection and 
study, and we would advise all those who like an occasional 
intellectual treat to read it, and ponder the numerous pregnant 
suggestions it contains. All the facts connected with the 
pathology of cancer are carefully passed in review, and the 
aid of the cognate sciences is abundantly brought to bear on 
the elucidation of obscure and difficult points ; but, towards 
the close of the Address, in speaking of the origin of tumours, 
he admits our ignorance in the following powerful but hope- 
ful w"ords : — " But, until it can be shown that tumours may 
be transmitted from one person to another by grafting or 
inoculation, it must be acknowledged that there is this sharp 
line of distinction between all of them and parasites. Para- 
sites come always from without ; tumours arise only from 
within ; from some part or natural structure of the body itself. 
And it may be said that, after all, nothing more is known of 
the origin of tumours than this. Once started, we may per- 
haps see something of the laws which regulate their existence, 
but concernino- their orioin we are altogether in the dark. 
Yet, still recognising in this darkness an obscurity which 
enshrouds also some of the largest facts in physiology, we may 
perhaps be able to discern the direction in which light must 
at length come." 

The Address opens with some cogent remarks as to the terms, 
local and constitutional, as applied to cancer, which are well 
worthy the consideration of all medical men. After showing 
the extreme difficulty in applying the terms to cancerous 
growths, he concludes this part of the subject with the follow- 
ing remarks : — " If the arguments in favour of the view that 
cancer is a constitutional disease be examined, it will appear, I 
think, that many of them are valid only in regard to the more 
advanced stages of cancer. The evidence in favour of the 
view that, wdien cancer first appears in a body, it is as a con- 
stitutional disease, seems to me far less clear and cogent." 

He next passes to the consideration of the structure of 
cancerous tumours, and under this division an able criticism 
of the cell-theory of Schwann will be found. It is shown that 
the worst cancers are those which are least difterentiated 
and most embryonic in structure, and we may quote the 
following : — " It would appear then that much danger lurks in 
the designation embryonic to cancer substance, and that it is 



Reviews. 361 

of the first importance to beware of this. Malignant growths 
are heterologous in structure, unlike in this respect any adult 
tissue. But their substance resembles in physical characters 
embrj'onic tissue. It is only on a level with it too — and this 
is of prime significance- — in grade of development. But it 
contrasts strikingly with it in this : that, while the destiny of 
tissue which is truly embryonic is to a higher form of structure, 
this, which has no such power, retains in full measure its 
primitive capacity of reproduction, and its comparative indiff- 
erence to the conditions under which it exists." 

We have said enough to give a pretty full and accurate 
idea of the scope of this Address. While it cannot be said that 
anything absolutely new has been added by it to our 
knowledge, it will be admitted by all that everything we do 
know — or at least suppose we know — of the pathology of can- 
cer, has been criticised and reviewed with the hand of a master. 



Trdnsactions of the College of Physicians of Philadelphia. 

Third Series. Vol. XVl'l. Philadelphia. 1884. 
Transactions of the Neiv York Academy of Medicine. In- 
stituted 1847. Second Series. Vol. III. 1883. 
These are two interesting volumes, which serve to show the 
energy which pervades the medical profession of the United 
States. The first is the larger and more handsome volume of 
the two, and contains the papers read before the College from 
November 1883 to 1884, inclusive. In addition to the papers, 
it also contains memoirs of Drs. Thomas Stewardson, George 
Fox, J. Forsyth Meigs, and Samuel D. Gross, and the address 
delivered by the President, Dr. Alfred Stille, at the close of 
his term of office. Among the papers we may n)ention one 
by C. W. Dulles, M.D., entitled " Criticisms on the Specific 
Theory of Hydrophobia," as being specially interesting to 
Glasgow readers from the full references it contains to the 
researches of our respected colleagues, Drs. Joseph Coats and 
George S. Middleton, in this department of medical science. 
As Dr. Coats has been frequently misrepresented, we may 
quote the following sentence to show that our American 
confreres have understood him better. — " Finally, Coats does 
not consider (though most persons who refer to him speak as 
if he did) the lesions he foiind to be distinctive of hydrophobia, 
but simply evidence of irritation in the blood," With regard 
to Middleton's observation, it is stated that "the most striking 
point of his publication lies in the fact that he found the 
same morbid appearances which were present in the cases of 



362 Reviews. 

hydrophobia, in cases of purpura hfemorrhagica, diabetes, 
fracture of the skull, erysipelas, head injury with htematoma, 
concussion of the brain with fracture of the spine, delirium 
tremens, peritonitis, tubercular meningitis, mental deficiency 
and excitement, hsematoma, tetanus, and uraemia. His paper 
concludes with the distinct avowal that ' as regards the 
pathology of hydrophobia it still remains true that nothing 
distinctive has been observed.' " 

The volume of the New York Academy also contains a 
large number of interesting communications. 



Pocket Memoranda relating to Infectious Zymotic Diseases. 

Arranged by Matthew Algernon Adams, F.R.C.S. London : 

J. & A. Churchill. 
We have here a useful aid to memory in the form of a 
folded card, containing much information such as one has often 
need of in attending cases of infectious disease. The card first 
gives a series of questions to be put as regards the source 
of the contagion. Then follows a list of precautions as to 
isolation, ventilation, and disinfection. The other side is 
devoted to a very well devised table and diagram, giving the 
average periods of latency, periods of fever before the rash, 
period after appearance of rash, and period of infectiousness 
subsequent to fever. These various periods are stated with 
fair accuracy, but the figures given here must merely be accepted 
as averages. It can scarcely be said, for instance, that at the 
end of 49 days from the appearance of the rash the infectious- 
ness of scarlatina ceases. We have some confidence, on the 
whole, in recommending this memorandum to our readers, and 
it might even be useful in the hands of the more intelligent of 
their patients. 



Haint Thovias' Hospital Repoiis. New Series. Edited by 
Dr. Seymour J. Sharkey and Mr. Francis Mason. Vol. 
XIII. London : J. & A. Churchill. 1884. 
We have much pleasure in drawing attention to this, the 
latest volume of the St. Thomas' Hospital Reports. It is very 
considerably bulkier than its predecessor, containing about 
150 more pages, and this would seem to indicate that some 
years the editors have much less difficulty in finding material 
than others. Among many interesting papers may be 
mentioned " a Case of Osteitis Deformans," by John R. Lunn ; 
" Cases of Tubercular Meningitis," by John S. Bristowe, M.D. ; 



Medico-Ghlniryical Societi/. 363 

and " Sketches of an Egyptian Cholera Hospital : a Personal 
Narrative," by T. D. Acland, M.D., Oxford. 

Tliose who wish information ahout the St. Thomas' Medical 
School will iind a calendar and prosjjectus at the end of the- 
volume. 



MEETINGS OF SOCIETIES. 



MEDICO-CHIRURGICAL SOCIETY. 



Session 1884-85. 

Meeting YL— 6th March, 1885. 

Professor Macleod, President, in the Chair. 

Dr. Macewen gave an address on the pathology and 
treatment of congenital talipes varus. 

Dr. Macewen said that he desired to make a few remarks 
regarding the pathology and treatment of congenital talipes 
varus, not that he had anything new or specially original to 
offer, but as it was a subject which had been engaging pro- 
fessional attention for some time past, he thought it advan- 
tageous to have it brought before the Society. 

He first of all briefly alluded to the .various theories which 
were advanced explanatory of the aetiology of congenital 
talipes varus, and said that data were still wanting to enable 
one to give a decided opinion in favour of any of the many 
theories advocated. 

With regard to the pathology, there were much better 
opportunities of forming an opinion. In congenital talipes 
varus the inner border of the foot is raised, the sole looks 
inwards, and tlie parts anterior to the transverse articulation 
are directed backwards, while the outer border of the foot is 
lowered and the dorsal aspect turned outwards, and in severe 
cases, even somewhat downwards, while the heel is drawn 
upwards. On looking at the anatomical details of the foot in 
this condition, the soft tissues on the inner side are seen to be 
contracted, while those on the outer are more or less elon^fated, 
this applies especially to the tendons and ligaments. With 
regard to the bones, some of them are found to be distinctly 
distorted, this is perhaps most marked in the case of the 
astragalus, which has its neck twisted in an inward direction, 
so that its scaphoid articular facet looks inwards. The axis 



•SG4 Meetings of Societies, 

of the surface which articulates with the tibia is, in severe 
cases, ahnost at right angles with that for the scaphoid. 
The outer side is generally abnormally increased in bulk from 
above downwards, whilst the inner side is diminished, — this 
may be seen most advantageously on vertical section of the 
bone. Besides that, in severe cases the astragalus is partially 
dislocated, so that its tibial articular facet projects beneath the 
skin for about one-third of its extent. It is also rotated, so 
that it is more in contact with the external malleolus than 
with the internal. The os calcis is somewhat deformed and 
rotated inwards, while its tuberosity is turned outwards. 

The cuboid is not much altered. The scaphoid is in a some- 
what similar condition, but the latter in severe cases is brought 
into contact with the internal malleolus. Some are inclined 
to believe that the internal malleolus is shorter than normal, 
and this had been found in one of Dr. MaceWen's cases; others 
believe that there is a twist of the tibia and fibula at the ankle, 
but this must be somewhat exceptional. If the bones were 
80 twisted it would be obvious that the ligaments and tendons 
on the inner side would also be necessarily shortened. 

With regard to treatment, tenotomy has been employed to a 
very great extent, and some are under the belief that the 
mere division of the anterior and posterior tibial tendons is 
all that is necessary to rectify the rotation of the foot ; but 
even those who hold this opinion have not apparently formu- 
lated in their own minds the important part played by splints 
and orthopsedic apparatuses, the application of which they 
•sanction after the division of the tendons. If, in reality, the 
rotation of the foot in congenital talipes varus could be cured 
by the mere division of the anterior and posterior tibial 
tendons, or of any of the soft parts, there would be no use of 
retaining orthopsedic appliances or splints after the first few 
weeks, as the cure would be affected by the lengthening of 
those tendons. This, however, is not the case, as every 
instrument maker can testify. Few surgeons, however, 
believe, that the mere division of those soft structures is in 
itself sufficient to rectify the deformity, and those who have 
paid special attention to the subject are aware that months, 
and in severe cases, even years of close attention are necessary 
to obtain a complete rectification of this deformity, through 
the instrumentality of orthopa3dic apparatuses. The failure 
which has sufficiently often attended tenotomy with the after 
application of such appliances has caused men to seek other 
methods of treatment. Dr. Buchanan cuts the whole of the 
soft structures down to the bone on the inner surface of the 



Medko-Ghirurgical Society. 365 

foot. Mr. Lund (Manchester) removes the astraoalus, Dr. Little 
the cuboid, and various osteotomies have been introduced, that 
of takino- away a wedo-e of tarsal bones havino- the cuboid as its 
base, advocated by Mr. Davis Colly, and simple linear osteotomy 
on the outer side of the foot, being among the cliief. Hahn 
(Berlin) recommends in certain cases a simple osteotomy of 
tibia and fibula near their epiphyses. 

