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THE
DUBLIN JOURNAL
OF
MEDICAL SCIENCE.
EDITED BY
JOHN WILLIAM MOORE, B. A., M.D., M.Ch., Univ. Duel.;
PRESIDENT OF THE ROYAL COLLEGE OF PHYSICIANS OF IRELAND ;
SENIOR PHYSICIAN TO THE MEATH HOSPITAL AND COUNTY DUBLIN INFIRMARY ;
CONSULTING PHYSICIAN TO CORK-STREET FEVER HOSPITAL ;
EX-SCHOLAR OF TRINITY COLLEGE, DUBLIN ;
FELLOW OF THE ROYAL MEDICAL AND CHIRURGICAL SOCIETY OF LONDON.
VQL. CVIIL
JULY TO DECEMBER, 1899.
DUBLIN :
FANNIN & COMPANY, Ltd., GRAFTQN-STEEET,
LONDON: SIMP-KIN, MARSHALL & CO.
EDINBURGH: JAMES THIN.
PARIS: IIACIIETTE & CO.
1899.
DUBLIN : PRINTED BY JOHN FALCONER, 53 UPPER BACKVILLE-STRKET.
V* A
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WEL
ICQiV-E INSTITUTE
LIST ARY
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No.
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*
THE DUBLIN JOURNAL
OF
MEDICAL SCIENCE.
JULY 1, 1899.
PART I.
ORIGINAL COMMUNICATIONS.
Art. I. — Cases of Tachycardia .a By J. Magee Finny,
M.D. ; Past President, Royal College of Physicians,
Ireland ; Physician, Sir P. Dun’s Hospital ; King’s Pro¬
fessor of Practice of Medicine, School of Physic, Ireland.
’ The subject of my paper is one of comparative rarity,
and the cases which form its basis are good illustrations of
it in its varied aspects as regards causation, duration, and
gravity. It is remarkable, writes Dr. Bristowe in 1887,
that cases of extreme rapidity of the heart’s beat should have
been so long overlooked, and yet the first three recorded
instances seem to have been made in the British Medical
Journal in 1866, by Dr. Cotton, Dr. Jas. Edmunds, and
Sir Thos. Watson ; and to their graphic description of the
condition in its typical aspects little could be added by
Dr. Bristowe, who himself, in 1887, published ten cases
in a paper which forms one of the most valuable contri¬
butions to the subject.1 The fact that the condition of
paroxysmal heart-hurry so often occurs in otherwise
healthy individuals, may possibly account for its being
a Read before the Section of Medicine, in the Royal Academy of Medicine
in Ireland, Friday, May 19, 1899.
VOL. CVIII. - NO. 331, THIRD SERIES. A
2
T achy car dia.
so rarely observed, and further, its occurrence may take
place without the smallest consciousness on the patient’s
part that his heart’s rate is in any way perverted or
accelerated, unless, and until, a medical man, on trying
to count the pulse, may call his attention to its rate.
The name of “ Tachycardia ” is of modern days, and
seems to have been given — 15 years after Dr. Cotton’s
oase — Py Proebsting, a pupil of Gerhardt, in 1881.
Whittaker, whose description is perhaps the best of
those I consulted — prefers the word polycardia or pykno-
cardia ( irvtcvos crcpvypo^ of Hippocrates), heart-hurry.
He says — “ It was in old times included under palpitation.
The distinction is now drawn between the two, in that
palpitation is a beating of the heart that is felt by the
patient, while tachycardia is an increase in the frequency
of the beats. Tachycardia, like palpitation, is always only
a symptom, and never a distinct disease. In palpitation
there is usually, but not necessarily, an increase of fre¬
quency ; but the heart may throb violently, yet may beat
slowly. Tachycardia is usually, but is not necessarily,
perceived by the patient.” 2
In fact, one of the great distinguishing peculiarities of
pathological as contrasted with symptomatic tachycardia,
is the little disturbance it gives to the sufferer. It may be
so slight that the patient goes about his duties as
“unconscious as a babe of anything unusual ” (Balfour),3
or there may be some slight sense of .oppression, some
nervous excitement or dyspnoea, or a little lividity.
Thus, it is more a state of altered rate of the heart’s
action, not a disease of the heart, and as it occurs in
paroxysms, Bouveret gave it the name of “ Paroxysmal
Tachycardia.” It is as though the heart’s action was gone
wrong, and the organ, no longer under control, beat of its
own free will. Some fancifully speak of it as of a watch
running down, when the check on the mainspring is
broken, or as an engine, on an incline, no longer under
control of the brake.
Physiology teaches that the heart is under the control of
two nervous influences — the stimulating filaments from
the sympathetic cervical ganglia to the cardiac ganglia,
By Dr. J. M. Finny. 3
and the repressing or inhibitory nerve derived from the
pneumogastric. Experiment has shown that when the
inhibitory nervous influence is withdrawn or destroyed
the heart’s beat is accelerated up to 140 or 160 — but
not faster (Martius) 4 — and pathologically a lesion in the
medulla, destroying the origin of the vagus, has similar
results, forDoelger reported, in 1883, a case of apoplexy of the
inhibitory centre of the medulla, in which the pulse rose to
168. 5 And again, the motor ganglia in the heart itself maybe
over stimulated. But neither pathological nor physiological
research has as yet explained how the heart can suddenly
rise from 70-80 up to 240, 260, or 308 — and after a period,
shorter or longer, revert with equal suddenness to its
original rate. It is worth noting that during the paroxysm
of tachycardia there is no increase of arterial pressure,
or of work done by the heart. The rapid action is
primarily due to shortening of the diastole, and therefore
during systole so little blood is expelled that the aggre¬
gate amount is not increased in the minute. Physiology
further shows that the accelerator nerves in the heart
have no trophic relations to the heart, and therefore the
rapidity of the pulse, due to acceleration or irritation,
should produce little effect on the heart or general
system. In fact, essentially, paroxysmal tachycardia is
a neurosis of the heart, a “ cardiac nerve storm” (Wood).6
Talamon suggests that it is of the nature of an epileptic
seizure, and may be found in persons of neuropathic his¬
tory.7 Gibson considers all these views purely speculative,
and adds another — that its essential nature is 1 analogous
to the respiratory changes observed in the Gheyne- Stokes
respiration.8
In truth, paroxysmal tachycardia is induced by no known
cause, although it has been attributed to, and seemingly
produced by, excess of tobacco, a fall, a blow, or reflexly
by indigestion, worms, nasal polypi, urinary calculi, &c.
Larcena classifies the causes of tachycardia under eight
headings, as given in Whittaker’s exhaustive article,
already referred to : — (1) In diseases of the heart and
blood-vessels; (2) febrile; (3) peripheric compression of
one or both vagi or their nucleus ; (4) organic diseases of
4
T acliy car dia.
the nervous system ; (5) general diseases e.g., typhoid,
diphtheria, &c. ; (6) toxic — e.g., alcohol, &c. ; (/) reflex,
from any organ ; (8) neurosis.
Tachycardia may occur at any period of life— from 70
years of age (Balfour)9 to 6 years. This latter I will men¬
tion, as it is the youngest case on record, and the most
recent, as far as I can discover (described by Herringham).
It was a child of 11, who for 5 years previously had had
sudden attacks of heart-hurry without cause, and lasting
36 hours to 13 days, subsiding during sleep. The pulse-
rate ranged during the attack from 240-260. There was
very little precordial discomfort ; no pain ; respirations
were accelerated, with slight cyanosis, but no anasarca or
pulmonary oedema. There was no evidence of cardiac
disease, except enlargement of the organ in the transverse
direction both in the intervals and still more during the
attack. The child had been, previous to the first attack,
in robust health, and the history pointed to an absence
of rheumatism or syphilis. Different forms of treatment,
based on various theories as to the cause of the tachy¬
cardia, were tried, but had no effect in checking or alleviat¬
ing the attacks.10
In one of Bristowe’s cases the paroxysms of recurrent
tachycardia were of some years’ duration the attacks
lasting 3 days, in another they lasted 5 weeks. In the
intervals, some patients enjoyed perfect health, others
were invalids — and one (case 4, p. Ill), was actively
employed as a governess, with much responsibility, aged
forty, who travelled about inspecting schools, while her
heart was beating 200-260 (average 216). After five weeks
the heart suddenly fell to 70-80, and for fifteen years these
paroxysms would recur with very little general distress or
discomfort. In the end this lady died with symptoms of
cardiac obstruction. There was no autopsy.11
The following two cases in my own practice illustrate
the occurrence of paroxysmal tachycardia in the foregoing
aspects. Case I. was a lady with pre-existent and well-
marked valvular and arterial disease. Case II. a lady in
whom there existed no previous disease.
0
By Dr. J. M. Finny.
Case I. — Paroxysmal Tachycardia — -Mrs. M., aged sixty-eight,
of Westport, of active habits, though of a spare build, and not
unhealthy, while on a visit to towrn was suddenly seized on March
20th, 1887, on her return from a drive in her carriage, with
shortness of breath. She complained of a slight sense of tightness
or oppression across the chest, but was not aware of any palpita¬
tion nor did she feel ill, and she was able to walk up three flights
of stairs to her bed-room. Her daughter noticed some pallor and
sent for me. I found her as described. Her pulse was 180,
small and running. The tension was low, while the first sound
was shortened and accompanied by a systolic murmur, the second
sound being more marked and ringing, and by it the heart’s
pulsations were counted by the stethoscope. Best in bed, and
digitalis andbrom. potassium with carminatives, were soon followed
by relief, and in three hours, when I again visited her, her pulse
had fallen to 120, and she was generally better. The next day
the heart and pulse were normal, 78. The state of the valvular
lesion could now be readily made out, and I satisfied myself she
had mitral regurgitation and dilatation of the aorta with rigid
valves, probably all due to atheroma. There was no evidence of
dilatation. A. return of the tachycardia occurred again a few days
later without any cause, while she was indoors, but it was of shorter
duration, and did not last more than six hours. The patient
thought very light of her ailment, and seemed to think too much
was made of it.