With regard to personal treatment. Dr. Macewen said, with- 
out committing himself to any fixed ideas on the subject, that 
he at present adopted the following plan. Believing that the 
bones were the parts principall}- affected, he directed his 
attention specially to them, and any division of the soft 
structures on the inner side of the foot, which may be 
necessary in severe cases, he regards as only a means to the 
end of enabling the osseous deformity to be rectified. In 
infants and in children he does not believe that the division 
of the anterior and posterior tibial tendons is necessary. He 
places the patient under chloroform and manipulates the foot 
so as to undo the rotation and inward curvature. Having 
done so, the limb is put up in paraffin, and what is gained at 
that sitting is fixed. Six weeks afterwards the foot is aofain 
manipulated and put up in paraffin, and this process is 
repeated, if necessary, a third or a fourth time. When the 
I'otation and the inversion of the foot has been overcome, the 
tendo Achilles is divided, and the foot is placed in its proper 
position. Afterwards a cheap tin spliixt (which was shown) is 
applied, and the patient allowed to run about. (Dr. Macewen 
showed a case where this method had been adopted, and was 
in progress of treatment, none of the tendons having been 
divided, the tendo Achilles had not yet been touched. The 
rotation of the foot had been overcome.) In persons whose 
bones are completely ossified, and in severe cases, he had 
recourse to some form of osteotomy or excision of a bone. 
Many years ago he removed a wedge from the tarsus, and 
also performed linear osteotomy with considerable success. 
All the wounds healed without pus production. Of late he 
had removed the astragalus in four or five cases with very 
satisfactory results, as far as they liave gone, although it is 
still too premature to formulate any very definite opinion 
concerning their ultimate behaviour. In the last one operated 
on (a cast of which was shown) the scaphoid touched the 
internal malleolus, and the anterior portion of the internal 
lateral ligament was very tense and had to be divided. He 
showed two cases which were still under observation, from 
which the astratjalus had been removed : he also showed the 



:iQQ Meetings of Societies. 

astragalus which had been excised from the last case, and 
demonstrated the deformities, showing a greatly curved neck, 
the scaphoid articular facet looking inwards, and being set 
at less than a right angle, with the tibial articulating surface 
of the astragalus. 

He concluded by reiterating that his present position is a 
tentative one. He had not committed himself to one particular 
form of osteotomy or excision, but was guided by the 
individual peculiarities of the case. 

Dr. Whitson also showed cases of talipes varus, illustrating 
the method of treatment by excision of the astragalus. 

Dr. Renton said that in his own experience he had seen 
very good results from the practice of division of the tendo 
Achilles, and then of the structures which maintain the 
incurvation of the astragalo-scaphoid joint, as recommended 
by Professor Buchanan. In some cases in which he had thus 
operated, with only partial success, he attributed his partial 
failure to the incomplete way in which the procedure had 
been carried out. When Dr. Buchanan's recommendations 
had been thoroughly carried out by him the results were 
satisfactory. The chief difficulty lay, subsequent to the 
operation, in getting the parents to carry out the instructions 
regarding the apparatus ; and on these instructions being 
obeyed he laid great stress. For a time he recommended 
the use of Banks's sandals, but in some cases he had found 
them not powerful enough. Recently he had put the ca.ses 
up in plaster of Paris, which he found to effect the purpose 
required remarkably well. 

Dr. J. A. Adams said, that speaking not as a surgeon, but 
from the point of view of an anatomist, having dissected two 
cases of talipes, he must express his conviction very decidedly, 
that any attempt to remove this deformity without dividing 
the tendons was wrong in principle, and would in most cases 
be ineffectual. There was no doubt a certain deformity of 
the astragalus, but this was the consequence of the con- 
traction of the muscles, tendons, and other soft structures. 
The procedure of excising the astragalus was one the pro- 
priety of which he could not see. 

Dr. Maceiven said that the record of cases of dissections of 
talipes was not very extensive ; and as Dr. Adams had said 
that he had dissected two cases, he should like very much to 
hear him describe exactly what he had seen. 

Dr. Adums could not at the moment give details as to the 
pathology. 

Dr. Alexander Patterson said that in some cases of talipes 



Merlico-Chirurgical Society. 367 

varus the rectitication of the deforniity could be effected by 
siniple measures ; but when the child reached the age of about 
twelve months, the operation of cutting- the tendons had to 
be resorted to, and in most cases would suffice, with after 
treatment. In a third class of cases, however, it was necessary 
to take out a wedge of bone ; and Dr. Patterson minutely 
described this operation as performed by him in some twenty- 
two cases. 

Professor George Buchanan said that the assumption 
underlying Dr. Macewen's practice was that the bones were 
always to a greater or less degree distorted, and that as a 
consequence of this, the tendons, ligaments, and other softer 
structuics were all shortened. His own belief was that this 
was in most cases a reversal of the order of events as they 
actually occurred ; that the cause of the distortion was the 
foot being held in its abnormal position by the contraction or 
rigidity of the soft parts — the muscles, tendons, and fasciae. 
He thought there was some reason to believe that the con- 
tortion of the bones of the foot was not a cono-enital condition. 
At all events, it was a matter of observation, that in a young- 
child there was very slight deformity at all, but when it 
began to walk, the slight initial deformity got worse and 
worse. Dr. Macewen had alluded to the fact that there were 
several classes of cases. In regard to that class in which it 
was possible by manipulation to rectif}^ the deformity, there 
was very little difference of opinion. . Nor was there any 
great difference of opinion as to the extreme cases of distor- 
tion in which it was necessary to cut out a piece of bone. 
In several cases he had himself performed osteotomy. In 
the intermediate class of cases, between these two extremes, 
there were not many cases in which an operation on the soft 
structures, with after treatment, was not adequate and com- 
paratively safe ; whereas in operations on the bones, the cases 
in his experience were apt to go wrong. The mechanical after 
treatment of tenotomy was of great importance. 

The President said that he understood Dr. Macewen's 
position to be this : that excluding those cases which could 
be cured by manipulative and mechanical treatment, he 
would, avoiding altogether the operation of cutting the ten- 
dons, have recourse to osteotomy. (Dr. Macewen objected to 
this statement as being his position.) Now his own conviction 
was that the cases calling for operations on bone were ver}' 
uncommon. The majority of cases required nothing more 
than division of the tendons. In regard to removing a wedge 
of bone, he had in rare cases done this, but certainly in nothing 



368 Meetings of Societies. 

like 22 cases, as Dr. Patterson had done ; and he could not 
recall a case in which there was any large suppuration, or, 
in fact, any trouble or danger. He paid no attention as to 
what bones he was cutting into. The deformity originated 
in a contraction of the muscles, and the alteration in the bone 
was a secondary result of the action of the tendons. If it 
went on to a great extent the internal lateral ligament might 
require to be divided. He was astonished that Dr. Macewen 
would refuse to cut the tendons. He did not see that any 
man would be justified in taking out a piece of bone as a 
routine practice in cases in which an operation on the soft 
structures would answer the end. 

Dr. Maceiven, in reply, said that as his position had been 
somewhat misapprehended by one speaker, he would re-state 
it briefly. Starting from the view that the bones, as well as 
the soft parts in congenital talipes varus were deformed, the 
affection could not be cured without acting on the bones. As 
long as ossification was not complete in the tarsus, the recti- 
fication could be eftected by manipulation directed so as to 
restore the shape of the bones, and by the maintenance of the 
position so gained by the application of plaster or paraffin 
boots. After the rotation and inversion was rectified, the 
tendo Achilles had to be divided. Tenotom.y of the tibial 
tendons was not required, and though it looked effective it 
was wrong to teach that the division of these two tendons 
cured the disease. 

Tlie President asked Dr. Macewen whether he maintained 
that during his (the President's) 25 years' experience he had 
simply been acting under a delusion, and that the cases had 
not been cured at all ? 

Dr. Macewen, continuing, said that many cases had no 
doubt been cured, but not by division of the tendons. These 
cases had been cured through the mechanical means employed 
to maintain the foot in its right position during months and 
years after the division of the tendons. If the tenotomy of 
the anterior and posterior tibial tendons cured the deformity, 
why should there be any necessity for prolonged after-treat- 
ment by expensive orthopaedic apparatus ? The surgeon 
cured the case, not by such a tenotomy, l)ut by acting 
unwittingly on the bones through the medium of the boots 
which the instrument maker supplied. His objection to the 
division of the tibial tendons was that, as a matter of 
observation, it did not rectify the deformity. Hospital 
surgeons were under the disadvantage that they seldom saw, 
in such cases, the final result. They operated before their 



Medico-Chiniiyicdl Society. 'M)'.) 

class, and the assumption was that the case was cured. Sonn' 
surg'eons had dechxred that they always cured their cases of 
congenital talipes varus by tenotomy, and by tenotomy alone. 
Yet he had had several of these cases after these surgeons had 
operated on them, in which the deformity was not rectified, 
and where it was only cured after removing one of the tarsal 
bones. (Dr. Macew'en here showed a photograph of one of 
these cases, taken a year after the tenotomy had been 
pei'formed, in which the deformity was still very pi'onounced.) 
Tenotomy was surely not required, if division of the soft 
structures had the effect of rectifying the distortion. He held 
that as long as the bones remained in their distorted condition, 
division of the soft structures could not effect a permanent 
cure. In regard to the sequence of events, whether the bones 
caused the muscles and ligaments to contract, or the contracted 
soft parts produced the distortion of the bone, that could be 
determined only by observations on development. Now, 
there were several recorded observations in which the 
deformity of the bones had been found to exist in atero. But 
the data on which to form an accurate judgment as to the 
letiology did not yet exist. In regard to osteotomy, in severe 
cases, and those where bones had become ossified, it was very 
difficult to effect a permanent cure in any other way than by 
operating on the bones. Whether the best way to do this was 
by osteotomy linear or cunieform, or by removing the 
astragulus, was still sub judice. 



GLASGOW PATHOLOGICAL AND CLINICAL SOCIETY. 



Session 1884-85. 
Meeting YII.—14th April, 1885. 



The President, Professor George Buchanan, in the Chair. 

JJR. Beatson showed a case of aneurism of the popliteal 
ARTERY CURED BY LIGATURE. The patient was a man, aged 
.■i8 ; and the swelling in the ham of the left leg was first 
noticed in July 1883. No cause could be assigned for its 
appearance. In September, 1883, he consulted J)r. Beatson 
about it. At that time the tumour was the size of a pigeon's 
egg, and showed all the characteristic signs of an aneurism. 
No. :•>. 2 1; \«!. XXIII. 



J370 Meetings of Societies. 

Ho was advised to go under treatment for it, Vjut he could not 
just tlien be absent for any lengthy period from his Vjusiness, 
and, as he derived great benefit from the use of an elastic 
bandage on the liml), lie did not seek advice again until July 
of 1884, when he wrote Dr. Beatson to the effect that he had 
been seized a fortnight previously with such sudden pain in 
the limb that he was confined to bed with it, and could not 
use the leg. When visited at his own house, the left leg was 
found very much flexed, and the seat of severe pain, which 
was described as extending from the hip-joint to the points of 
the toes. There was complete inability to straighten the 
limb, and examination of the popliteal space showed that it 
was occupied by a large pulsating swelling, which had a very 
fluid feel, and bulged chiefly on the inner side. There was 
ciedema of the foot, and prominence of the superficial veins. 
It being evident that there had been a sudden and considerable 
increase in the aneurism, as shown by the supervention of 
marked pressure symptoms, the patient was the same day 
removed to the Training Home for Nurses. As the result of 
a consultation, it was decided that ligature of the femoral 
artery seemed, under the circumstances, the most suitable line 
of treatment, and this was done by Dr. Beatson on 24th July. 
The operation was performed antiseptically, and the ligature 
used was one of carbolised catgut. The wound was healed in 
ten days, and the ])atient left the Home on 11th August, with 
the aneurism firmly consolidated and free from all pulsation. 
Since then he has continued well, and the limb has quite 
recovered its freedom of movement. 

Dr. Knox said that it seemed that there was still some 
obstruction to the return of the venous blood — the limb was 
thicker than the other one, and the superficial veins enlarged. 
He might mention that he had on\j once seen gangrene follow 
ligature of the femoral. The patient was a pedestrian, and 
had ruptured his femoral, which had been ligatured in 
Birmingham three years before Dr. Knox saw him. When 
he presented himself at the Western Infirmary, several of the 
toes had been lost ; and he had a large ulcer on the dorsum of 
the foot, which had been present for a long time. The general 
opinion after consultation was that amputation was the only 
thing for it. Dr. Knox performed Syme's amputation, from 
which the patient recovered well. 

The President said he saw the case with Dr. Beatson, and 
thought that ligature was the proper treatment, although 
the opinion w^as prevalent that this should not be attempted 
before a previous trial of pressure or flexion of the limb. He 



I 



Pdtholoc/icdl and Glinienl Society. 371 

had a ditferont opinion, partly t'l-oui want of success in cases 
treated by pressure, and partly from the consideration that 
pressure is not likely to do in cases whei'e the aneurism is so 
extensive as in Dr. Beatson's case, and where the tumour is 
nearly on the point of becoming a diffuse aneurism. 

Mr. Maylard exhibited A large periosteal fibroma of 
THE LOWER JAW, removed in conjunction with the corresponding- 
half of the maxilla. The following report of the case, taken 
by the House Surgeon, Dr. Colville, was read : — 

Mrs. H., a3t. 26, was admitted into the Western Infirmary, 
on the -ith of Auijust, ISS-i, sufterino- from a tumour connected 
with the right half of the lower jaw. She first noticed it about 
a year ago as a small movable lump, the size of a pea, situated 
on the outer surface of the jaw, in front of the masseter 
muscle. Since then it has gone on steadily increasing, but 
recently has become more rapid in its growth. The patient 
has lost a little flesh lately, but nothing to speak of. On 
examination, a large growth is seen extending from the middle 
line beneath the jaw, backwards to the posterior border of the 
ramus. The tumour has a firm and solid consistence, in some 
places an almost cartilaginous feeling. It is intimately con- 
nected with the jaw, but the articulation is unaflfected. The 
tumour can be seen inside the mouth extending beneath the 
tongue. The growth causes little or no pain ; there is freedom 
in respiration, and no diflSculty in deglutition. 

There is no history of tumour in other members of her family. 

l-jfh August. — This morning, the patient being placed under 
the influence of chloroform, Mr. Maylard proceeded to remove 
the right half of the lower ya.w. The jaw was sawn through 
with a chain-saw a little beyond the symphysis. By forcibly 
pulling down the tumour and the bone (the usual skin incision 
having been previously made), the various structures on the 
inner and outer side of the tumour w^ere easily stripped oflf. 
A final rotatory wrench, with a few touches of the knife, 
dislocated and completely separated the bone. There was little 
or no haemorrhage until the last stage of the operation, when 
either the internal maxillary artery, or one of its branches, 
was ruptured. The large space, however, left after removal of 
the <4:rowth, allowed of the vessel being: easily ligatured. A silk 
suture was passed through the tongue and fastened to the ear 
on the healthy side, the organ being pulled somewhat forward. 
The e<Jges of the wound were brought together with silver and 
catgut sutures. To allow of free drainage, an incision was 
made well under the original position of the jaw, and an india- 



372 Meeiings of l^ocieties. 

rubber tube introduced. The wound, before being finally 
closed, was swabbed with a solution of chloride of zinc. 

For four days all went on satisfactorily, but on the fifth 
after the operation the patient became feverish, the face on 
the right side swelled, and the breath became very foetid. 
This, however, was only transitory, as on the following day 
she was much better, and continued to progress to recovery 
without any further untoward symptoms. 

oOth August. — (Three weeks from the date of the operation.) 
The patient was dismissed from the Hospital with the parts all 
healed. The tongue had regained a considerable portion of its 
power of protrusion, the tip projecting beyond the teeth for 
about a quarter of an inch. Articulation had become clear and 
distinct. M.astication was however nil. The remaining half 
of the jaw had become, by cicatrisation, so extensively drawn 
towards the afiected side, that coaptation of the teeth was 
impossible. 

Rernorks.—Mx. Maylard said that he had that morning seen 
the patient {i. e., eight months after tlie operation), who, in 
answer to his request, had come to the Hospital to show 
herself. There was no indication whatever of any recurrence 
of the tumour, and the patient was enjoying excellent health. 
The tongue could be almost perfectly extruded ; sensation, 
however, had not returned to the side on which the lingual 
nerve had been divided ; movement also of the facial muscles 
had become completely restored. The remaining half of the jaw 
had become still farther drawn to the opposite side, so that the 
teeth which it carried were placed beneath the tongue. As 
these teeth were much decayed and seemed likely to irritate 
the under surface of the tongue, it was suggested to her that 
they should be extracted, but she was most emphatic in not 
having them touched, as by their aid she was enabled to crush 
and partly masticate her food between them and the tongue. 

With regard to the tumour, Mr. Maylard remarked, that on 
looking at the preparation it would be seen to extend from 
the symphysis to near the neck of the condyle ; in size and 
shape somewhat resembling one's fist, and enveloping rathei* 
than displacing or infiltrating the body of the bone, which is 
distinctly seen passing through the centre of the section. The 
molar teeth, however, are loose from being dislodged from their 
sockets by the pressure of the growth around the alveolar 
margin. The longitudinal section shows the tumour to be 
composed of a dense and tough fibrous tissue, the fibres 
apparently radiating from the surface of the bone. On micro- 
scopical examination, the tumour presented all the characters 



Pathological and Clinical Society. 373 

of a typical fibroma, wavy bundles ot" interlacing white fibrous 
tissue with, scattered here and there in varying numbers, 
small cells. 

Dr. Knox said that he thought this was the largest tumour 
of the lower jaw he had seen. It was rare to find them not 
inalignant. His experience was that there was usually a 
considerable amount of permanent paralysis in operations 
performed in the usual way. He thought if anything could 
be done to prevent this and save the facial nerve and the duct 
of the parotid gland it should be tried. He therefore, in the 
last two cases, in addition to the mesial incision, had made an 
incision through the angle of the mouth upwards and out- 
wards for about an inch and a half. In this way he could 
retiect the cheek sufficiently to get to the articulation of the 
jaw. A similar operation is described in the late Professor 
Spence's work. 

Mr. Maylard said that we should try to prevent the 
jaw being drawn to the opposite side. This had been 
attempted in some cases by the insertion of an interdental 
splint and other means. It was remarkable, however, in this 
case how efi'ectually the patient was able to masticate by 
simple pressure of the tongue against the teeth. 

Professor George Buchanan showed several cases of 
URINARY CALCULI, notes of which will be found at page 821. 

Dr. David Newman showed a calculus weighing 1,400 
ORAINS, removed by Bigelow's operation ; also a calculus 
removed by RAPID dilatation, a report of which will be 
published in our next issue. 

Dr. Macphail showed two calculi removed from a 
woman aged 58 by rapid dilatation of the urethra. 
The symptoms began with cystitis, due to use of a dirty 
catheter. The whole operation only took three quarters of 
an hour, the urethra being dilated in about ten minutes. It 
was done on Sunday last, and now she was much more com- 
fortable than she had Ijeen before. 

Dr. W. L. Reid said that the rule was that if the diameter 
of the calculus was larger than an inch there was risk of 
permanent injury to the urethra. Over against this there was 
the great safety of removal by incision j)er vaginam, and he 
would have been disposed to have removed it in this way. 

Dr. Knox referred Dr. Reid to a paper by Professor Ogston, 
of Aberdeen, in which he showed the great advantage of 



374 Meetings of Societies. 

rapid dilatation. During- this winter he (Dr. Knox) had per- 
formed the same operation on a woman, and removed three 
calculi, one considerably larger than Dr. Newman's. He did 
not take ten minutes to dilate the urethra, which he would not 
call very rapid dilatation. There was a little tearing and a 
little hgemorrhage. There was incontinence for a week, after 
which patient recovered well. Another case in which he 
operated was where calculus had existed for 14 years. She 
came to the Western Infirmary Dispensary complaining of 
incontinence. He dilated, crushed the stone, and removed it 
in bits. She had permanent incontinence, but this was due, he 
thought, to the long dilatation of the neck of the bladder by 
the calculus. 

Dr. J. Craiuford Renton thought it very valuable to have 
heard such a decided opinion in favour of lithotomy from 
Professor Buchanan. His opinion coincided with Thompson's, 
that no one should adopt lithotrity without having con- 
siderable experience of lithotomy. He had recently had 3 
cases of renal calculus. The first case resembled in its 
symptoms that described by Professor Buchanan, and the 
patient always complained of pain at the point of the penis, 
and occasionally passed a drop or two of blood. Dr. Renton 
thought of stone in bladder, but could find none with the 
sound. Some weeks after the patient had another attack of 
pain, and passed the stone. Then he had two medical students 
with renai calculi. The one passed it after two nights of 
pain. The other one had a great deal of pain, and one 
morning Dr. Renton removed a calculus which was impacted 
in the urethra. 

Professor Buchanan said that no reference had been made 
to the other method of removing stones from the female 
bladder — viz., ordinary lithotomy in the female, by making an 
incision through the edge of the vagina. He had done this 
twice, in both instances with a good result, before Marion 
Sims' operation for vesico-vaginal fistula had been introduced. 
Now, however, he preferred to remove them by the vagina 
in the way indicated by Dr. W. L. Reid. He wished it to be 
understood that he was not an advocate of lithotomy as 
against lithotrity; but he thought that lithotrity was not 
universally applicable — viz., in those cases where the urine 
was alkaline, ammoniacal, and putrid, and where there was a 
rugose condition of the walls of bladder. In these cases 
lithotomy is preferable because (1) of the immediate removal 
of the stone ; and (2) because of drainage which was 
established. 



Pathological and Clinical Society. 375 

Dr. Ja:mes Patox, of Greenock, showed calcareous masses 
removed from the PLEURAL cavity durincr Hfe and gave notes 
of the case (see page 328). 

Dr. J. Lindsay Steven showed a specimen from the Western 
Infirmary Museum, which ilkistrated very nearly the same 
state of matters as had been described by Dr. Paton. Notes 
of it will be found in the Museum Catalogue. 

Dr. Macewen said that he had been asked some time ago 
to remove a portion of rib, to facilitate drainage, from a 
patient who had had, consequent upon an empyema, a 
purulent discharge from the right pleura of over a year's 
duration. The patient was aliout 40 years of age and very 
weak ; the right lung seemed to have been quite destroyed, 
and there were several cavities in the left lung. The heart 
was normal, and, as far as could be ascertained by external 
examination, there was no atheroma of the vessels. A 
portion of rib was removed, and one and a half pints of 
pus evacuated. When the finger was introduced into the 
pleura, it detected several calcareous plates, which were 
adherent to the granulation tissue, into which the parietal 
layer of the pleura had been converted. At first these cal- 
careous masses conveyed to the finger the impression of caries 
of the ribs. On removal it was clear that they were made 
up of calcareous depositions — fresh formations, and not bone 
which had undergone degenerative changes. It was with 
considerable difficulty that the finger could be made to touch 
the stump of the lung, which seemed to have many calcareous 
plates adhering to it. Patient lived for some time after the 
operation. There was no post-raortern. 

Dr. David N. Knox showed a specimen of rupture of 
THE bladder, and read notes of the case (see page 324). 

Dr. Neiunian said that the only difficulty was. Why did 
the urine not escape continuously through the rupture ? 
It was probable, he thought, that the rupture at first was 
not complete, and that peritoneum had given way after- 
wards. 

Dr. Maceiuen had met with two cases of rupture of the 
bladder where the observation had been verified by j^od- 
mortem examination. One was published in the Lancet about 
ten years ago. In it there was no history of injury. The 
b'ladder was ruptured at the upper and back parts, and the 
abdomen was filled with urine. There was almost no trace of 
inflammatory action over the peritoneal surface. The other 
occurred in the person of a prize fighter who had received 



-^76 Meetings of Societies. 

very severe bruises over body, and especially on the abdomen, 
which was discoloured from ecchymosis over many parts. 
He was in a dying condition at time of the examination. The 
abdomen was greatly distended, and fluctuation was distinct 
in the abdominal cavity. A few ounces of urine were found in 
uhe bladder. Patient died shortly after he had been seen. In 
this case great peritonitis was present. Liver was ruptured. 
Ecchymosis on many of the viscera. The peritonitis here was 
due to the injuries and not to the urine which filled the cavity 
of abdomen. Urine, _2-><''' •^f', uncontaminated, does not excite 
inflammation. 

Dr. Beatson spoke of the chronic adhesions as being probably 
the condition which had prevented the escape of urine into the 
abdominal cavity. He thought that there must have been 
circumstances present to prevent escape of urine into the 
peritoneum. 

Dr. Knox could not accept Dr. Newman's explanation. The 
man during the first three days could not make water, on the 
fourth day he voluntarily made it, and on last day involuntarily. 
As regards Dr. Beatson's remarks, the chronic inflammation was 
chiefly observed on the intestines, liver, and spleen, but the 
adhesion of intestine to bladder was little more than blood clot. 
He thought there could be no doubt of there being urine in 
peritoneal cavity. 