There was no return during the fortnight she remained in town,
and she was able to return to the West of Ireland. Of her subse¬
quent history I learned that she had for three years following been
able to go about her place and to take moderate walking and driving
exercise, though with attacks of her heart, and that finally she
“ died of her heart,” although of the exact nature of the fatal
malady I am unaware.
Case II. — Becurrent Paroxysmal Tachycardia — Mrs. D., aged
fifty-four, of a nervous type, without children, consulted me in
1894, and was under my care off and on from January to June,
with various symptoms connected with cessation of menstruation —
e.g ., flushings, palpitations — and she fell into flesh. She had a
fresh complexion, and looked ten years younger than her age.
She frequently complained of pains under the sternum, and thought,
as many ladies do at that climacteric period, that her heart was
diseased. I mention this because it made me pay particular
attention to that organ, and I was quite satisfied that the heart
6
T achy car dia.
was sound in every respect. I made her take active exercise,
and by it and other appropriate treatment she lost a stone in
weight in six months and was then in excellent health. I saw
her occasionally during the next two years, looking fresh and well.
On January 7th, 1897, I was urgently summoned to see her by
Dr. Byrne at 11 o’clock p.m. ; she was in bed, well propped up
with pillows, and though her face had a frightened, nervous
expression, it did not strike me as that of grave disease. She was
disinclined to speak, and evidently thought her “ end was near.”
On taking the radial I was astonished at its rapidity ; it was
past counting, but the beats of the heart were over 200 ; Dr. Byrne
thought 240. The respirations were quite easy, about 30. I he
lady°had had some worry with her servants that day, and also
had some dyspepsia. The attack was preceded by a little pain
under mid-sternum.
Remembering my former case, I gave a hopeful prognosis, and
the treatment suggested consisted of sp. am. arom., tinct. digitalis,
brom. pot., and infus. valerian.
The attack lasted two hours and suddenly stopped. A second
attack occurred in April, 1897, in the evening, and it was practi¬
cally like the first. My friend, Surg.-Lieut.-Col. Crean (retired),
happened to be spending the evening with her. He tells me that
until she said the attack was on— and it was on for a couple of
hours before she spoke— he noticed nothing amiss with her beyond
the fact that she was a little more silent than usual, and he thought
no one else in the room had observed it, as she continued to play
the game of whist without comment. He did not try to count the
pulse, so as to avoid unnecessary alarm, but it was very rapid. He
urged her to lie down, but she felt more comfortable sitting up.
“ The strangest feature in the case,” he writes, “ was the rapidity
with which the attack vanished. Within ten minutes after first
feeling the pulse she quietly remarked 4 it is gone now,’ and the
pulse had fallen to about 80.”
This lady went abroad in the autumn of 1897, and spent
thirteen months travelling, and visited Homburg, Rome, and the
Italian Riviera. While in Nice she learned to ride a bicycle.. During
this time she had no return of tachycardia. Since coming home
however, she has had a few attacks similar to those described,
only she is not now alarmed. She told me (February, 1899) that
she attributes them to slight stomach derangement and annoyance
with servants, that the attack does not occur at the time of the
worry, but generally at bed-time, and is always ushered, m by a
slight sense of pressure under the sternum. She was m good
7
By Dr. J. M. Finny.
•j
health when I saw her, and I again examined the heart and found
it normal in all respects, neither dilated nor hypertrophied, and free
from all adventitious sounds. She asked about cycling, and I
advised her to continue the exercise.
These two cases illustrate recurrent or paroxysmal
tachycardia — one in a case of pre-existent and per¬
manent organic valvular and arterial disease ; the other
in an organ apparently healthy, and yet neither to be
attributed to direct cardiac lesion nor followed by heart
failure.
In striking contrast I now refer to Case III., where the
tachycardia was persistent for 16 days, where its cause
seemed to be obscurely due to an acute febrile state,
and where its termination was fatal on 16tli day by
almost universal arterial thrombosis, and by gangrene of
both lower extremities.
Case III. — Extreme Persistent Tachycardia of 16 days duration ,
ending in Gangrene of the Lower Extremities — E. E., aged twenty-
three, housemaid, residing at Lansdowne-road, was admitted to
Sir Patrick Dun’s Hospital on 17th January, 1899, after four
days’ illness. Dr. Samuel Bradshaw, Dalkey, Co. Dublin, who
sent her to hospital, stated that on the 15th he attended her for a
very sore throat, with temperature 103°, pulse 140, and that next
day the temperature rose to 104°. There was no evidence of
either diphtheria or scarlet fever.
On admission her tongue was coated with a white fur, the
tonsils, pillars of the fauces, and the pharynx were red and
swollen, but were free of all exudation and ulceration. There was
very little dysphagia ; there was no eruption ; and she made no
complaint, except of great weakness. The temperature on admis¬
sion was 100-4°, and rose at 6 p.m. to 101*5°. The pulse was 160,
respiration 32 (and very quiet), and at night 146 and 32. The
urine was acid, loaded with lithates, sp. gr. 1030, and contained
some albumen. With the exception of the albuminuria and the
quick pulse it looked like a case of ordinary cynanche tonsillaris ,
The following day (sixth of her illness) the temperature fell t©
97*6° in the morning, and rose to 98*4° in the evening. The pulse,
on the other hand, rose to 200, and this high rate wa3 maintained
for the succeeding eleven days.
The following chart will best explain its course : —
8
T achy car dia.
Date
1899
Jan.
17
18
19
20
21
22
23
24
25
26
27
28
Temperature
Pulse
Respira
M.,
100*4°
160
32
E,
101*5°
146
32
M.,
97*6°
200
—
E.,
98*4°
196
28
M.,
96*4°
220
— •
E.,
96*4°
216
32
M.,
96°
184
—
E.,
96°
208
34
M.,
97°
196
34
E.,
98*4°
204
32
M.,
96°
200
36
E,
98*2°
206
36
M,
97*8°
208
—
E.,
98*6°
208
40
M.,
97°
238
—
E.,
100*2°
212
30
M.,
100*2°
226
34
E,
102°
220
28
M„
98*4°
228
38
E.,
100*6°
220
38
M.,
100°
228
34
E.,
]00°
220
36
M.,
100°
228
30
Day of Illness
5
6
H
I
8
9
10
11
12
18
14
15
16
This table shows an extreme degree of tachycardia, reaching on
several occasions 228, and on three, at the hour of my visit, about
11 a.m., it rose to 240 in the minute. It was by no means an
easy thing to count the pulse at the wrist, but by palpation over
the heart and by auscultation the rate was made out with less
difficulty. The cardiac impulse was most readily felt above the
fifth rib. The radial vessel was very compressible and small at all
times, but on the last four days it became at times imperceptible.
The sounds of the heart were also very short and abrupt, the first
having lost its longer and deeper natural tone. The cardiac
dulness was normal. One of the most remarkable features was the
want of ail consciousness on the part of the patient of any heart
trouble — palpitation, irregular action, fluttering, angina, &c., and
she was able to breathe quietly, converse, and move from side to
side, and to sit up without any dyspnoea or distress. On one or
two occasions she had slight vomiting of a watery nature, the
bowels were easily regulated by an enema, and her sleep was fair.
The treatment was chiefly expectant, though quinine and tinct.
digitalis were employed, but without any effect on the heart s rate.
On 20th January (eighth day) she was feeling very much better.
She was cheerful and bright, and enjoyed a cup of tea for breakfast
9
By Dr. J. M. Finny.
and a light pudding for dinner. In fact to all appearance slie was
recovering most satisfactorily. That day the bowels moved three
times, and she slept but little in the night following. Now a
remarkable change for the worse took place. At the time of my
visit on 21st she complained of cramps in her right leg, in the calf
and the outside of the leg. Pressure of the muscles and nerves
pained greatly, and she was unable to move the toes. Over the
inner aspect there was diminished sensation, but cutaneous sensi¬
bility was exaggerated above a hand’s breadth below the knee.
Some watery extract of opium was ordered every third hour.
January 22nd. — The loss of sensation in the right leg was still
more pronounced, anaesthesia being absolute from three inches
below knee, while pain was acute behind the knee. The smallest
movement or touch caused her to cry out. The leg presented a
marbled, deep purple-red colour, measured an inch more than its
fellow, and was colder than normal. About noon she had agonising
and sudden pain in the calf of the left leg, so that she writhed in
suffering, and got no relief until two half grains of morphia were
hypodermically injected and the leg wrapped in hot cloths. It was
noticed that the left foot was like white or yellow marble, quite
cold (icy or cadaveric) and insensible to touch or pain, and motion¬
less. Across the instep and lower tibial region small superficial
veins, partly filled with blood, stood out like delicate tracery on the
waxy background. No pulse could be felt in either tibial vessel.
It was plain that dry gangrene had set in, and the toes were
already shrivelling up and withered. On attempting to extend the
toes or flex the ankle it was found to be stiff as the limb of a
corpse in rigor mortis , and this was exactly the condition, since in
24 hours the joints and muscles had become supple again.
January 23rd.— The right leg, the seat of the first thrombosis,
was deeper in colour, but the circulation was better established,
and sensation had returned three inches lower down from the
knee, while the line of demarcation was more sharply defined. On
the other hand, the left leg was further affected, and the deep
purple colour of the posterior parts of the calf now extended
above the knee for six inches, and the internal saphenous vein was
thrombosed and cordlike up to the saphenous opening. External heat
kept up the temperature of the limbs, and morphia in large doses,
frequently repeated, gave ease. The urine, which was acid all
through, contained a large quantity of lithates, and also some
albumen and blood ; sp. gr. 1038. The blood and albumen increased
on 25th January, and broken down corpuscles and granular debris
were seen under the microscope, but no tube casts. There was some
10
T achy car dia.
febrile reaction to-day — np to 100°. The left thigh measured 19f
to 17 £ in. on the right, and from the knee down dark blotches with
some dry vesicles at the ankles told that gangrenous mummification
was advancing. The toes are black and dry.
January 26th. — The ricrht leg shows improvement as to the
diminished area of insensibility, as sensation to touch has extended
down three inches on the outside, and a touch can be recognised
almost to the inner malleolus. To-day fine crepitant rales are
audible over the front of the right lung, and on January 2/th they
were over the left, and bloody sputa were brought up. She was
not disturbed to examine the backs of the lungs. The respirations
were 38 in the minute. The urine contained a little indican, and
perhaps less blood, and was of a lighter colour.