Alveolar Sarc;oma of Larynx. 

Dr. David Newman showed the larynx removed from the 
dead body of a man who suffered from this disease, and who 
came to the Dispensary for Diseases of the Throat at the 
Royal Infirmary, on Friday last. When the patient was seen, 
for the first time, he stated that the first symptom that 
attracted his attention was pain in the region of the larynx. 
Within the last few days, however, the pain had commenced 
to radiate to the ears and lower part of the mouth. This 
symptom, he said, had been present for about twelve weeks. 
During the first few weeks there had been no great inter- 
ference with speech or respiration. About six weeeks ago 
he complained of difficulty on deglutition, and slight dyspnoea, 
and since that time the symptoms had gradually become 
more marked, so that there was almost complete aphonia, 
unless when the patient made a special effort ; only then 
did he succeed in producing a vocal sound. There was no 
great interference with the passage of air through the larjoix 
during inspiration, and expiration was comparatively free. On 
palpation of the neck Dr. Newman found the larynx to be 



Pathological and Clinical Society. 377 

ilistorted, the al?e of the thyroid cartilage, particularly the 
left, pressed forwards and awaj- from the middle line. 

On laryngoscopic examination the tumour appeared as an 
ill defined swelling, occupying chielly the left side of the 
larynx, but also involving the right vocal cord and the base 
of the epiglottis. The opening of the glottis was seen to be 
considerably diminished in size and pressed to the right side. 
The ar^'teno-epiglottidean 'folds were indurated and O'dema- 
tous, and the base of the epiglottis was so swollen that it 
was with difficulty that the interior of the larynx could be 
seen. The mucous membrane of the larynx was smooth, and 
in no part was there any evidence of recent or old inflam- 
matory changes. 

WTien seen at the Dispensary the patient was so weak 
and reduced in health that Dr. Newman directed him to be 
admitted into the hospital immediately, not only on account 
of the condition of the lar^-nx, but also in order that his 
general condition might be attended to. Patient was admitted 
at once to Ward X, and when placed in bed the house- 
physician found him to be so exhausted that he considered 
it advisable not to submit him to a careful examination in 
the meantime, as it was evident from a physical examination 
of the chest that he was suffering from hypostatic congestion 
of the lungs. Patient gradually became weaker, and died on 
the evening of admission. 

A 'post -mortem examination showed, that the patient had 
been suffering from chronic tubular nephritis ; dilatation of 
the right ventricle, and hypertrophy and dilatation of the left 
ventricle, without valvular disease ; hypostatic congestion of 
the lungs ; and nutmeg liver. 

On examination of the larynx the tumour was found to be 
about the size of a walnut, and was situated l)etween the alas 
of the thyroid cartilage and the mucous membrane of the 
larynx, all the intervening tissues having been infiltrated by 
tlie neoplasm. It did not extend above the thyroid cartilage, 
nor below the cricoid cartilage on its posterior aspect. In 
front, however, it passed up as high as the lower third of the 
epiglottis, and the anterior part of the thyroid cartilage was 
infiltrated and perforated by the tumour, and a small portion 
of it was found occupying the space in front of the crico- 
thyroid membrane. The great bulk of the tumour occupied 
the left side of the larynx, but some of the tissues in front 
and to the right were also found to be invaded. The right 
vocal cord particularly was involved, and the lower third 
of the epiglottis measured fully a quarter of an inch in 



378 Meetings of Societies. 

thickness. No secondary formations were discovered. On 
section the substance of the tumour M^as found to be of a 
uniform, moderately firm consistency, and pale yellow colour, 
and, on microscopic examination, was found to present the 
characteristic appearances of an alveolar sarcoma. The 
tumour possessed a distinctly alveolar arrangement, some of 
the alveoli being occupied by three or four embryonal cells, 
while others contained a large number of large cells closely 
resembling epithelium in appearance. At some parts the 
tumour was composed of simple round and spindle cells, with- 
out any distinct tendency to an alveolar arrangement, while at 
other parts the masses of cells were intersected by delicate 
strands of connective tissue, which divided the cells contained 
in the larger alveoli into smaller clusters. At one part of the 
section examined, several myeloid cells containing numerous 
nuclei were seen, and almost at the same point a distinct osseous 
trabecula was found. The trabecula was not situated, as far as 
could be discovered, close to or in contact with cartilage, but 
appeared to be in the substance of the tumour. This is the 
only part where the elements of the tumour showed a tendency 
to form osseous tissue. 

Dr. Newman remarked that the specimen was of special 
interest, not only on account of the situation it occupied in the 
larynx, but also from the fact that it is a rare form of sarcoma, 
and is, as a rule, highly malignant. Sarcomata generally 
originate in the mucous membrane of the larynx, and rapidly 
attain a considerable size ; usually invade all the structures 
they come in contact with ; seldom, unless they happen to be 
of the small round-celled variety, encroach on the mucous 
membrane ; and usually cause death before secondary forma- 
tions appear. This form of sarcoma is closely related to the 
carcinomata, and it is frequently extremely difficult to declare 
whether such tumours should be placed amongst the sarcomata 
or the carcinomata. The principal points which distinguish 
this form of sarcoma from carcinomata are — (1) the stroma 
and the cells, which are embryonic connective tissue, are inti- 
mately interwoven ; (2) the blood-vessels run amongst the 
cells and in the stroma; (3) metastasis is usually by the 
blood-vessels ; and (4), as a rule, the lymphatics are not 
involved. Whereas in cancer the stroma and cellular elements, 
which are epithelial in their origin, are easily separated from 
one another, the blood-vessels run in the stroma only, and 
metastasis is primarily by the lymphatics. Both growths are, 
however, equally malignant, but cachexia is seldom observed 
so early in the sarcomata as in the cancers. 



Glasgoiv Southern Medical Society. 379 

From a clinical point of view, this case is of great interest, 
as it is one of the conditions of the larynx which, taken p^-)* 
se, may call for excision of the larynx. Last month (March, 
1885) M. Labbe, of Paris, extirpated the larynx successfully 
for a tumour of the same nature as the one now shown. Such 
a tumour cannot be removed b}' intra-laryngeal methods, so 
that either thyrotomy or excision of the larynx must be 
resorted to, according to the site and extent of the tumour. 
When the nature of the tumour has been clearly ascertained, 
the sooner it is removed the better ; by allowing it to remain 
the danger of the development of secondary formations, 
and the chance of the general health being affected, are greatly 
increased. 

Dr. Newman excised a larynx two years ago for cancer ; 
but in the case from which this specimen was removed, 
operative interference could not be thought of owing to the 
condition of other oruans. 



GLASGOW SOUTHERN MEDICAL SOCIETY. 



Session 1884-85. 
Meeting XL — 2nd April, 1885. 



The President, Dr. Napier, in the Chair. 

The President showed a specimen, and gave a short 
account of cupreine, the new cinchona alkaloid. This 
alkaloid is obtained from the cuprea bark (from the Remijia 
Pedunculata, Triana), and derives its importance from the 
fact that it exists as an impurity in almost every sample of 
([uinine at present in the market, more of the cuprea bark 
being now imported for the extraction of quinine than of all 
the other cinchona barks put together. Its physiological 
properties have not yet been determined. Its chemical 
properties are somewhat remarkable ; though itself a base, 
it combines with certain other bases, such as soda, ammonia, 
and quinine. Its combination with quinine (2 parts of quinine 
to 3 of cupreine) forms the body known as homoquinine, 
a crystalline substance obtained from cuprea bark, and 
formerly regarded as a separate alkaloid. 



380 Meetings of Societies. 

The President showed specimens from, and read notes of, 
a case of advanced aortic disease. He apologised for the 
fragmentary character of his notes, the patient having been 
first seen when actually moribund, so that the history had to 
be gathered mainly from his friends. The patient was a man 
of 34, of distinctly rheumatic family history ; his father is 
alive, rheumatic, and said to be suffering from heart disease. 
All the patient's troubles had dated from an attack of typhoid 
fever 18 years before. After the fever, while enjoying fairly 
good health, he had complained frequently of obscure 
" rheumatic " pains in the limbs, especially in the morning- 
after rising. It was chiefly during the last three years of his 
life that health had failed : he couo^lied a ffood deal, became 
short-winded, and had occasional fainting attacks. Towards 
the close of last year these symptoms had become much more 
marked. One morning, early in December last, after rising 
apparently in his usual health, he suddenly fell to the floor 
from a chair on which he was sitting by the fireside ; his left 
arm and leg were paralysed, and felt quite dead and numb, 
this condition lasting for several minutes, and ultimately 
passing off entirely. 

Patient was seen about two months before his death by a 
medical practitioner, who informs me that at that time he 
diagnosed extensive aortic disease, a V.S. and a V.D. murmur 
of aortic origin, but no mitral disease ; the heart seemed much 
enlarged and dilated. The symptoms then complained of 
were frequent cough, extreme dyspncea, and a puffy and dusky 
appearance of face. There was no swelling of the feet. A 
pill was at that time prescribed, containing reduced iron, nux 
vomica, and digitalis, and from this the patient derived much 
benefit ; unfortunately he was induced by some irresponsible 
adviser to cease taking the medicine, and from that time 
became steadily worse. 

On 11th March, when first seen by Dr. Napier, the patient 
was plainly moribund, and in fact died two or three hours 
after, so that no very exhaustive examination could be made. 
He was only semi-conscious, but made distinct complaint of 
pain in the cardiac region. The surface was livid and cold, 
and there was no oedema. The breathing was very rapid and 
laborious, the pulse feeble and so rapid as to be uncountable. 
The heart appeared to be acting laboriously, its impulse being 
appreciable over a considerable area on the left side ; in this 
respect it offered a marked contrast to the state of the pulse. 
So far as could be determined there was no heart murmur 
audible at this time. The pupils were contracted. The 



Glasgow Southern Medical Society. 'iSl 

patit'iit liail taken a few doses of a mixture (given to him by 
an unqualified practitioner) containing- a little morphia, and on 
the supposition that this might have something to do with 
at least some of his symptoms, a small dose of atropine was 
injected subcutaneously, but with no good result. 

Post-mo rte III examination made IS hours after death. 

Lungs normal and crepitant throughout, and presenting no 
adliesion. The pericardium contained about half an ounce of 
pale coloured fiuid. The heart was much enlarged, and its 
cavities ililated; its walls, especially that of the right ventricle, 
were thin, pale, and soft, and its chambers were full of clot. 
Most marked and advanced disease of the aortic valve was 
found, of an atheromatous type ; two of the segments of the 
valve had coalesced, and formed a rough and prominent ridge 
round about two-thirds of the orifice. The third segment was 
torn along nearly its whole length, remaining attached by one 
end, the rest of it waving free in the lumen of the vessel. 
This segment also was rough and wart-like on the surface. 
The mitral valve showed spots of conmiencing disease. The 
liver was a typical example of the " nutmeg liver." The 
kidneys showed numerous haemorrhagic infarctions, some of 
which were fresh. The remaining organs appeared normal. 
The brain was not examined. 

In commenting on the case, Dr. Napier said that in the 
light of the post-raortein examination the history and 
symptoms above detailed became clear enough: he suggested 
that the temporary paralysis which occurred in December last 
was probably due to embolism. 

Mr. E. M'Millan, in introducing a discussion on the the 
REARING OF HAND FED INFANTS, read a paper which will be 
found at page 332. 

Dr. Tindal coincide*! with Mr. M'Millan's views in regard 
to condensed milk in considering it a poor substitute for 
mother's milk. He was in the habit of using Mellin's food 
when artificial feeding was necessary. 