January 28th. — Without further change in the general condition
the patient died of asthenia. The painting [exhibited] , which was
taken two days before death, gives a realistic picture of the state
of the lower part of each leg.
The autopsy was made by Professor O’Sullivan, Patho¬
logist to Sir Patrick Dun’s Hospital, and by Dr. Littledale,
his Assistant in Trinity College, Dublin, to whom I am
deeply indebted also for their most exhaustive and careful
microscopical and bacteriological investigation. The fol¬
lowing was the result : —
The Heart was apparently normal ; the cavities contained soft
clots. The myocardium was perfectly healthy, and so were the valves.
The Vessels of the lower extremities.- — Exactly at the bifurcation
of the common iliacs a dry, fine, greyish-red thrombus was found ,
the right common iliac contained a very small clot, but the left
iliac, left femoral, and all its branches, were filled with a firm clot.
No thrombosis was present in the right popliteal.
Hungs and Pleurae. — Fine fibrinous exudation on the surface of
both pleurm, and haemorrhagic effusion was present in the right
pleural cavity. The branches of the right pulmonary artei y weie
thrombosed, and almost the whole of the lower lobe was consolidated
by infarcts of a dark red and black colour ; the surface of the
affected part was raised above the general level. A large infarct
was in the lower lobe.
Kidneys. — The left was normal, the right contained an infarct.
The liver was fatty and congested. The spleen small and pale.
There was a complete absence of any micro-organisms — cocci or
bacilli — in any portion of the clots or infarcts or tissues.
The Sciatic Nerves. — The left was necrosed and would not. stain,
but it was free from degeneration ; the right was healthy.
By De. J. M. Finny. 11
The Spinal Corel— The ganglionic cells in the anterior cornua
were deeply pigmented. The anterior nerve rbots were degenerated
on the left side, the posterior roots in both, but chiefly on the left side.
This last case presents a terribly sad picture of a condi¬
tion but very rarely fatal ; and naturally the question
presses, Was the tachycardia of sixteen days duration the
cause of this young and previously healthy woman s
death? Did the rapid action of the heart, and, presu¬
mably, the imperfect emptying of the ventricles and auricles
cause ante-mortem clotting in these chambers of the heart,
and thereby induce arterial embolism — almost universal ?
Or, Were the tachycardia and the cardiac stagnation
alike the result of a toxin— connected with the inflamma¬
tion of the throat and the primary fever which ushered in
her illness? Or again, Was the tachycardia an accidental
concomitant of this young woman’s illness might it have
come on at any time unprovoked ? and had the fatal throm¬
bosis no closer connection than that of pure accident ?
My own idea — it is but hypothetical — is that the primary
fever and sore throat were of either a diphtheritic or
influenzal nature; and that the “heart-hurry” wTas the
result of toxic infection of the cardiac ganglia ; that owing
to the same toxic influences — as we see in diphtheria and
fevers — the muscle of the heart became weakened, and the
thrombi -in the auricles and ventricles becoming detached
caused embolism of the various arteries throughout the
body, and, in particular, of the iliac and femoral arteries,
which led to gangrene of both legs.
The number of cases of paroxysmal tachycardia which
ended fatally are very few, and those in which post-mortem
results are published still fewer. Brieger12 states that of
30 cases there were but 2 in which a post-mortem exami¬
nation was reported, and these presented entirely negative-
results as to its pathology.
Gibson 13 — the most recent writer on heart diseases — •
states there are only 6 cases which have been examined
after death. It is not clear that Brieger’s two cases are
included among these six — presumably not. In one there
was fatty degeneration of the heart-muscle ; in two there
was chronic interstitial myocarditis ; and in three there was
cardiac dilatation. He adopts Dr. West’s view^ that the
myocardium is the seat of the lesion, and thinks the nerve
12
Tachycardia.
endings to be implicated, although no instance of any such
condition of the nerve endings has been reported.
In this connection it is interesting to note that in my
case there was a complete absence of any lesion of the
myocardium.
All observers seem to think that permanent tachycardia
is a forerunner of graver cardiac lesions. It can never be
looked upon as a favourable sign, as it signifies arrest of
the heart’s action, and leaves to be feared the develop¬
ment of symptoms of weakness and exhaustion.
Sudden death occurred in Sir Thomas Watson’s case,
also in one of Dr. Bristowe’s cases, where a young man, in
seemingly good health at the time, died while playing the
piano.
Bouveret givesB deaths out of 27 cases — 2 by syncope,
2 by asystolic collapse, the rest by pulmonary congestion
and intestinal heemorrhage.
I can find no record of any case of tachycardia in which
gangrene of the extremities occurred.
Briefer mves one case in which thrombosis of the right
jugular vein was found, and also infarction in the lungs
and kidneys, but the woman, aged thirty-three, had had
dropsy and heart troubles for many years, and was jaun¬
diced when she died, and the heart was widely dilated.12
Balfour met a case of tachycardia in a middle-aged lady,
which was preceded by severe mental emotion, and was
followed by a threatening of symmetrical gangrene of the
finger-tips ; but from this she completely recovered.
REFERENCES.
1 Brain, July, 1887, and Diseases of the Nervous System, 1888.
2 Whittaker. Twentieth Century Practice of Medicine. Yol. IY. P. 404.
3 Balfour on Senile Heart. 1894.
4 Whittaker. Loc. cit.
■r> Annual of Universal Medical Science (Sajous). Y ol. I. 1892. Wood on
Essential Paroxysmal Tachycardia.
6 Ihid'
7 La Med. Moderne, quoted in American Journal of Medical Science. 1891.
P. 617.
8 Gibson, Dis. of Heart and Aorta. 1898. P. 804.
9 Balfour. Loc. cit.
49 Herringham. Trans. Clin. Soc. Lond. Pp. 99—104. Jan., 1897.
11 Bristowe. Loc. cit.
12 Brieger. Charite Annalen, reference in Practitioner, 1889. Yol. II. P.449.
13 Gibson. Loc. cit.
Three Cases of Diabetes Insipidus.
13
Art. II. — Three Cases of Diabetes Insipidus I By J.
Lumsden, M.D. (Univ. Dubl.) ; Physician to Mercer’s
Hospital.
Haying had the singular good fortune to have had during
the past year under my care at Mercer’s Hospital three
cases of what I regard as genuine examples of diabetes
insipidus (that form spoken of as hydruria by Ralfe), and
as the affection is undoubtedly a rare one, which is proved
by the fact that only eight cases appeared in the London
Hospital Records from 1876 to 1895, and Ralfe, who wrote
the article in Clifford Allbutt’s “ System of Medicine,” only
collected sixty-nine authentic cases, and Roberts seventy-
seven, I therefore thought the notes of my two cases
would be of some interest to this Section, although I have
little fresh to add in throwing light on the setiology or
pathology of the affection. My third case I owe to
the courtesy of Dr. Burgess, who kindly allowed me to
take her into hospital, the full notes of which case you
•/
may remember were read in an interesting paper by Dr.
Burgess two years ago at a meeting of this Section.
Case I. — M. M., aged nine years, admitted June, 1898; family
history unimportant. His father, a healthy labourer, died from
influenza after a few days’ illness. Mother, a charwoman, is
apparently healthy ; several healthy brothers and sisters living. I
could discover no history of any constitutional delicacy in any
branch of the family after careful inquiry. The boy is fairly
well nourished, blonde, of a fresh, healthy complexion, bright, clear
eyes, and fairly moist skin. He has a right inguinal hernia, which
was unsuccessfully operated on five years ago, and he at present
wears a truss. Tongue and lips very dry, and he complains of an
insatiable thirst ; appetite very poor ; vomits occasionally after
solid food ; urinates frequently, and shivers very often before
micturition. Physical examination reveals no abnormality ; heart’s
action somewhat irregular and excitable ; pulse intermittent at
times, of low tension, its rate varying from 75-110. Complains
frequently of headache, which is sometimes very severe, causing
him to cry, and lasting for nearly a day at a time ; is not referred
to any particular part of the head. He is of an excitable and
a Read before the Section of Medicine, in the Royal Academy of Medicine
in Ireland, on Friday, May 19, 1899.
• 14 Three Cases of Diabetes Insipidus.
emotional temperament; flushes up when spoken to. Increased
patellar reflexes ; quadriceps reflexes slightly present, and an
attempt at ankle clonus ; sensation normal ; temperature normal,
sometimes subnormal.
About six or eight months ago it was first noticed he was
drinking large quantities of water ; it apparently came on
gradually, and did not follow an illness or accident, although a
history of a fall on left side of head three or four years ago is to
be obtained. His thirst became greater, and if clean water could
not be found he would drink milk, buttermilk, and even the soapy
water from his mother’s washing tubs. As far as I can gather, the
polydipsia first appeared on admission; he drank from 560 to 660
ounces of fluid in twenty-four hours ; the greatest quantity con¬
sumed in one day being 860 ozs. = 43 pints. Subsequently when
his allowance was restricted in amount he would run to the bath¬
room when the nurses’ backs were turned and drink from bath tap,
and on two occasions he was seen to drink his own urine. He
invariably drank more than he passed ; the amount passed, however,
was hard to measure accurately, as he frequently wet his bed. He
voided from 500 to 600 ozs. in 24 hours, the greatest quantity
measured for one day being 750 ozs. (37 pints). The urine was of
a pale greenish or bluish colour, alkaline, or very faintly acid in
reaction; sp. gr. 1001-1002. No albumen or sugar was ever
discovered, although daily examined for a peiiod extending o\ei
five months. No increase of phosphates, and nothing abnormal
found microscopically. The urea varied in amount from 150 to
600 grains in 24 hours, and calculating from Ealfe’s table of
physiological urea excretion estimated from weight and age, which
takes into account the active nitrogenous metabolism of youth, the
amount voided at first was distinctly excessive, especially as at
that time his appetite for albuminous and solid food was very poor,
his diet being entirely milk. Eyes examined by Mr. Story revealed
no abnormality ; blood normal. His tonsils, which were chroni¬
cally enlarged, were removed by Mr. Maunsell, and post naso¬
pharynx cleared of some adenoids which existed.