Dr. Duncan said that the three forms of food which he had 
most frequently employed in the case of infants who were 
deprived of their mother's milk were diluted cow's milk, 
Frankland's artificial hinnan milk, and Mellin's food for 
infants. The majority of healthy infants throve quite well 
upon diluted cow's milk, and when they did so, he gave 
instructions that these children should not have any other 
form of food for the first three months of theii- life. After 
that time he usually prescribed some form of malt food to 



382 Meetings of Societies. 

be given twice a day in addition to the milk. In the case of 
children not being able to digest ordinary cow's milk, he had 
frequently prescribed milk prepared after Frank land's method 
with very good results. The Glasgow Dairy Company pre- 
pared a milk of this kind which he had sometimes prescribed 
when the patient could have it sent, and this answered quite 
as well as the milk prepared at home. He did not approve of 
the use of condensed milk, as he had found that children fed 
solely upon that milk, although they got fat and looked well, 
were less able to stand illness, and were more liable to softness 
of the teeth and bones. He further condemned the direction 
so frequently given to procure one cow's milk. Stall fed cows 
were so frequently unhealthy and tubercular that there was a 
danger that the cow selected might furnish milk not only 
inferior in quality, but also diseased. He thought it much 
better to take the ordinary dairy milk, which was a mixture 
of the milk of many farms, and therefore probably of an 
average quality. In support of this view he instanced the 
case of a child he had attended who died after a long illness 
characterised by wasting and diarrhoea. The cow on whose 
milk this child was fed died about the same time, and on 
examination this cow was found to be affected with widelj' 
diffused tuberculosis. Speaking of diarrhcea, he said that in 
some cases it was kept up by the large quantities of milk 
which the thirst of the child induced it to drink. The undi- 
gested curd acted as an irritant, and in these cases was found 
in large quantities in the stools. The stools in all cases of 
infantile diarrhoea should be carefully examined. 

Dr. Polloh generally used equal parts of cow's milk and 
water, with 160 grains of sugar, and 2 grains phosphate of 
lime, but if that did not seem to agree with the child he 
ordered whey and cream. He deprecated a wholesale con- 
demnation of Swiss milk, as he considered he often obtained 
yood results from it, usino: a fjood brand and diluting it well. 

At this stage of the proceedings Mr. Glaister moved and 
Mr. Gilmour seconded the adjournment of the discussion. 



Meeting XU.—lGth April, 1885. 



The President, Dr. Napier, in the Chair. 

Mr. Glaister, in re-opening the discussion on the rearing 
OF HAND fed INFANTS, said: — "As mover of the adjournment of 
the discussion on Mr, M'Millan's paper, it falls to me to-night 



Glasgow Southern Medical Society. 383 

to re-open it ; and before enterini^- into the merits of the paper 
I am certain that the other members of this Society will 
endorse the thanks which personally I tender him now, and 
which he deserves, for bringing so fully and practically before 
us the very important subject of artificial infant feeding. I 
am not certain but that this subject gives to the general 
practitioner as much trouble, and compels as much consideration, 
as any other subject which is brought under his notice in the 
course of his practice. There is no doubt that our infant 
mortality is very high, and that it is contributed to by 
improper feeding in the early months, but how far it is so is a 
very difficult thing to say or determine. Those who from 
their age are entitled to judge aver that artificial feeding of 
infants is more prevalent now than twent}^ years ago ; then it 
was rather the exception for a child to be brought up artificially, 
now, among certain classes, it is rather the rule. It would be 
interesting to enquire into the reasons for this change ; but 
that would lead me beyond reasonable bounds in this discussion. 
Generally speaking, the causes may be divided into those that 
are compulsory, in the case of those mothers of the poorer 
classes who are compelled to labour daily in mills and ware- 
houses ; and in the case of all mothers where there is some 
structural or functional imperfection of the mammary glands 
and their secretion ; and those which have been thought to 
have their origin in expediency, arising out of the demands of 
social or public life. It seems to me that, in respect to the 
latter class, the medical profession may fairly take to itself 
some blame, in respect to its tacitly permitting, or feebly 
objecting to, the habit which allows a mother of the higher 
circles to content herself with simply bearing her child, and 
after that throw its upbringing into the hands of nurses. It 
seems to me to be the duty of our profession to point out that 
the principal dut}'' of the mother in family life begins only 
after the birth of a child ; that it is not enough for a woman 
to be simply a factor in the production of children, in respect 
that she should be allowed to think that her duty ceases and 
determines after the birth ; but, on the other hand, that the 
suckling of her infant is the most important duty a woman 
has to her offspring, and that in her nursing it or not, may 
possibly depend, to an extent which we cannot yet exactly 
appreciate, the future health of the child. Nature intended 
that eveiy woman who, things being equal, was able to do so, 
should nurse her oflCspring, and it seems to me to evidence 
the want of the true maternal instinct when any woman who 
can does not nurse her child. 



384 Meetings of Societie^^. 

" But taking the cases where the child is deprived of the 
natural food, what substitute can we give for it, antl what is 
the test ? Every one in his experience comes across children 
who seem to ' thrive ' on the most peculiar feeding — feeding, 
indeed, which flies in the face of all physiological laws, and 
one is forced almost to the conclusion that the equation in this 
regard is not, as are children so is the feeding, but, as is the 
child so is the feeding; that is, that we have not to formulate 
rules to ourselves as to what precise food is to be given to all 
children, but to temper our treatment and feeding by circum- 
stance and the individual child. Although this is the result 
of experience in practice, there is no doubt but that we must 
start from some rules of dietary which, all things considered, 
will be most likely to contribute to the proper feeding of 
children. Nature has provided the milk of other animals for 
this purpose when the mother's milk is not to be had, but 
these all differ materially, not, however, in the elements con- 
stituting them, but in their respective quantities. 

" The milk of the cow is to be had almost everywhere, and 
may, under certain modifications, be used as a substitute. We 
are often asked the question. Should the child be fed on one 
cow's milk or not ? My experience is that there is no special 
advantage in havino- one cow's milk, and that there are 
disadvantages attaching to the practice — e.g., disease in the 
cow, and its possible death ; and under usual circumstances, in 
town particularly, it necessitates a close residence to the place 
where the cow is, and prevents going from home, as the cow 
cannot conveniently be taken along as part of the family 
' iiinpediinenta' when en route for coast or country. And, 
besides, there is no good reason why the milk of many cows 
mixed together should be harmful when the child is 
habituated to its use. The question after this is, by what 
means precisely shall the cow's milk be modified that it shall 
as nearly as possible resemble the mother's milk. In the 
former there is about one-third more caseine, about the same 
quantity of fats, and less sugar, than in the latter. Our aim 
must therefore be to add some diluent to reduce the percentage 
of caseine, and to add sugar to bring up the percentage of this 
constituent. What shall the diluent be ? This seems to be 
the vexed question. Shall it be simple ^vater, lime water, 
soda water, barley water, rice water, or some of the foods on 
the Liebig system ? That question, it seems to me, can only 
be answered by use on the child, for it is very evident that 
nursing a child in this way is an experiment from beginning 
to end, since experience shows that what may do well with a 



Glasgoiu Southern Medical Society. 385 

child at one time may not do at another. Every one with a 
large family practice must have met with cases illustrative ot* 
this. 

"The only conclusive thing one can say is that what best 
agrees with the child is that food which will best contribute 
to its nutrition ; but what that best thing is can only be 
discovered by experience. All the artificial foods — Savory 
and Moore's, Ridge's, Mellin's, kc, kc, have their place ; but 
it seems to me in the earlier months, first and second, only as 
diluents of cow's milk. My experience of condensed milks 
does not incline me to speak favourably of them, since I 
have seen children who have been brought up almost ex- 
clusively on them turn out ricketty ; as also children, who 
developed markedly the same appearances on the exclusive 
use of artificial foods as above mentioned. 

" The one great difficulty in towns, particularly in summer, 
is the keeping of milk sweet ; the lactic acid fermentation 
comes on so rapidly, and leads to many of the disturbances, 
colic, diarrhrea, &c., embraced under the general term gastro- 
intestinal irritation, which cuts off not a few children. The 
handiness of the usual feeding-bottle, too, contributes to its 
abuse ; the child is put into its cot with the teat in the mouth, and 
overfills its stomach ; and it gets the teat thrust into its mouth 
whenever and wherever it cries. The loni^ india-rubber tubingf 
also is a cause of the early souring of the bottle contents, 
from imperfect cleaning. Another prevalent mistake, in 
making up bottles for the infant's use, is the adding of too 
much sugar ; and in these days of much use of beet sugar I 
am not certain but that more harm results than formerly, 
when pure cane sugar was more used. 

" The method of Dr. Frankland bears on the face of it a value, 
of which, however, I cannot speak personally, not having any 
experience of its use. Only one thing more, and I have done. 
After the child has reached the age of three months or earlier, 
depending on the appearance of the sali\ary overflow from the 
mouth, I find the greatest benefit from the use of Scott's oat- 
meal flour. Given two or three times daily, it acts very 
beneficially, and from the quantity of phosphate it contains, 
contributes to the better formation of bone. I can speak 
practically of its value, and as to its being much relished by 
children. 

" Byron once said bitterly of the Edinburgh Reviewers, that 
they 'cultivated literature on a little oatmeal.' It seems to 
me that Scotia's food, modified to suit children as Scott's food 
is, will rear up a healthy and hardy set of children." 

No. 5. 2 C Vol. XXIII. 



886 Meetings of Societies. 

Mr. T. F. Gilmoiir said some of the danofers and difficulties 
in rearing- hand fed infants were due to causes at and before 
birth. The mother should be told to prepare her breasts for 
the duties they are soon to discharge by frequent washing and 
rubbing, pulling out the nipples and gentle titillation. This 
not only improves the breasts, but has probably a moral influ- 
ence advantageous to the child. The physician should always 
examine the placenta, and record his notes, as its condition 
often gives valuable hints regarding the constitutional state of 
the mother and the line of treatment most likely to benefit 
the infant. The baby's food should be given regularly and 
slowly, as nearly as possible at the rate supplied by suckling: 
the best bottles in this respect are the " Fountain " Feeders. 
He thought weakly infants were often the better of a few 
drops of pure cod oil given once or twice a day. He had 
found Lentil powder, given in the shape of Du Barry's Food, 
very successful. Fresh cow's milk was best of all ; its great 
variability in solids and in specific gravity was easily met by 
using mixed milk, the diflerences of which neutralized each 
other. It was noteworthy that in all nulks the proportions of 
casein and sugar were more nearly uniform than the other 
ingredients ; and this, he thought, showed that their uses were 
the most important, the nutritive qualities being those which 
imitation foods most safely supplied. He condemned more or 
less all advertised foods as generally exceeding the truth in 
their statements, and claiming undue pretended medical 
sanction or autliority — virtues which they did not possess, 
and thus often trifling with infant life and the happiness of 
the family. 

Mr. Alex. Miller agreed with Mr. Glaister that cow's milk 
should always be tried in the flrst instance, providing the 
mother's milk could not be had. But when it was considered 
necessary to use a food of some description, he generally 
advocated Nestle's food, which he considered superior to any 
of the numerous foods in the market, more especially if the 
Milk Maid brand were used. 

Dr. Stirton remarked that in Nubia, where the Revalenta 
Arabica is largely cultivated, it is common to give a dose of it, 
with the addition of a little Lupinseed, every night to 
children : and that perhaps this was the secret of Arab 
children being so plump and healthy looking in infancy. 

Dr. Barras strongly advocated Savory & Moore's food 
short of cow's milk. If it was properly prepared, he considered 
no food better adapted for regulating a child's bowels. 

The President said that undoubtedly one of the great 



Glasgow Sonthefit Mcd/cal Six-iefi/. 'is? 

causes of infant mortality was improper artificial feeding, a 
point which was confirmed by the greater mortality i)i 
countries where it was the exception rather than the rule 
to nurse the child at the breast. There could be no doubt 
that the practice of bringing up infants " by hand " is on the 
increase. Dr. Napier suggested that part at least of the 
explanation of the greater infrequency of nursing at the 
breast in civilised than in uncivilised communities might be 
the fact that certain of the outlying or non-vital functions 
were performed in a more languid or less natural manner as 
civilisation advanced ; just as sight and hearing became 
more defective with civilisation, so it might be that the 
secretion of milk becomes scantier or rarer under similar 
conditions, more especially in the feeble and less vigorous 
mothers who are apt to be more numerous in communities 
where civilisation counteracts to some extent the law of the 
survival of the fittest. Most of those who had spoken were 
against the use of " one cow's milk " in the hand feeding of 
infants, and in favour of the use of the ordinary mixed milk. 
Dr. Napier agreed with the arguments Ijrought forward in 
support of that view, but thought that one most important 
argument had been omitted — namely, the change which the 
milk of a cow is apt to undergo in composition at the times 
when the cow should be menstruating. Some years ago the 
child of a very intelligent patient of his (a clei'gyman) had a 
series of most severe attacks of diarrhrea and vomiting, 
occurring at intervals of three weeks, and in one of these 
attacks the child nearly died. As the child was being- 
brought up on " one cow's milk," the diarrhoea was very 
naturally ascribed to some change of a periodical character 
taking place in the milk ; and as it is well known that the 
cow menstruates at intervals of three weeks, we connected 
the change in the quality of the milk with the occurrence of 
the times at which the cow should have menstruated had she 
not been yielding milk. This view of the matter received 
some confii-mation from the fact that the attacks ceased when 
the child was put on the ordinar}- mixed milk brought into 
the house for the use of the other inmates. Under the 
influence of these views it became interesting to notice 
whether some such periodical change in the milk could be 
traced in the human suljject ; and Dr. Napier thought that 
in a number of cases which he had watched very closely, 
he had observed a regularly recurring disturbance of stomach 
and bowels at times when the nursing mother should have 
menstruated. The ordinary Swiss milk, especially the very 



388 Meetings of Societies. 

swoet varieties, he condemned ; no doubt it made large fat 
children, but he was quite sure he had more than once seen 
such children succumb to complaints from which children 
l)rought up on other foods ought to have recovered. He 
favoured the use of the old fashioned nursing bottle, oval, flat, 
and with no tubes, the teat being fastened to the end of the 
bottle. Nurses complained that such a bottle had to be held 
in the hand during the whole time the child is drinking, and 
that thus the child cannot be put to bed with the bottle beside 
it, and allowed to drink ad libitum. Dr. Napier thought 
that this was precisely one of its great recommendations. He 
had often been puzzled to account for the fact that farmers 
and dairymen so persistently adhered to the barrel as the 
usual vessel for the conveyance of milk, a form of vessel the 
inside of \^'hich it is absolutely impossible to clean in a 
satisfactory manner. Last autumn he, along with another 
practitioner in Crossbill, had occasion to see a number of 
patients suffering from acute and severe diarrhoea, vomiting, 
and cramps, from mild choleraic sj'mptoms in fact, brought on 
in all the cases by the use of the same afternoon's milk 
supply. When the milkman w^as put to the question regard- 
ing the matter he admitted, in such an easy way as to show 
that he was familiar with the phenomenon, that " it was just a 
soor barrel." With reference to the length of time a child 
should be nursed at the breast, he thought it should be 
extended beyond three months ; when the supply is abundant, 
and the child evidently thriving, there is no occasion to add 
solid food till at least the seventh month has been passed. 
Oat flour is a satisfactory enough food, but the main difficulty 
with it is to get it properly cooked, prolonged boiling being 
necessary. As regards the use of milk which is acid in 
reaction, about the deleterious influence of which one speaker 
was somewhat sceptical. Dr. Napier thought that experience, 
apart from theory', settled that point decisively enough ; yet it 
was rather singular that acid milk, which was so badly borne 
by infants, was often well borne by adults. In South Africa 
it is the custom among the Boers and the Kafirs to use milk 
only after it has become sour and solid, astonishment being 
often expressed that the Englishman should prefer it " raw." 

Mr. M'Millan, in reply, said — " I have to thank the members 
for the favourable remarks they made on my introduction to 
this discussion. It was quite impossible to take up every 
point, and I have been much pleased to find so many valuable 
practical hints given by those who have taken part in the 
discussion. I approve of Dr. Tindal's suggestion in regard to 



Glasgow Southern Medical Society. 389 

the admixture of barley water and veal tea in certain cases 
where other food might not be suitable ; but I would not 
rely on barley or its decoction alone, as it is poor in nitro- 
genous material, containing as it does dextrin, which is 
difficult to digest even by the adult. I agree with Dr. Duncan 
that great care ought to be exercised in avoiding the giving 
of farinaceous food until the child is three months old ; and 
further, would reconunend it as a safe rule not to give a child 
farinaceous food until the appearance of the first teeth. 
Dr. Pollok was in the habit of recommendino- suo-ar of 
milk and phosphate of lime added to milk and water. This 
combination is noted by Dr. King Chambers in his Manual of 
Diet, p. 1.35 (Ed. 1875). The only objection to this method is 
that the proportion of casein is reduced. 

" Dr. Pollok advocated the use of condensed milk. In addi- 
tion to what I have already said on the use of condensed milk, 
I would direct the attention of the members to a paragraph in 
a short article in the Lancet for February 9, 1884, by Edmund 
Owen, F.R.C.S., where he says: — 'The opinion which I have 
been compelled to form in my work in the out-patient rooms 
of the Children's Hospital is that the worst nourished of the 
hand fed infants are those that have been reared on condensed 
milk and the various patent food stutFs ; and that whenever an 
infant cannot have human breast-milk, the best substitute will 
be found in fresh cow's milk, prepared and administered secun- 
dum artem.' I also show you a plate in Dr. Barlow's essay 
on Rickets, which illustrates the evil results of improper 
feeding. I may note further that Swiss milk has a medium 
amount of casein, less fat than either human or cow's milk, 
and too much sugar, leading to frequent digestive derange- 
ments. I agree with Dr. Glaister's very suggestive remarks, 
and also with Dr. Gilmour in reference to the time of feeding. 
Dr. Gilmour seemed not to attach much importance to the 
acid condition of cow's milk. I am satisfied that acidity 
renders the food very unsafe, and would recommend the use of 
litmus paper in the nursery, so as to avoid this contingency. 
I am glad to endorse Dr. Gilmour's opinion of the value of 
the Fountain feeding bottle. I agree with what Dr. Napier 
has said, with the exception of his recommendation of the 
old-fashioned flat ft-eding bottle without the tube. I think 
the cork in this bottle an objection, and I believe there is a 
greater risk of the child drawing air with its food. In 
reference to the use of oatmeal, which has been advo- 
cated by some of the members, I would refer you to an article 
in the Lancet for 1878, p. 685, by Dr. Cheadle, on Scurvy 



390 Medical Items. 

Supervening- on Rickets. He there points out the important 
fact that tlie dieting of infants has mainly to do with this 
condition. In one case he narrated, where the principal food 
was oatmeal, the child got ricketty and more and more feeble. 
For eight months, with the exception of some broth 
occasionally, it had been limited to one kind of food only — 
viz., farinaceous food, he says it was more than a ricketty 
diet, it was a scurvy diet." 

The Treasurer showed an improvement on his new medical 
ledger, which seemed to exhibit in sufficient detail all the items 
posted from the day book, with the minimum of trouble 
expended in posting. 

Mr. J. S. Nairne then gave a record of a year's private 

SURGICAL PRACTICE. 

The President said that the only point in Mr. Nairne's paper 
which he would notice, as his name had been mentioned in 
connection with it, had reference to the new tracheotomy 
tube. When his tube was returned, after having been used at 
the case of tracheotomy described by Mr. Nairne, he found 
the greatest difficulty in cleaning it. He boiled it in water, 
soaked it in spirit, in chloroform, in ether, and after each 
process pushed a quantity of cotton wool through the tube, 
and always got out a little hardened exudation, and thus could 
never satisfy himself that it was thoroughly clean and fit for 
use in another case. Ultimately he made it red hot in the 
fire, in the hope that no diphtheria germs would be able to 
pass unscathed through such an ordeal. The inner tube 
devised b}^ Mr. Nairne, which opens longitudinally, can be 
cleaned perfectly satisfactorily ; there is thus no chance of 
conveying infection from one case to another, or of blocking' 
up of the tube. 



MEDICAL ITEMS. 

UNDER THE DIRECTION OF 

ALEX. NAPIER, M.D. 

Percussion as a Means of Precise Diagnosis. — Dr. A. 
E. Sansom ably advocates greater accuracy in our method of 
percussion. " As generally adopted, its indications are only 



Medical Items. 391 

regarded as approximations to the truth about concealed 
organs, as rehitive rather than positive data." Piorry re- 
cognised eleven varieties of sound elicited by percussion, and 
thereby " imposed upon the ear a task of discrimination too 
great for the average human organ." To appreciate differences, 
rather than recognise or classify varieties of sound, is the 
object to be aimed at. Hearing and the sense of touch convey 
the results of percussion, and in regard to this latter channel, 
Dr. Sansom insists on the advantage of using a pleximeter, so 
held that the sensitive linger-tips rest on its horizontal plate. 
If the finger is used as a pleximeter, there is a sacrifice of 
percussion. " It cannot but be so ; for the soft tissues act as a 
' bufi'er ' to arrest the vibrations that it should be our prime 
object to recognise." Applied to the heart, pleximeter 
percussion gives delicate results. Pericarditis gives one 
uniform note, so also does hj^pertrophj^, but where there is 
dilatation, " it is quite possible to detect a thickening of the 
valves, when this is constituted by a dense fibrous material, 
or where there has been calcareous change." Repercussion 
may demonstrate very decided areas within an already defined 
area of cardiac dulness, " where the vibrations are in marked 
degree less pronounced than those over the general area," and 
" these islands of greater dulness may correspond very closely 
in position with the valvular orifices." The possibility of 
superficial thickenings — adherent pericardium, &c., giving 
rise to these, must be tested by collateral evidence. 

Equally delicate results follow the application of this 
method to the lungs. 

In Dr. Sansom's hands the pleximeter has detected an area 
of dulness, where auscultation and finger-percussion yielded 
no abnormal sign, and the diagnosis was afterwards confirmed 
by other means. Our present knowledge regarding the 
phenomena of vibrations is limited, and Dr. Sansom pleads 
for a number of independent observations by those who will 
pursue them in the spirit of those who have yet much to 
learn. — {TAverpool Med. Chh: Jour., January, 1(S8.5.) — A. K. C. 

Injections of Ether and Iodoform in Cold Abscess. — 
Professor Verneuil ol>tains a rapid cure in almost all his cases 
of cold abscess, abscess from diseased Ijone or from congestion, 
&c., by ethereal injections of iodoform of the strength of one in 
twenty. The abscess is first emptied by means of Potain's 
aspirator, and then receives from 100 to 800 grammes of the 
iodoform solution. By not exceeding this quantity (i. e., five 
to fifteen grammes of iodoform) no fear of accidents need be 



392 Medical Items. 

felt. The liquid penetrates into all the anfractuosities and 
diverticula of the abscess, the ether becoming absorbed or 
evaporated, the antiseptic agent being deposited uniformly 
on the pyogenic membrane, the action of which it modifies. 
This simple means, so exempt from danger and so easy of 
application, has proved highly successful, very large abscesses 
having yielded to three or four injections. — {Rev we de Thera- 
peutique, loth August, 188-1.) — The Practitioner. Mar., 1885. 

The Treatment of Lupus. — Professor Schwimmer states 
that after a trial of all the remedies which have been recom- 
mended for lupus, he has found the best results from the 
employment of mercurial plaster in conjunction with the use 
of pyrogallic acid. He remarks that the number of patients 
affected with the most malignant forms of lupus who were 
subjected to this treatment, and who remained under careful 
observation until its close, amounted to twenty. The following 
was the course pursued with all of them. For several days 
after admission the diseased surfaces were kept completely 
covered with vaseline smeared on cloths, in order to facilitate 
the removal of all secondary morbid products, such as scabs, 
&c. A ten per cent pyrogallic ointment was then applied over 
the same area, and renewed two or three times in twenty-four 
hours. This dressing was employed for four to six days, or 
in cases where the cutaneous tissues were insensitive, for six or 
seven days. On its removal vaseline was again applied for one 
day, after which the entire suppurating surface was covered 
with mercurial plaster. Healing began in from ten days to a 
fortnight in most localities, but isolated nodes and tubercles 
could still be detected in the cicatrised integument. Pyrogallic 
acid was now once more applied for three or four days, causing 
renewed suppuration of the partially healed infiltrations, while 
those more firmly skinned over remained unaffected. When 
treatment was repeated, so much pain in many cases was ex- 
perienced on the second day that mercurial plaster had to be 
at once substituted for the ointment ; but if this was not the 
case, the latter was left on for two or three days longer. The 
grey plaster was allowed to remain, being changed once daily 
if the suppuration was trifling, twice or thrice if it was more 
profuse — until cicatrisation was complete, which sometimes 
required four weeks. When the complaint was peculiarly 
indolent and obstinate, the same process was gone over a third 
time, but treatment never extended further than this. He 
adds that the severest and most extensive forms of lupus — 
those hitherto most difficult and frequently impossible of 



Medical Iteinis. 393 

management — may often be essentially ameliorated by these 
simple and comparatively painless procedures. — {Journal of 
Cutaneous a)nl Vcuoral Disnines, Vol. 2, No. 9.) 