In this case result of treatment ivas altogether disap¬
pointing, although when finally discharged last February
his general health was wonderfully improved, weight
increased, appetite good, and all symptoms disappeared;
yet the polyuria and polydipsia were still excessive-
drinking from 300 to 400 ounces, and passing about 300
ounces daily.
15
By Dr. J. Lumsben.
During his stay in hospital I tried him with the follow¬
ing treatments : — Infusion valerian, valerianate of zinc
(i grain thrice daily to 12 grains in 24 hours), bromides,
arsenic, ergot with iron, cod-liver oil and tonics, antipyrin,
opium, codeia, belladonna, guaiacol, galvanism, phosphoric
and nitric acids, and blisters to nape of neck and epigas¬
trium. Some of the drugs in this very formidable list
appeared to give some temporary relief, but nothing more,
and his improvement, such as it was, I attributed to the
effects of hospital life, and the altered hygienic surround¬
ings and good food.
Case II.— P. R., aged sixty-four years, labourer, admitted
March, 1899. Family history good. Father and mother lived to
be over eighty. Three healthy brothers living. Has been a very
heavy drinker (of stimulants), chiefly beer, all his life. He says
for the past twenty years he has complained of excessive thirst and
frequent micturition ; it came on without any apparent cause ;
latterly has become more excessive. Ten years ago he states he
was in the habit of drinking upwards of twenty pints of beer daily.
He gives a history of a violent blow on the head which rendered
him unconscious for some hours twenty years ago, and it was
immediately after this he first noticed the polydipsia. Since then
he has had several falls on his head, but none apparently of a
serious nature.
In appearance he is a healthy, vigorous-looking man, 12 st. 4 lbs.
in weight, of ruddy complexion, healthy aspect.
He has lost nearly a stone during past few months. Skin very
dry ; complains of dryness of mouth ; no excessive flow of saliva;
tongue covered with a dark brownish fur ; bowels regular ; sleeps
well, and appetite good, but not excessive. Physical examination
reveals no abnormality except a musical symbolic murmur occa¬
sionally to be heard at the heart’s apex. No cardio-vascular
evidence pointing to granular kidney. Heart’s impulse feeble.
Pulse 72, regular, and of distinctly low tension, and no evidence
of hypertrophied walls. Pupils equal. Reflexes sluggish. Com¬
plains of frequent occipital headache, and pains in lumbar region,
the former very acute at times. Quite contented while allowed to
stay quiet and in bed, but complains of being easily tired and
feeling nervous when up ; occasionally complains of nausea, though
never vomits. Thirst is excessive, drinking from 260 to 360
ounces in twenty-four hours, and passing about twelve pints of a
16 Three Canes of Diabetes Insipidus.
pale-coloured urine ; density 1003; very faintly acid or neutral;
no albumen ; no sugar ; inosite is present. No casts or other
morbid product to be discovered microscopically. Urea from 240
to 516 grains in twenty-four hours.
Dr. Story reports commencing cataract left eye. Signs of chronic
glaucoma ; visible pulsation of vessels without any signs of neuritis
or retinitis.
His age, alcoholic history, occipital headache, and polyuria
naturally makes one suspicious of granular kidney, but careful and
repeated examinations fail to detect the presence of albumen or
tube casts ; this with the low tension pulse, the absence of all
ocular and cardio-vascular symptoms, the degree of polyuria which
is in excess of that generally associated with contracted kidney,
appear to me to justify the diagnosis of diabetes insipidus. Since
his admission he has been tried with valerianate of zinc, inf us.
valerian (double strength), phenazonum and nitric acid ; the former
diminished the polyuria and polydipsia by half, but did not reduce
to normal.
Dr. Burgess has very kindly given me permission to
mention the following case, the notes of which have
already been read by him before this Section : —
Case III.— A girl aged seventeen. History of a severe fall on
the back of the head four years ago, shortly after which polyuria
and polydipsia appeared. She used to drink upwards of twenty
pints daily. When admitted under my care she was passing and
drinking about fourteen pints daily. No symptoms of granular
kidney whatever. Pulse distinctly low-tensioned. Urine , light
greenish colour ; sp. gr. 1002, neutral ; no albumen ; no glucose ;
no inosite. Urea greatly decreased in quantity.
I tried her first on several drugs without any improvement
resulting. I finally ordered valerianate of zinc, commencing Jgr.
thrice daily, and increasing gradually till she was getting 22 grs.
in twenty-four hours. After a week of this treatment the amount
of urine voided began to diminish gradually, and at the end of a
month it had reached the normal for the first time since the affec¬
tion declared itself. She remained in hospital subsequently for
over a month, the treatment being continued for a week or two
and gradually withdrawn. She has been under my constant
observation ever since, and has been taking syrup of the iodide of
iron and cod-liver oil. Her general health has much improved.
She has put on weight, and has been drinking and passing a
normal quantity of fluid. How long this normal state will last, or
17
By Dr. J. Lumsden.
whether she will relapse, I cannot say ; but I think it is very inte-
’esting to note the marked improvement while on the drug given in
increasing doses.
The same drug in my other cases, although apparently
causing some improvement at first, finally had to be
stopped, either because it disagreed or failed to reduce the
passage of urine to the normal limit.
Diabetes insipidus is apparently a very rare affection —
its astiology varied, little known of its pathology, its treat¬
ment unsatisfactory, and its course uncertain ; sometimes
influenced by treatment, and even cured ; at other times
persisting for a number of years, without any visible dete¬
rioration of health beyond a feeling of weakness and
general malaise ; and sometimes running an acute course,
terminating fatally in a few months ; and sometimes the
affection disappears of its own accord untreated.
Its origin is evidently nervous, and is supposed to result
from a want of inhibitory control of the vaso-motor renal
nerves. Injury to the nervous system, such as a fall or
knock on the head, a violent emotion, such as fright or a
sunstroke, is its not infrequent antecedent. Tumours of
the brain, and lesions chiefly about the neighbourhood of
the fourth ventricle, have been met with in several cases,
and it will be remembered in one of Bernard’s famous
experiments on animals puncture of a certain spot in the
floor of the fourth ventricle near that region, injury of
which causes glycosuria, produced polyuria.
The most reasonable view, as expressed by Osier, is —
that it results from a vaso-motor disturbance of the renal
vessels, due either to —
1. Local irritation, as in a case of abdominal tumours ;
or to
2. Central disturbance, in the case of brain lesions ;
or to
o. Functional irritation of the centre in the medulla,
giving rise to a continual renal congestion.
Clinically it may be divided into five forms —
1. That in which the aqueous superflux is most
marked — called hydruria (by Willis).
B
lft Widal’s Reaction in Typhoid Fever.
2. Cases attended with a copious discharge of urine
with a deficiency of urea — anazoturia.
3. Cases accompanied by a superabundance of urea —
azoturia.
4. A form described by Tessier as phosphaturia,
or phosphatic diabetes, which he distinguished
from azoturia. This form is associated with
certain dyspeptic conditions, and is characterised
by a considerable increase in the excretion of
phosphoric acid in the urine, while the urea is
not increased in amount.
5. And lastly, a form described by Dr. Fuller, and
called by him baruria, which is characterised by
a general increase throughout of the solid
urinary constituents, whilst the acpieous secre-
tion remains tolerably constant.
Art. HI .— Clinical Investigations on Widal’s Reaction as a
Diagnostic in Typhoid Fever? By H. E. Littledale,
M.B. ; Assistant in the Pathological Laboratory, Trinity
College, Dublin.
During last year, while Besident Medical Officer in Sii E .
Dun s Hospital, I had the opportunity of making clinical
investigations on what is generally known as Vi idal s test
for enteric fever, and examined the blood of 120 cases of
different kinds. I must, however, specially mention that it,
was the clinical diagnostic value of the test and nothing else
that I wished to try.
The methods I adopted throughout were briefly these.
A tube of bouillon was inoculated with typhoid bacilli fiom
a stock agar culture, and kept at 37 G. for from 8 to 20
hours, and examined just before use to see that the bacilli
were active and free from clumps. Blood was drawn from
the patient’s ear lobe by making a stab with a needle and
squeezing out the blood into sterile glass tubes, which I made
over a Bunsen burner, and the ends of the tubes were then
sealed in the Bunsen flame. When the serum separated out
a Read before the Section of Medicine, in the Royal Academy of Medi¬
cine in Ireland, on Friday, May 19, 1899.
1 %
By Mr. H. E. L ittle dale.
it was expelled from the tubes on to a large sterilised micro¬
scope slide by breaking off one end of the tube and heating
the other in the flame. The slide was sterilised simply by
heating it in the flame, and then letting it cool. On the
other end of the slide a certain number of the typhoid
bouillon drops was measured out with the platinum loop, the
loop then heated out and let cool, and a drop of the blood
serum taken up on it, and mixed with the bouillon. A
hanging drop was then made from this mixture and examined
with a Leit.z No. 7 objective immediately, and at varying in¬
tervals up to two hours, and sometimes longer. At first I
used to take the blood on filter paper, let it dry, and get the
serum by rubbing up the dry blood stained part with sterile
bouillon, but I gave this up, as it was impossible to estimate
what proportion of serum one had in the solution. The
results I obtained I classified into positive, negative, and
doubtful : positive results being those in which the most
of the bacilli were matted together into clumps appearing
in a typical case about one-third the size of a threepenny
piece with a Leitz 7 objective 3 eye-piece and 170 mm. tube
length. Besides this clumping action, the motion of the
bacilli was usually very considerably slowed, but this is not
always so, as I came across some undoubted typhoid cases
of a severe clinical character, in which the unclumped bacilli
remained exceedingly active for hours ; and again, there w'ere
a few cases not typhoid which caused extreme slowing of
motion in the bacilli, but no clumps. I also considered a
result positive when the clumps were very much smaller
than those above-mentioned, but very few bacilli left un¬
clumped.
A doubtful reaction I considered was one in which a few
small, loose groups of bacilli formed, usually with slowing of
motion, but no, or at all events very few, typical clumps.
By groups I mean masses of bacilli lying rather side by side,
and not in the tangled mass that a clump is, and from which
bacilli occasionally disengaged themselves, and wandered
away.
A negative reaction was one in which there was no trace
of clumping. The maximum time limit I adopted was two
hours, and if no clumping had taken place then I considered
20
Widal's Reaction in Typhoid Fever.
the reaction negative, but I occasionally did not get time to
examine the hanging drops after two hours, and sometimes
had to do it after as late as three hours or later.
This is my own standard, which may, of course, be a
fallacious one. The proportion in which the blood serum
and bouillon ought to be mixed to give a standard reliable
result is a very doubtful question. At first I used to use
what I called a 1 to 9 dilution— that is, one drop of blood serum
mixed with 9 drops of bouillon— but Durham and others have
shown this to be fallacious, and my own experience is that it
is useless clinically except where it gives a negative result.
I then adopted a 1 to 39 dilution, but I think this is also
open to error, though to a much less degree, as I only had two
cases which were not typhoid which gave a doubtful reaction
with this dilution.
Throughout the entire series of investigations I used the
same stock culture of typhoid bacilli growing on agar.
I shall now describe the results obtained from a clinical
point of view, and to do this I have necessarily had to
arrange them under several different headings.
The first series is one of 42 cases, which were clinically
undoubted typhoid, and usually obviously diagnosticated on
admission. Every one of these cases gave an absolutely
positive Widal reaction. Some, however, were only tested
with the i dilution, but most of them with the 3V dilution.
All of these cases were in the second week of the disease or
later, with the exception of five, two of which were on the
fifth day, one on the sixth, and two on the seventh day of
illness. These were the only cases in which I was certain of
the early date of the disease, and all of them were tested
with the At dilution, but I am unable to say if the reaction
can be obtained earlier than the fifth day.
The second series is one of nine cases which were clinically
doubtful, either for a time or throughout the entire stay in
hospital, while the Widal reaction was absolutely positive in
every case. I shall give a very short account of each ot
them.
The first case was a man who was admitted with the
symptoms rather of rheumatic fever than of typhoid, with
severe pains and swelling in his shoulder joint, but the
21
By Mr. IT. E. Littledale.
onset of his illness and its subsequent course was very like
typhoid. He had, however, no diarrhoea, and had only two
spots resembling typhoid rash. His spleen was considerably
enlarged. He gave an absolutely positive Widal result in
the third and fourth weeks, but he was taking salicylate of
sodium when the test was applied, and I do not know whether
that may not cause clumping.
The second was a case which turned out an obvious typhoid
case, but had no signs of typhoid fever, except high tempera¬
ture for several days after a positive test result was obtained.
The third case, similar to the last, proved to conclusion
post-mortem.
The fourth case was also similar to the second.
The fifth case, sent in late one evening as scarlatina, with
very sore throat and slight redness about the neck, gave an
absolutely positive result that night, and turned out to be an
obvious typhoid case, and not scarlatina.
The sixth case, sent in during what was stated to be the
third week of illness, gave an absolutely positive result on day
of admission. He never developed any typhoid signs, except
rather severe bronchitis and delirium, and his temperature
dropped by crisis eleven days after admission, and remained
normal till he went out.
The seventh was a case I know nothing of clinically, but
was, I believe, a very doubtful one : the reaction, however, in
the second week was quite positive.
The eighth case was admitted with a history of several
weeks' illness, with absolutely no sign of typhoid, except a
slight rise of temperature, which reached normal a few days
later, so this case was evidently at the end of his illness on
admission, also absolutely positive Widal.
The last case was one which never had any signs of typhoid
but headache and an irregular temperature for three weeks
after admission, but gave absolutely positive results on several
occasions.
All of the cases which remained doubtful throughout
were examined with the ^ dilution, but except in the
case of the last, I do not know if they ever had typhoid
before. The last-mentioned case never had any illness
before that he could recollect.
22 Widal’s Reaction in Typhoid F ever.
The next series is one of eight cases in which the
elinical diagnosis was doubtful; the Widal reaction was
also doubtful. Most of these cases were examined only
with the dilution, and several of them can hardly be
considered doubtful, but I think it best to put all cases m
a separate group when there was any sign, however small,
of clumping.
The first case was a boy with symptoms very like
typhoid, but without any diarrhoea, spots, or enlarged
spleen. He, however, developed physical signs of pneu¬
monia, three days after admission, in right upper lobe,
and temperature started to fall by a very slow crisis next
day. He never had any symptoms or physical signs of
pneumonia prior to this. Widal on fourth day, ^9 dilution ;
20 hours active culture gave, as result, no effect after one
hour ; after two hours, motion quite active ; a few small
clumps. Same on sixth day. On sixteenth day -9- dilu¬
tion, nine hours very active culture, a few clumps, and
motion slowed after two hours. No change aftei two and
a half hours with dilution.
The second case was a man aged fifty-three, which no
one would ever have diagnosticated as typhoid from his
symptoms and signs. He came to the dispensary some days
before admission with headache, and history of being ill
for several days, with marked constipation. His tempera¬
ture was 100 F., but he refused to come in that day.
Three days later, however, he was admitted, with a
temperature of 100’4° F., thickly-coated tongue, bowels
moving only very slightly, but no other symptoms 01
signs, except a feeling of incapacity to work. His tem¬
perature fell to normal the day after admission, and re¬
mained so for two or three days, then rose again to 101 1 .
for two days, and after wavering about 100 F. for a week
longer, it ultimately became quite normal. Constipation
seemed to be the cause of his illness, as when his bowels
were got into regular order he got quite well. He never-
had any illness before, except “fever and ague,” 30 years
previously, rn Mauritius. On srxth day of rllness, wrth a
ten-hour very active culture, dilution, there was an
immediate formation of a few small clumps, and the motion
By Mr. H. E. Littledale. 23
was slowed, but it was just the same three hours later — a
conditiou I never saw in undoubted typhoid, as the clumps
always increased in size and number. A J dilution gave
immediate formation of small clumps, which became very
much bigger after two hours.
Examined again on the 10th day with a 20 hours very
active culture, dilution, the motion was unaffected, and
only a few small clumps formed, and one or two large groups
after three hours.
The next case was one which gave doubtful reactions on
several occasions with 1 dilutions, hut absolutely negative
with ^ dilution. This case had a very typhoid-like onset,
and when I saw her on admission she looked a very probable
typhoid case, but beyond headache, constipation, coated, dry
tongue, and high though irregular temperature, she never
developed any other signs of typhoid, and after running a
course of about four weeks with this irregular temperature
she became convalescent, and was soon quite well.
I have since heard that she now has a slight cough and
pain in her side — that is, eight months after the above attack.
80 it may possibly be an obscure tubercular case.
As all the other doubtful reactions were only examined
with the J dilution I shall not detail them, as such results
are of no value, as the previous case well shows.
The fourth series consists of 20 cases which were clinically
doubtful, in which the Widal reaction was absolutely negative
even in J dilution. Some of these cases were treated as
typhoid for safety sake in spite of the Widal reaction, and
quite rightly 1 admit, but this shows their close resemblance
to typhoid, although no single one of them was a typical
typhoid case.
I shall just cite one of these cases as it shows the value of
the Widal test. This was a case of a child with acute
tuberculosis which came in with a history exactly like typhoid,
and a temperature of 104*0° F. The case wTas diagnosticated
acute tuberculosis chiefly from the extreme cyanosis, out of
proportion to any of its physical signs. There was, however,
profuse diarrhoea, large spleen, distended abdomen, but no
spots.
After two weeks the child died, and general tuberculosis
24
Widal’s Reaction in Typhoid Fever .
was found post mortem , and no sign of typhoid lesions. 4 he
Widal reaction was absolutely negative, even with 1 in 10
dilution. I think we have here an instance of the value of
the test when we can separate with certainty acute tuber¬
culosis from typhoid.
The fifth series was 28 cases, medical and surgical— in
fact any case wdiich had no suspicion of typhoid and m e\eiy
one of them with a i dilution the result was negative.
The sixth series is one of five typhus cases, all of which
gave an absolutely negative result. One of them, however?
is worth citing, as it shows the uselessness of the J dilution.
This was a man who had been two weeks ill. who had every
possible sign of typhus. I only saw him ooce with Di.
Falkiner, so cannot relate the subsequent course of his case.
Examined in the second week, this man gave an absolutely
negative reaction with a dilution, and an equally
absolutely positive one with the J dilution, the same culture
and serum being used in both cases, and the tests applied
just after each other.
The seventh series consists of three cases supposed to
have had typhoid two years, six years, and four months ago,
all of which gave an absolutely negative result.
The last group is a curious one, and consists of three
diphtheria cases.
The first was a case being treated with antitoxin, the last
dose of which had been given ten days previously. This
case gave an absolutely negative result with J and ^
dilutions.
The second case had received its last dose of antitoxin
three days previously. Examined with a 40 hours culture?
which, however, was very active and free from clumps, and
_i_ dilution gave an immediate slowing, almost cessation, of
motion, and few small clumps. My only subsequent note,
however, is “ very large clumps ten hours later.” With J
dilution motion was stopped and very large clumps were
formed, which were visible to the naked eye an hour later.
The next case had received 3,000 units of antitoxin eleven
days previously ! typhoid culture, very active ; ten hours old ;
i dilution gave immediately great slowing of motion and
large clumps, one hour later the unclumped bacilli appeared
25
Bv Mr. H. E. Littledale.
rather more active ; J dilution gave immediate cessation of
motion, and enormous clumps quite filling up the field.
I next examined two bottles of antitoxin serum as to their
agglutinative capability, having first proved the serum quite
sterile. With the first bottle I merely mixed one drop of
serum and one of bouillon together, and the result I find I
have notified is “cessation of motion and clumps after two
hours.” The second bottle I tested with a J dilution — i.e., one
serum, nine bouillon— and the immediate result was slowing
of motion, no clumps ; two hours later, however, there were
numerous large and small clumps.