Dr. F. H. Martin on Manganese as a Remedy in 
Menstrual Troubles. — In a paper read before the Chicago 
Medical Society, Dr. Martin alluded to a former publication of 
his own on the subject, in the Medical Record for 1883, and 
stated that, having continued his observations, he felt able to 
add much confirmatory evidence of what he had already 
advanced. He was convinced that manganese would relieve 
certain forms of menorrhagia and metrorrhagia, as well as 
amenorrhrea. As these conditions depended upon so many 
different causes, it was necessary to point out exactly the 
states in which manganese was indicated. He had been led to 
regard the remedy, in any form, as a direct stimulant to the 
uterus and its appendages. It might act as a direct vaso- 
motor nerve stimulant to the vascular system of these organs, 
and thus, in consequence of the improved circulation, increase 
their tone and nutrition ; or it might exert its whole force by 
stimulating the sexual nerve ganglia, or possibly the nerve 
centres. At any rate, its action was prompt and immediate in 
the tonicity of the uterus and its appendages where lack of 
tone was dependent on defective innervation. 

In young girls, who were irregular in the early months of 
menstrual life, from natural weakness of the partially devel- 
oped organs of generation or an over-Vvorked nervous system, 
the organs were robbed of their natural nerve force. Per- 
manganate of potassium in dose of two grains thrice daily, 
dissolved in hot water, seemed to possess the stimulating 
properties requisite to bring about a healthy action. The 
results had invariably been good. 

Patients who suffered with suppression or excess of the 
menstrual flow as the result of exposure to cold, would invari- 
al)ly ])e found to have weak and susceptible menstrual organs. 
In such cases the action of manganese was most prompt and 
i,n-atifying. In the author's experience there had been no 
failure, provided the trouble was due to the effects of cold 
alone. The permanganate was given in large doses, and its 
almost magical effect was shown by the appearance of the 
flow within twelve hours. 

Manganese was an efficient remedy in certain forms of 
menorrhagia and metrorrhagia. Although menorrhagia and 
amenorrhoea were exactly opposite manifestations, they were 
very often due to the same causes. When the cause was 



394 Medical Items. 

anaemia or any depressing constitutional disease producing a 
perversion of the functional activity of the organs, the per- 
verted action consisted of an irregular or excessive flow, and 
it would yield as readily to the stimulating action of man- 
ganese as the oppasite condition. 

Although, like nickel, zinc, iron, and silver, mans^anese acted 

^O ' 7 7 7 ' O 

as a tonic to the blood in cases of anaemia, chlorosis, &c., it 
could not be owing to that fact alone that it exerted its 
peculiar influence on the catamenia, for its action was too 
prompt. It might be given in the form of the permanganate 
of potassium, or as the binoxide of manganese. The former 
should be dissolved in water, and, when possible, it should be 
given after meals. It could also be prescribed in dry gelatine 
capsules, but it was less likely to irritate the stomach if it was 
diluted. The binoxide, though less readily absorbed on 
account of its insolubility, was not irritatinej, and could be 
readily administered in pill form. — New York Med. Journaly 
24th January, 1885.— R. S. T. 

Preserving and Embalming Bodies. — ^A. Sauter de- 
scribes {Der Fortschritt, No. 3, oth February, 1885) several 
cheap and easy methods of preserving and embalming- 
bodies. If only a temporary retardation of putrefaction and 
decomposition be required, the filling up of the coffin with 
sublimated wood-wool will answer better than any other 
means, being at the same time easily procured and prepared. 
Common wood-wool, which may be purchased of any surgical- 
dressing manufacturer, is treated with a solution of one part 
of bichloride of mercury, 100 of alcohol of 5 to 10 per cent, 
and dried for use. Instead of wood-wool, common sawdust 
prepared in the said manner will likewise answer. The 
corpses ought to be previously washed with the same solution, 
diluted with ten parts of water. 

The best and easiest manner of embalming consists in 
gradually injecting, under gentle pressure, the preservative 
fluid into the carotid artery by means of an Esm arch's 
irrigating- can or by a larger ordinary injecting-syringe. The 
quantity required will vary from six to eight pints (three 
or four litres), consisting of one part of carbolic acid, ten of 
glycerine, fifty of alcohol, and forty of water. This fluid will 
preserve the body, and retain the epidermis for several days. 
If, however, it be desired to keep the corpse in perfect 
condition for several months or longer, this must be followed 
by a second more copious injection of one part of chloride of 
zinc and three parts of water, slightly tinged with fuchsin or 



Media 1 1 Items. 395 

with a saturated neutral solution of sulphate of aluminum 
coloured with cochineal. After having injected the whole 
quantity of the fluid (about ten to sixteen pints), the carotid 
ai'tery and the jugular vein must be tied. The surface of the 
body may be lubricated with vaseline or covered with varnish 
of sandarac, to which 1 per cent of carbolic acid is added. 
The cavities of the body are filled with sulilimatcd wood-wool, 
or with cotton-wool soaked in glycerint' containing 5 per cent 
of carbolic acid. 

These methods of preserving corpses will neither require 
unusual skill nor great expense. — The London Medicfd 
Record. IGth March, 1885. 

Neumann on the Anatomy and History of Syphilides. 
— At a meeting of the Society of Physicians of Vienna, on the 
20th March, Professor Neumann said — Syphilides, with the 
exception of gummata and broad condylomata, are not 
sufficiently well known to us. Baerensprung has thus charac- 
terised them : — " The recent forms consist of an uncircumscribed 
inflammation and exudation in the upper part of the papillary 
body of the skin. They cause hypertrophy and destruction of 
the papillary body. On the other hand the late manifestations 
of sj^hilis are exudations which begin in the subcutaneous or 
submucous tissue. These result not in resorption, but in 
breaking down of tissue in ulceration, and finally in cicatricial 
formations." Virchow confirms what Baerensprung has said, 
and asserts, that the syphilide is not a permanent formation, 
but consists of transitory elements, thus causing the ulceration, 
which is their prominent feature. The central region is never 
the first to break down. All observers agree that it is the 
upper part of the papillary body that is principallj' affected 
by syphilides. Professor Neumann then proceeded to enunciate 
the results of examinations conducted by himself in conjunction 
with his assistants, Drs. Finger and Ehrmann, on the anatomy 
of syphilides. 

(1.) Syphilides are composed, as has been previously observed, 
anatomically of a round celled growth, which lies close to the 
blood-vessels. Without doubt the vessels of the upper layers 
of the cutis, and of the papillary bod}^ are next affected. The 
vessels of the deeper layers of the cutis, /. e., the panniculus 
adiposus (arteries and veins), are also affected. The intensity 
of the pathological changes is not so great in recent forms of 
muscular syphilis, as in papular and tubercular efflorescences, 
and in gummata. 

(2.) The disea.sed products are at first strictly limited to the 



396 Medical Items. 

papillary bodies, and do not penetrate to the epidermis. As 
these products however increase, this boundary is passed, and 
the rete becomes infiltrated. Its lower boundary becomes 
indistinct, and the round cells are found lying immediately 
beneath the tightly stretched, horny layers of the epidermis. 

(3.) In the recent state, the exudation cells are, strictly 
speaking, of a rounded form. After a time however they 
become spindle shaped and lengthened, and are found lying 
around the walls of the blood-vessels. 

(4.) The pigment is in the form of granules of different size, 
and it varies from orange to brown in colour. These granules 
lie partly in the exudation cells, partly in the connective tissue 
cells. In the former case they are easily absorbed, in the 
latter, resorption is difficult or impossible. If the cell growth 
has penetrated into the rete, the cells are seen even in that 
situation to be pigmented. 

(5.) The fibres of the papillae appear loosely bound together, 
and clouded with molecules. This clouding is also seen in the 
deeper layers of the cutis of gummata of the skin. 

(6.) The hair follicles are variously altered. The root sheath 
of the hair is surrounded by round cells, and its outer layers 
are thickened. In the lichen and acne forms of syphilides 
these thickenings form club shaped excrescences, and cyst-like 
formations. Similar changes are seen in the sweat glands. 

(7.) It is noteworthy that giant cells similar to those observed 
in tuberculosis have been found in syphilides. They are seen 
in greatest quantity in the acne and lichen forms, but exist 
also in gummata of the skin. I have never found them in 
muscular syphilides, in recent lenticular formations, nor in the 
initial lesion of syphilis. 

(8.) Certain tissues of the skin appear to present a peculiar 
opposition to the inroads of this disease, e. g., the unstriped 
muscular tissues. 

In a few sections of skin, round cells were found, corres- 
ponding to the course of the vessels of the erector muscles of 
the skin. On the other hand, papules on the scrotum, in which 
the contractile muscular fibres are so numerous as to form a 
network, were in every case quite free from infiltration. 

(9.) As the various syphilides of the skin represent merely 
different degrees of intensity of the same process, a sharply 
defined histological boundary cannot be drawn between the 
different forms. Still we can say, that in individual cases, in 
which the vessels are affected, the hair follicle is the principal 
origin of the disease, in other cases it is in the papillary body 
where it is first seen. 



Medical Items. 897 

(10.) Tlie pigment following- recent sypliilides disappears 
when the round cells are absorbed. 

(11.) I have discovered during my investigations, that with 
the disappearance of the clinical features of the disease, tlie 
anatomical changes are not always removed. Exudation cells 
as well as pigment, remain for a considerable time in the 
deeper layers of the cutis. At this time it may appear to the 
eye of the clinical observer that all traces of syphilis have 
<lisappeared. 

Finally, I observed that the cord-like structure in the course 
of the lymph vessel results only from induration and exuberant 
growth of the endothelium of the lymph vessels. This cord 
lies partly in the median line of the penis, usually above 
dorsal artery and vein, and can also be felt externally to the 
symphysis. It extends to the lymphatic glands, and is often 
provided with nodular outlets, which communicate with the 
channel of the lymph vessel. 

Paralysis following Hypodermic Injections of Ether. 
— Arnozan {Gaz. Hehd. de Med. de Chir.) contributes a long 
article on this subject, in which he cites a number of interest- 
ing cases. In several instances in which injections were made 
under the skin of the posterior aspect of the forearm, paralysis 
of the extensors was noted within a few minutes. Under the 
use of the constant current the condition eventually disap- 
peared. In one case a deep injection into the thigh was 
immediately followed by darting pains, which persisted for 
two weeks. The leg became livid, and wasted away, and the 
reaction of degeneration was observed. The patient subse- 
quently developed a trophic ulcer on the heel, and improved 
very slowdy, though under treatment for a year. The writer 
thinks that the phenomena described are really symptomatic 
of neuritis, which is due to the irritating action of the ethei- 
that has been deposited in the neighbourhood of the nerve. — 
Canada Lancet, April, 1885. 

Two Notable Laparotomies. — At the Surgical Section of 
the oTtli. Vei-Hc III mhiry Jjev.fsrhn Xatur for iScher und Arzte, 
at Magflburg, Mikulicz of Cracow, states that in all cases of 
perforation of the stomach or bowels, when the patient's 
strength rendered it possible at all, laparotomy is the treatment 
indicated. The cause of the lesion is immaterial, whether it be 
from direct or indirect violence, or from pathological changes, 
and the presence of peritonitis, so far from being a counter 



.S98 Medical Items. 

indication, renders the operation the more necessary, and 
may even favour the subsequent healing. 