This agglutinative action is, I believe, common to the
blood serum of horses in general, and not merely those that
are immunised to diphtheria.
I have now concluded the list of cases which I examined,
and I shall merely say a few words as to what I consider
from my small experience the test is worth clinically, and
also mention a few practical points in connection with its
application.
The most valuable and reliable results which the test
gives is its negative value, and, as far as my experience
allows me to judge, I think if a case gives a negative result
absolutely in the second week one may be certain that it is
not typhoid.
As to the doubtful results, I believe they can be eliminated
by using higher degrees of dilution and as young a culture
as one can get. A six hours old culture is the earliest I
have ever used, and, if all conditions are favourable, an
actively growing culture should be obtainable in this time.
There will, however, I am afraid, always be cases which are
on the border line between positive and negative, and no¬
thing but long experience and absolute ignorance on the
part of the investigator as to the clinical course of the case
will enable him to make up his mind, as it is impossible to
give an impartial opinion when one is absolutely certain that
a case is or is not typhoid clinically. It is for this reason
that I have cited more or less in detail the results clinically
and to Widal of the doubtful cases.
In conclusion, I shall just say a few words more about the
methods of applying the test. Objections will be raised to
26
Widal’s Reaction in Typhoid Fever.
my method of mixing the typhoid bouillon and serum owing
to the difficulty of getting a drop of constant size in the
platinum loop, but this may be avoided and a uniform drop
obtained by getting the loop quite full, and just let the drop
touch the slide, and by this means a uniform drop is always
obtained. Other methods in use consist in drawing up
definite quantities of blood serum and typhoid bouillon
into graduated capillary tubes, and mixing them as in
Thoma’s hasmocytometer ; or a better method is first to
dilute the serum, say twenty times, with sterile bouillon,
and then mix a drop of it with an equal quantity of typhoid
bouillon to get a dilution.
Personally I do not think these methods are sufficiently
superior to the one I use to counterbalance the extra amount
of trouble they entail.
A point one must be careful about in applying the test as
I do is to be certain that the glass slide on which the serum
and bouillon are to be mixed is quite cool, which takes
several minutes after it has been heated for sterilisation in
the flame.
The best method, I think, to get the serum from the
tube — especially when one gets it in a vaccination-tube, and
has only a limited amount at one’s disposal — is to break off
one end of the tube, hold the other end in a forceps, and
hold a platinum loop edgeways to the broken end; then
warm the other end gently in a spirit lamp flame, not a
Bunsen burner, as it is too hot, and sends the serum out
with a spurt. In this manner all the serum necessary will
be caught in the loop.
Lecture on the Cerebellum.
27
Art. IY. — Lecture on the Cerebellum .a By J. S. Risien
Russell, M.D., F.R.C.P. ; Assistant Physician to Uni¬
versity College Hospital, and to the Rational Hospital
for the Paralysed and Epileptic, Queen Square, London .
Tt has been sugg*ested to me that a brief account of some
of the chief results, the outcome of my experimental work
on the cerebellum, would be likely to be acceptable to the
members of this Club, and that it would be well for me to
indicate, as far as possible, what practical bearings these
results have on the localisation of cerebellar disease in man.
I propose, therefore, in the first instance, to ask attention
to a few points in regard to the functions of the cerebellum,
which are chiefly of interest to the physiologist, and I shall
subsequently deal rather more fully with the experimental
results which have a practical bearing on cerebellar locali¬
sation in man, and which are therefore likely to be of more
interest to those of us, who-, as physicians and surgeons,
have to deal with diseases of the cerebellum.
In the course of my experiments it was necessary for me
to produce various lesions of the cerebellum, the nature of
some of which I show you by the aid of lantern slides which
Prof. Scott will be kind enough to throw on the screen.
Monkeys, dogs and cats have been used in the course of my
investigations, but in that the most satisfactory results are
obtained in the dog, I propose to show you photographs only
of the lesions in that animal. The first slide is merely that
of the normal cerebellum of a dog, which is shown with
a view to refresh our memories with regard to the
conformation of the organ in this animal. The following
slides indicate some of the lesions produced during the
course of the inquiry: — Total ablation of the organ, re¬
moval of a part or the whole of the middle lobe, ablation
of one lateral lobe or of one lateral half of the organ, includ¬
ing one lateral lobe and the corresponding half of the
middle lobe.
The time at my disposal will not allow of my discussing
the questions which arise out of the results obtained by all
of these operative procedures, so that we must content
a Delivered at a meeting of the Dublin Biological Club, on Tuesday,
April 11, 1899.
28
Lecture on the Cerebellum.
ourselves with a consideration of the phenomena which are
met with after ablation of one lateral half of the cerebellum
(see Fig. 1).
Of the results that are obtained by such a procedure,
and which are more exclusively of interest to the physio¬
logist, none is more striking than the effect which the
ablation of the half of the cerebellum has on the excitability
of the cortex of the opposite cerebral hemisphere. Two
methods were adopted to test this : (1) The administration of
absinthe by intra-venous injection so as to evoke general
convulsions (I may remind you that in evoking such
convulsions absinthe exerts its chief influence on the cere¬
bral cortex) ; and (2) Excitation of the cortex cerebri by
means of the faradie current.
In order that you may appreciate the effect which removal
of one-half of the cerebellum has on the excitability of the
opposite cerebral hemisphere, as evidenced by the character
of the convulsions evoked by absinthe under such circum¬
stances, it is necessary for me to first show you tracings of
the convulsions evoked by absinthe in a normal animal
whose cerebellum is intact. It is further necessary for me
to explain how the tracings which I am about to show you
were obtained.
To deal with the latter point first, it may be
said briefly that the animal being under the anaesthetic
influence of ether, the extensor muscles of the fore limbs
were connected by means of strings with two of Marey s
spring myographs of equal strength, the writing points of
which were made to record on a blackened surface of paper
stretched between two revolving cylinders, which were kept
in motion by means of a clock. On this blackened travel¬
ling surface were recorded the contractions of the muscles
during the convulsions evoked by absinthe, the essential
oil of which was injected into the external jugular vein of
one or other side of the neck in doses of two to five
minims as the occasion required. Every care was, of course,
taken to make the conditions as far as possible similar on
the two sides in so far as the apparatus used was concerned.
Tracings thus obtained from the muscles of the fore limbs
of the normal animal show that the behaviour of the muscles
during the convulsions is similar on the two sides, and the
DR, RISIEN RUSSELL ON “THE CEREBELLUM,”
Fig. 1.
DR. RISIEN RUSSELL ON “THE CEREBELLUM
rl
Plate II.
Fig. 2.
By Dr. J. S, Bisien Bussell. 29
curve is seen to be made up of initial clonic contractions,
followed by a long period of tonic contraction, which in its
turn gives way to a few terminal clonic jerks (see Fig 2).
You will readily observe from the tracing I next show
that the most remarkable alteration is brought about in
regard to the behaviour of the muscles of the two fore limbs
when one lateral half of the cerebellum has been removed.
Instead of the curves as obtained from the two sides being
similar they are markedly dissimilar, and indicate that the
convulsions in the muscles of the limb on the side of the
cerebellar lesion are much in excess of those of the opposite
side, and that there is not only this excess in regard to the
convulsions on the side of the lesion, but an actual diminu¬
tion in the convulsions on the opposite side, as evidenced by
the records obtained from the extensor muscles of the
fore limb (see Fig. 3). But it requires no specially careful
scrutiny of the tracings to convince you of another striking
change from the normal, that has been brought about by
the ablation of the half of the cerebellum ; clonic spasm now
completely replaces the tonus observed at a certain stage of
the convulsions in the normal animal, in so far as the con¬
vulsions on the side of the cerebellar lesion are concerned.
There is thus an exaggeration of the amount of muscular
contraction in the fore limb on the side of the cerebellar
lesion, in addition to which the tonic stage of the normal
convulsions has been completely obliterated by clonus of
the most exaggerated character.
This result, though striking, does not absolutely prove
that the excitability of the cortex of the cerebral hemi¬
sphere of the opposite side to that from which the half of the
cerebellum has been removed is increased, therefore it
became necessary to test the excitability of the cortex on
the two sides by means of the faradic current. By this
means it was found that whereas normally a current of
about the same strength is required to evoke contraction
in the muscles of the twro sides of the body, according as one
or the other cerebral hemisphere is stimulated, after ablation
of one lateral half of the cerebellum the strength of current
required to evoke a response on excitation of the opposite
hemisphere is considerably less than that required to evoke
a response from the cortex of the cerebral hemisphere on
30
Lecture on the Cerebellum .
the same side as the cerebellar ablation. Moreover, it was
found that this difference in the excitability of the two
cerebral hemispheres is due largely, at any rate,
to an increase in the excitability of the cortex of
the hemisphere opposite to the side of the cerebellar
lesion. And in so far as this increased excitability
is evidenced by the amount of resulting muscular
contraction you will remember that such evidence is to be
looked for in the behaviour of the muscles of the limb on
the side of the cerebral lesion, in that the relation of a
cerebral hemisphere to the muscles of the limbs is a
crossed one, the right cerebral hemisphere, for instance,
being concerned chiefly with the movements of the left
limbs. This being so then, the removal of the left half of
the cerebellum induces a state of increased excitability of
the cortex of the right cerebral hemisphere ; this increased
excitability is manifested by the mode of behaviour of the
muscles of the left limbs — that, is, those on the side of the
cerebellar lesion.
It would thus seem that normally the one half of the
cerebellum exerts an inhibiting or controlling influence on
the neurons of the cortex of the opposite cerebral hemi¬
sphere, and that with ablation of the half of the cerebellum
this influence is removed, and increased excitability of the
opposite cerebral cortex results.
If we next turn our attention to the consideration as to
whether there is any way by which such influence's can
reach the cortex of the opposite cerebral hemisphere from
one half of the cerebellum we find that there is such a path
by way of the superior cerebellar peduncle. After ablation
of one half of the cerebellum the fibres of the superior cere¬
bellar peduncle on the same side degenerate, and these
degenerated fibres when traced brainwards are found to
decussate, and some of them are found to terminate in the
region of the opposite red nucleus, while the remainder tei-
minate in the opposite optic thalamus ; no such degeneiated
fibres having been traced to the cortex of the opposite cere¬
bral hemisphere. "While there is thus no direct path to the
opposite cerebral cortex, there is an indirect one through
the optic thalamus.