Among- other cases he brought forward was one of " a young- 
man who suddenly awakened from sleep by a knock at the 
door, and springing quickly out of bed, felt a severe pain near 
the umbilicus, which was followed by symptoms of ileus. 
He was seen GO hours after the accident, and as the symptoms 
appeared to point to internal ' Incarceiution,' (obstruction), 
laparotomy was advised and carried out. There was found in 
the peritoneal cavity more than a litre of thin, stinking pus, 
with fragments of undigested potato floating in it ; and to the 
left side, near the brim, of the pelvis a perforation of the ileum 
about 6 in. long by -i in. wide. As the mesenteric glands were 
much swollen, and no other cause of the perforation could be 
found, Mikulicz believed that he had to deal with a ruptured 
ulcer in a case of ambulatory enteric fever. The edges of the 
wound were raised, brought together by 12 silk sutures in its 
long diameter. The further progress of the case was good ; 
except that the external wound opened up again. After dis- 
charging about 200 ccm. of pus, however, it healed by 
granulation."— (CV'>ify((/6^. /. CJiir. No. 45, 1884.) 

" Dr. W. T. Bull, visiting surgeon at the new York Hospital, 
performed, 8rd November, a remarkable laparotomy, the result 
of which has thus far, 22nd November, been strikingly 
successful. The patient was a male, the victim of accidental 
shootincr with a 82 calibre revolver, the ball entering to the 
left of and just below the navel. There were no symptoms of 
perforation, and he was in good general condition twelve 
hours afterwards. The bullet wound was explored under 
ether, and found to penetrate the abdominal cavity. Lapar- 
otomy was performed, sutures taken in seven intestinal 
perforations, and the ball removed from the wall of the 
sigmoid flexure. Favourable progress has since been made 
without serious symptoms of any kind, complete recovery 
being only delayed l)y an extra peritoneal abscess in the 
abdominal wall." — {Boston Med. and Surg. Journal, 27th Nov., 
1885.) D. MT. 

Epitaph. — On a gravestone in a country churchyard in 
England, on Mrs. Arabella Greenwood, who died in childbed ; 
written by the Rev. Mr. Greenwood, D.D. : — - 

O Deathe ! O Deathe ' thou has cutte down 

The faii-est Greenwood in all this towne ! 

Her virtues and good qualities are suche 

That shee might have married a lorde or a judge, 



Medical Items. 399 

But such was her condescensionge, and such her humilitie, 
She chose to take me, a Doctor of Divinitie, 
For which lieroicke acte, slie stands confeste 
Al)0ve all others the PlutMiix of her sexe, 
And like that birdee one younge shee did begette, 
That she might not leave her sexe disconsolate. 
Mie griefe for her is so verie sore 
I can onlie write two lines more : 
For this, and everie good woman her sake, 
Never let a blisterre be putte on a lyinge-in-woman's back. 
— Boston Weeklj) Magazine, 17th December, 1803. 

The Crow and the Country Doctor. {A Medical Fable.) 
— The J'Jdinhiiiyh Med. Jour., March, 1885, tells us that 
" A Flock of Crows was much alarmed one day at the sight of 
a strange ohject in the midst of a field upon which they 
customaril}^ fed. They at once called upon an Old Crow who 
practised his profession in those parts, and wdio made a 
speciality of corns, to give his opinion about the matter. The 
Crow, having examined the object, shook his head, and said 
that it was a serious case, and that it was lucky he had been 
summoned so soon, though he should have been called earlier, 
and he would like the advice of his friend the Owl, who had 
had the benefit of travel abroad, and who was particularly 
skilful in cases which called for the Steady Use of the Eyes. 
He would also like to have the Frog, who was spending his 
summer vacation by a neighbouring pool, and who had a wide 
reputation for his physiological knowledge, to see the case. 
The Crow, the Owl, and the Frog met, and having studied the 
object at a suitable distance, withdrew to the Shade of a High 
Wall in order to deliberate. The Frog first opened his mouth, 
and observed that it was a nice Case, which reminded him of a 
very curious experience that he had had with a piece of Red 
Flannel two summers before, when he received a severe con- 
tusion upon tlie centre of Goltz. After telling all about this 
very apposite event, the Owl oljserved that such cases were 
extremely rare. He had, however, had two very much like 
them, the details of which he had forgotten. He then related 
some very humorous obstetrical stories, which much amused 
the Crow. 

" Having received these opinions, the Crow thanked his Col- 
leagues for the valuable light they had furnished. He had 
himself been at first disposed to think the trouble a case of 
Terror Corvomni, or Scare-Crow ; but the advice given 
reminded him now that the appearance in the cornfield exactly 
resembled a country doctor whom he occasionally met, and 



400 Books, t&c, Received. 

who, after practising medicine for forty years, was at present 
trying to live on What he had Saved. 

" This diagnosis was finally agreed upon, and reported to 
the anxious Crows outside, who were much relieved. 

"Moral. — This stor}^ shows the profit that is got from 
consultation, and the lucrative nature of the practice of 
medicine." 

Books, Pamphlets, &c., Received. 

Operative Surgery in the Calcutta Medical College Hospital ; 

Statistics, Cases, and Counnents. By Kemieth Macleod, A.M., 

M.D., F.R.C.S.E. London : J. & A. Churchill. 1885. 
Transactions of the Obstetrical Society of London. Vol. XXVI. — 

For the Year 1884. London : Longmans, Green k Co. " 1885. 
The Inhalation Treatment of Diseases of the Organs of Respiration, 

including Consumption. By Arthur Hill Hassell, M.D., with 

numerous illustrations. London : Longmans, Gi-een k, Co. 

1885. 
Bacillary Phthisis of the Lungs. By Germain See. Translated 

and Edited for English Practitioners. By William Henry 

Waddell, M.R.C.S. London : Kegan, Paul, Trench & Co. 1885. 
Doctrines of the Circulation : a History of Physiological Opinion 

and Discovery in Regard to the Circulation of the Blood. By 

J. C. Dalton, M.D. Philadelphia : Henry C. Lea's, Son & Co. 

1884. 
Transactions of the American Surgical Association. Vol. 11. — 

Edited by J. Ewing Mears, M.D. Philadelphia : Blakiston, 

Son & Co. 1885. 
The Bradshaw Lecture for 1884 on the Pathology of Cancer. By 

W. S. Savory, F.R.S. London : J. & A. Churchill. 
Endemic Goitre or Thyreocele. By William Robinson, M.D. and 

M.S. London : J. & A. Churchill. 1885. 
The Lettsonian Lectures on Bronchial Asthma, By John C. 

Thorowgood, M.D. London : Bailliere, Tindall k Cox, 1885. 
The Student's and Junior Practitioner's Guide to the Medical 

Profession. By Charles Bell Keetley, F.R.C.S. Second 

Edition. Edited by the Author and Robert Marr, M.D. 

London : Bailliere, Tindall k Cox. 1885. 
Voice Use and Stimulants. By Lennox Browne, F.R.C.S.Ed. 

London : Sampson, Low, Marston, Searle, k Rivington. 1885. 
The Child's Voice, its Treatment with Regard to After Develop- 
ment. By Emil Behuke and Lennox Browne, F.R.C.S.Ed. 

London : Sampson, Low, Marston, Searle, k Rivington. 1885. 
The Advertiser's Guardian, 1885. By Louis Collins. 
A Treatise on Gout, Rheumatism, and the Allied Affections. By 

Peter Hood, M.D. Third Edition. With a Chapter on Sleep. 

London : J. & A. Churchill. 1885. 




rilOTOClKAPH OF CASE ok LETROSV dksckibed in Ai'kil No. ok 

Glasgoiv Medical Journal, page 303. 

Photographed by W. F. SOMMERVILI.E, M.B. 



THE 



GLASGOW MEDICAL JOURNAL. 



No. VI. June, 1885. 



ORIGINAL ARTICLES. 



INSANITY— MODERN VIEWS AS TO ITS NATURE 
AND TREATMENT. 

By Professor W. T. GAIRDNER, M.D., LL.D. 

(Being the Address delivered at tlie close of the Winter Session 1SS4-85 

before the Glasgow Universit.}/ Medico-Ch>rurgical Society, 

hy the Honorary President.) 

[The lecturer cormncnced by intimating that his address, 
though unpublished in its present form, "was not new, having 
already formed a part of the Morison Lectures on Insanity, 
delivered at the Royal College of Physicians of Edinburgh, 
in June, 1879. He expressed his strong sense of the necessity 
for more attention being paid to this subject in the medical 
curriculum of study, and pointed out that recent instances 
had tended to show that public opinion would not much 
longer tolerate a state of the law and practice in dealing 
with the insane, in which the most delicate and important 
([uestions arising as to the insane mind might be submitted 
to persons medic?dly educated, but in reality wholly devoid of 
experience, or even of systematic instruction, in this depart- 
ment of the healing art. The object of the address, however, 
and of the whole series of the Morison Lectures of which it 
forms a part, was to show that the principles underlying the 
modern ti-eatment of the insane are precisely the same as 
those which have been emerging into more and more promi- 
nence in connection Avith what are admittedly liodily diseases. 
In assenting to the representations made to him as to the 
No. 6. 2D Vol. XXIII. 



402 Professor Gairdner — Insanity — 

publication of the address in the Glasgovj Medical Journal 
Dr. Gairdner has thought it desirable, for the sake of com- 
pleteness, to include a considerable amount of introductory 
matter which, originally presented in the Morison Lectures, 
could not be so compressed as to admit of deliveiy in the 
time allotted to the academic address, and which, moreover, 
preserves, as now issued, the form of the Morison Lecture, 
rather than of its second destination. The notes added have 
an interest, in some respects, even apart from the argument 
of the lecture itself; and it is hoped that their publication 
may not only add to the force of the argument, but attract 
the attention of some who are not habitual readers of medical 
literature, or of the Glasgow Medical Journal.'] 

What is Insanity ? The attempt to answer this question 
by means of definitions has been notoriously unsuccessful ; 
and among the distinguished legal visitors here present,* there 
is probably not one who has not often been in the position of 
watching the struggles of a scientific expert to free himself 
from the coils of some verbal entanglement of this kind, to 
which he has rashly committed himself in cross-examination. 
But without too much anticipating what I shall have to say 
hereafter as to the sources of these difiiculties, it may be pro- 
per to inquire, at the outset, how it has come about that a 
word which, according to its etymology, simply means 
unsoundness, has in the special field of mental pathology 
become the cause of so many opposing theories and puzzling 
dilemmas. The mere verbal questions may be almost dis- 
missed with the remark, that there is probably no real differ- 
ence implied or expressed between the alternatives allowed in 
our English and Scotch schedules for dealing with the insane, by 
which they may be pronounced " lunatic," or "of unsound mind," 
in preference to the more usual general designation of " insane." 
For myself, I almost always prefer the expression " of unsound 
mind," to the others, both as less under the suspicion of being 
biassed by theory, and as on the whole more comprehensive, 
and more intelligible to the average man. It admits, no 
doubt, of the metaphysical subtlety or quibble that one can- 
not be absolutely sure that it is after all the mind, or soul, 
that is unsound in the technical sense of the word ; and of 
the moral paradox that in any case the unsoundness is too 

* The Morison Lectures on Insanity are delivered, on the invitation of 
the President and Council of the Royal College of Physicians, to audiences 
including senators and members of the College of Justice, as well as 
distinguished clergymen and members generally of the medical pro- 
fession. 



Modern Vieivs as to if.s Xatitre and Treatment. 403 

general to become a distinction ; for, is not our whole spiritual 
nature, according to the New Testament, as well as the most 
orthodox theologies, thoroughly unsound ? It is hardly 
necessary at this stage to do more than merely suggest, as 
tending to complicate the question of insanity, the doctrine 
that underlies the sober language of the general confession in 
the English Prayer Book, that "there is no health {i.e., no 
wholeness or soundness) in us." So that the first question 
comes to be, when we pronounce a man technically insane or 
of an u