There thus appears to be evidence that ablation of one
DR. RISIEN RUSSELL ON “ THE CEREBELLUM.”
Plate III.
Fig. 3.
DR. RISIEN RUSSELL ON “ THE CEREBELLUM.”
Plate IV.
Fig. 4.
31
By Dr. J. S. Risien Russell.
tJ
half of the cerebellum abolishes some inhibiting influence
which is normally exerted by the cerebellum on the cere¬
brum, and that the path by which such impulses may
travel is the superior cerebellar peduncle ; but another
possibility has yet to be considered and negatived before we
are in a position to conclude that the explanation that
has been offered, and which seems most probable, is in
reality the correct one. The possibility to which I refer is
that the phenomena observed after ablation of the half of
the cerebellum, both on electrical excitation of the cere¬
bral cortex and on the administration of absinthe, may in
reality indicate that some inhibiting influence normally
exerted by the cerebellum on the neurons of the anterior
horns of the spinal cord, has been removed and thus allows
of the excessive discharge during the absinthe convulsions
and the increased response on electrical excitation of the
cerebral cortex.
This possibility is, however, negatived by the results
obtained on section of the inferior cerebellar peduncle,
including the so-called sensory tract of Edinger — the most
probable path by which any inhibiting influence from the
cerebellum can be expected to reach the anterior horn cells
of the spinal cord.
If the phenomena are to be accounted for by the removal
of an inhibiting influence exerted on the anterior horn-cells,
section of the inferior peduncle of the cerebellum ought
to be attended by similar phenomena to those observed on
ablation of the half of the cerebellum, instead of which a
totally different state of things obtains under such circum¬
stances. On evoking convulsions by absinthe after section
of the inferior peduncle, instead of the muscles of the fore
limb on the side of the lesion responding to a greater
degree than those of the opposite fore limb, there is a total
absence of any contraction of the muscles of this limb (see
Eig. 4). We have, therefore, this striking result that not
onlv is there not an excess of convulsions in the muscles of
«y
the fore limb on the side of the lesion, but that there is
actually a total exclusion of all convulsions from the
muscles of this limb.
This must suffice as regards questions of chiefly physio¬
logical interest, and in the time that remains at my disposal
32
Lecture or the Cerebellum.
I propose to call your attention to those points which
concern us more nearly in our clinical work, as physicians
and surgeons, in one of the most difficult clinical problems
with which we may at any time be confronted: viz., the
localisation of the seat of a lesion in the cerebellum.
As in the case of the question of more purely physio¬
logical interest, so here time will allow of my dealing only
with the phenomena consequent on ablation of one lateral
half of the cerebellum. I choose this rather than any other
aspect of the question, in that the problem we have most
frequently to solve clinically, in regard both to abscess and
tumour of the cerebellum, is which side of the organ is
affected.
The attitude is a very striking one, both as seen in
animals after ablation of half of the cerebellum and as
may be seen in man with a unilateral lesion of the organ.
The head is inclined to the side of the lesion so that the
ear and shoulder are approximated to each other, added to
which there is arching of the spinal column laterally
with the concavity of the curve to the side of the lesion.
In man the head may furthermore be rotated on its vertical
axis so that the chin points to the healthy side, that is
away from the side of the cerebellar lesion. Characteristic
as is this attitude, and valuable as it may prove to be in our
attempts at cerebellar localisation, it is robbed of no small
amount of its value owing to the fact that in certain cases
of cerebral tumour the same attitude has been present. In
some of these it is possible that the explanation of its
occurrence is to be found in the fact that there lias been
more or less direct pressure on the superior cerebellar
peduncle, but in other instances the growth has been too
far removed from this structure to allow of this explana¬
tion being regarded as at all likely to be the correct one.
Rotation of the subject about its longitudinal axis is a
phenomenon sometimes observed after ablation of half of
the cerebellum, but it is very rarely met with as a result
of cerebellar disease in man. The direction of rotation is
best described in terms relating to a screw, in that endless
confusion arises when we attempt to describe it in any
other way, notably as from right to left or left to right. A
very little consideration will be sufficient to make it obvious
By Dr. J. S. Bisien Russell. 33
to you that unless specifically stated to which they refer,
there must be a doubt as to whether right and left are used
in regard to the observer or observed, a distinction that is
important in that what is right to left if the terms relate
to the observer, is left to right if the terms relate to the
observed, unless the observed and observer be supposed to
be both facing in the same direction. Similar and other
difficulties arise when we attempt to describe the direction
of rotation in other ways, including the mode which finds
most favour with physicists: — viz., clockwise and anti¬
clockwise. Time will not, however, allow me to enter into
greater detail with regard to this matter; I must content
myself with briefly pointing out to you how rotation in
cerebellar affections is to be described in relation to a screw.
The animal or man is supposed to represent the screw, in
either case the head of the subject corresponding to the
head of the screw, moreover the screw is supposed to be
that in ordinary use in this country^ — viz., a right-handed,
male screw. With this conception before us all that is
needed in describing rotation in regard to lesions of the
cerebellum is to say that with a right-sided lesion the sub¬
ject rotates like a screw entering an object, while with a
left-sided lesion the mode of rotation is like a screw coming
out of an object.
General titubation and reeling are constant among the
phenomena which result after ablation of half of the cere¬
bellum, and both symptoms are of course commonly met
with in affections of the cerebellum in man. The reeling
after experimental lesions is, according* to my observations,
in a direction away from the side of the lesion, so that the
animal tends to fall towards the healthy side., Some con¬
fusion may, however, arise in this connection in that the
animal may sometimes be observed to fall over on to the side
of the cerebellar lesion, a state of things depending, as we
shall presently see, on motor paresis and inco-ordination
of the limbs on the side of the lesion, which fail to support
the animal and thus allow of its falling to this side. This
m a totally distinct phenomenon from the reeling* due to
distuibance of equilibration, in which the animal pitches, as
I have already said, away from the side of the lesion — i.e.,
towards the healthy side. Few, if any, of the symptoms
c
34 Lecture on the Cerebellum.
which result from cerebellar lesions in man are less reliable
in any attempts at localisation of tlie side of tbe cerebellum
affected than is the direction of reeling, for sometimes
it is away from the side affected, while at other
times it is towards that side. So uncertain is 'this
sign that I am in the habit of disregarding it
when attempting to determine which side of the cere¬
bellum is affected in any given case, unless the direction
of reeling agrees with the other signs present in indicating
the probable seat of lesion. In other words, where the
other signs present point to the one side of the cerebellum
as being affected, while the reeling suggests that it is the
opposite side of the organ in which the defect exists, I
rely on the other signs for localisation, and disregard the
evidence supplied by the direction of reeling.
Closely related to these disorders of equilibration that we
have just been considering is the oscillation of the eyes so
constantly seen after experimental lesions of the cere¬
bellum, and which is also commonly met with in disease of
the organ in man. The nystagmus which occurs in uni¬
lateral lesions of the cerebellum is lateral, and is most
marked when a voluntary attempt is made to turn the eyes
to the side of the lesion.
After experimental lesions another phenomenon met with
which is associated with nystagmus is ocular displacement :
a turning of the eyes away from the side of the lesion.
According to Luciani both globes participate in this displace¬
ment, so that there is conjugate turning of both eyes to the
healthy side. I have not, myself, noticed much departure
from its normal position of the eye on the side of the cere¬
bellar lesion, but the opposite eye is always displaced
markedly downwards and outwards — i.e., away from the
side of the lesion. It is rare to meet with this displacement
of the globes as a result of cerebellar disease in man, but it
wras present in a case of abscess of the cerebellum, recorded
by Dr. Acland and Mr. Ballance, and which through their
courtesy I was able to see, and I have also seen this dis¬
placement of the eyes after the operation for removal of a
cerebellar tumour on one side. It is not surprising that this
abnormal position of the eyes is not more commonly met
with, in that even after experimental ablation of half of
By Dr. J. S. Bisiee Bussell. 35
tJ
tlie cerebellum the eyes return to their normal positions
within a comparatively short time after the operation. If
compensation can thus rapidly come about aftei an acute
lesion, it is only natural to suppose that it may go on pari
■passu with the more slowly produced lesions in man, so that
the defect may never be noted. It is only in connection
with the more acute lesions in man that it would be reason¬
able to expect to meet with any such displacement of the
■eyes.
In connection with this part of my subject it is necessary
for me to warn you that in man, notably in cases where the
lesion of the cerebellum is a tumour, abnormal positions
of the eyes may be met with either as a result of pressure
on the nerves supplying the ocular muscles, or as a result oi
secondary infiltration of the pons by a growth originating
in the cerebellum. Of the nerves concerned with ocular
movements you are aware that the sixth, in consequence of
its slender size and long intra-cranial course, is the most
liable to suffer from the results of increase of intra-cranial
pressure. It is, accordingly, not uncommon to meet with
paralysis or paresis of one or other external rectus, and
note, further, that it does not at all necessarily follow that
it is the external rectus on the side of the cerebellar tumour
that suffers first, for, in some instances, it is the opposite ex¬
ternal rectus that manifests signs of weakness. I he impor¬
tance of paying due attention to this point will become more
obvious when I next tell you that it occasionally happens
that weakness of the internal rectus on the side of the
cerebellar lesion is present with displacement of the eye
on this side ou'twards. I mention this as a clinical fact
which I have myself observed, and which I have seen noted
in a few published records of cerebellar tumours ; but I
cannot pretend to offer any satisfactory explanation of the
reason why this muscle, alone of all those supplied by the
third nerve, should show the defect mentioned. Bow the
point of real importance with regard to this observation is
that a knowledge of the possibility of the occurrence may
prevent our falling into error as regards the localisation
of a tumour in one or other side of the cerebellum. Bor
it is conceivable that with weakness of the internal rectus
on the side of the lesion and consequent displacement of
36
Lecture on the Cerebellum.
tlie eye outwards, there may also be evidence of weakness
of the opposite external rectus with turning of that eye
inwards, so that both eves turn towards the side of the
lesion. But it has already been said that as a result of the
cerebellar defect alone the eyes may turn away from the
side of the lesion, so that without a knowledge that a similar
displacement may be otherwise brought about having a
totally different significance we may be led to localise the
tumour in the wrong side of the cerebellum, if we rely
too much on the ocular displacement. Where the ocular
displacement is directly due to the cerebellar lesion the
eyes turn away from the side of the lesion, while when the
displacement is secondarily induced in the way just indi¬
cated, the eyes turn towards the side of the lesion.
Time will not allow me to do more than offer a further
word of warning that due regard should be paid to the
possibility that turning of the eyes to one side may be
the result of secondary involvement of the sixth nucleus, as
a result of extension of the growth from the cerebellum
to the pons, and that, therefore, a careful search should
be made for any other evidence that may be present which
may be regarded as pointing to such secondary extension of
the neoplasm to the pons, before we regard the ocular dis¬
placement as the direct result of a defect of the cerebellum.
Before leaving this part of my subject I wish to say that
I regard the displacement of the eyes after ablation of
parts of the cerebellum as a truly paralytic and not an irri¬
tative defect, and that one of the most cogent reasons for
so regarding the condition is that after the displacement
has been recovered from it may be reproduced by placing
the animal under the anaesthetic influence of ether, for
then, at a stage which immediately precedes that in which
the eyes diverge in deep coma, the displacement at first
observed after ablation of half the cerebellum is again seen.
The anaesthetic may thus be regarded as drowning the
centres for eye movements on both sides ; but the side on
which there are fewest centres for such movements remain¬
ing* give out first, and thus the unrestrained influence of
the opposite centres bring about the displacement of the
globes.
TV hen speaking of reeling I said that titubation and
37
By Dr. J. S. Bisien Bussell.
inco- ordination are among the constant phenomena met
with in connection with cerebellar lesions ; it now remains
for me to point ont that this inco-ordination is more marked
in the limbs on the side of the lesion, and, indeed, that it
may in some cases be more or less limited to them. But
what I wish more especially to insist on is that this is only
one factor in regard to the defect of movement met with
in the limbs under such circumstances, and that in reality
there is in addition a true motor paresis of the limbs on the
side of the lesion. This phenomenon is only rarely met
with in man, owing no doubt to compensation going on
hand in hand with the slowly produced defects of disease.
It is noteworthy that when this defect hasi been met with
in man it is the superior extremity that appears to suffer
in greatest degree, wThile in animals the posterior extremity
on the side of the lesion is that which is most defective.
In both instances, however, it is the limbs on the same side
as the lesion that are affected, and not those on the opposite
side, as obtains in the case of a lesion of one cerebral hemi¬
sphere.
How in the case of hemiplegia of cerebral origin we have
abundant evidence that the path by which impulses reach
the opposite side of the spinal cord is the pyramidal tract,
and, moreover, these fibres degenerate after a lesion of the
motor centres or one which interrupts the motor conducting
fibres at any part of their course, and such degenerated
fibres can be traced throughout the spinal cord. Have we
any similar evidence in regard to a path by which impulses
can pass from the cerebellum in an efferent direction so as
to reach the anterior horn-cells of the spinal cord P Accord¬
ing to Marchi, and certain other observers, there is such
a tract, the fibres of which are situated at the margin of
the antero-lateral region of the spinal cord, and, moreover,
according to them, this tract of the fibres degenerates after
a lesion of the cerebellum just as do the pyramidal fibres
after a cerebral lesion, the only difference being that in the
case of the cerebellum the tract degenerates in the spinal
cord on the same side as the lesion, and does not cross over
to the opposite side as in the case of the majority of the
fibres of the pyramidal tract.
gg Lecture on the Cerebellum.
Mv own observations do not confirm those of Marcln,
however, for like Ferrier and Turner I find no evuDnee
that any tract degenerates in the spinal cord after a lesion
limited to the cerebellum. Fibres in the infenor peduncle
on the same side degenerate after ablation of one hal
of the cerebellum, and subsequently occupy -ie peri¬
phery of the lateral region of the medulla on the same
side,' but none of these reach the spinal cord. There is,
however, a tract of fibres at the periphery of tue ventro¬
lateral region of the cord, and it degenerates m an efferent
direction, but its fibres are derived from Deiters’ nucleus,
and they degenerate after a lesion of that nucleus If 1 next
remind" you that Deiters’ nucleus is connected with the
cerebellum by means of the so-called sensory tract of
Edinger, which is in reality composed of efferent fibres
from the cerebellum, you will readily recognise that tnoug 1
according to my own observations there is no direct path
from the cerebellum to the spinal cord, there is, nevert e-
less, an indirect one through Deiters’ nucleus , which is as
it were tlie lialf-way station. ,
Riqiditu due to spasm of the muscles of the limbs on t e
side of the lesion, and to some extent of those of the
opposite posterior extremity, is a constant feature a er
experimental ablation of one half of the cerebellum, and
the hack muscles share in this spasm. I do not, however
remember ever having seen any very definite evidence o
such' rigidity in an uncomplicated cerebellar lesion 111 man.
The influence exerted by the cerebellum on the muscles in
regard to tonus is a very complicated one, for Professor
Victor Horsley and Hr. Max Lowenthal have shown, among
other points of great interest, that when extensor tonus of
the limbs is obtained by removal of both cerebral hemi¬
spheres, faradic excitation of the upper surface of the
cerebellum, at the junction of the vermis and lateral lobe,
results in immediate relaxation of the tonus, whic , mw
ever, becomes re-established as soon as the current is shut
off, and that this effect is most marked in the limbs on the
side of the cerebellum that is stimulated.
Tendon J erics. — -After ablation of half of the cerebellum
both knee-jerks are increased, hut that on the side of the
lesion is the more exaggerated and remains so long after
39
By Dr. J. S. Risien Russell.
that of the opposite side lias become normal. A similar
state of things is met with in some instances in man ; in
others, however, no difference can be made out in regard,
to the activity of the knee-jerks on the two sides, while in
others both knee-jerks are abolished. This last pheno¬
menon was at one time regarded as of considerable diagnos¬
tic value, as indicating that the cerebellum was the probable
seat of the tumour when the phenomenon was met with
in a case in which there was doubt as regards localisation.
We, however, nowT know that absent knee-jerks in intra¬
cranial tumours have not this significance, but that it may
be impossible to obtain the knee-jerks when there is great
increase of intra-cranial pressure, as in a large tumour of a
cerebral hemisphere, or where pressure is quickly increased,
as in a rapidly growing tumour of the cerebrum.
Ancesthesia is met with after experimental lesions, and
corresponds in its distribution to that of the motor paresis, so
that the limbs on the side of the cerebellar ablation are
those chiefly affected ; but as far as I am awmre defect of
sensibility has never been met with as the result of an
uncomplicated cerebellar lesion in man.
So much then, gentlemen, for the information which we
derive from experimental physiology in regard to the
problems connected with cerebellar localisation. Does
clinical medicine afford us any information on the subject
which is not supplied by the results of experiments ? There
are two symptoms which, if present, are of the greatest
possible value in determining the probable side of the cere¬
bellum in which a tumour is situated, they are facial
'paralysis, of peripheral type, and deafness; both are on
the same side as the tumour. Moreover, as pointed out by
Dr. Beevor in a recent discussion on the localisation of
intra-cranial tumours, at the Neurological Society, these
signs further indicate that the tumour of the cerebellum is
situated in the anterior part of the posterior fossa as
opposed to its being in the so-called cerebellar fossa.
PART II.
REVIEWS AND BIBLIOGRAPHICAL NOTICES.
- -+* -
BE CENT WOBKS ON DISEASES OF CHILDREN.
1. The Diseases of Children. By James Frederic
Goodhart, M.D., F.R.C.P. ; Consulting Physician to the
Evelina Hospital for Sick Children ; with the assistance
of George Frederic Still, M.A., M.D., M.R.C.P.;
Medical Registrar and Pathologist to the Hospital for
Sick Children, Great Ormond-street. Sixth edition.
London : J. & A. Churchill. 1899. Pp. 720.
2. An American Text-book of the Diseases of Children.
By American Teachers. Edited by Louis Starr, M.D.,
and T. S. Westcott, M.l). Second edition. Revised.
London : The Rebman Publishing Company. 1898.
Two Yols. Pp. 1204.
3. Transactions of the American Orthopedic Association.
Yol. XI. Illustrated. Philadelphia. 1898. Pp. 461.
4. Growing Children, their Clothes and Deformity. By E.
Noble Smith, F.R.C.S. London: Smith, Elder & Co.
1899. Pp. 23.
5. Pediatrics. Yol. YI. Nos. 5-12. New York and
London. 1898.
6. Archives of Pedia trics. Yol. XY. 9-12, and Yol. XYI.
2-3. New York. 1898-9.
1. It is with feelings of deep satisfaction that we notice
the appearance of this book for the sixth time. We have
been looking forward to its publication for some months.
In its new garb it is much improved in appearance and
much pleasanter to handle. It is larger in every way . Dr.
Goodhart is to be congratulated on its successful issue, and
most of all for having associated with him so highly dis¬
tinguished and able a scholar as Dr. Still. We acquiesce
41
Recent Works on Diseases of Children.
in Dr. Goodhart’s expression on this point in his preface,
and, after carefully going over the work, notice many most
valuable paragraphs and observations, evidently from the
pen of Dr. Still, with whose conscientious labours in the
wards of Great Ormond-street we have the privilege of
being familiar. Dr. Still’s assistance increases materially
the value of the work, and his views are tactfully dovetailed
in with those of his senior and distinguished fellow-author.
Every chapter bears the stamp of revision : some few
paragraphs expunged and much fresh information added.
A few fresh points must be noticed. It is pointed out, in
alluding to treatment, that the children of the upper classes
are much more sensitive to medication than hospital
patients, and one should begin with small doses. In
children above the age of infancy champagne is considered
to be the most suitable of alcoholic stimulants, if such
indeed are required. Bleeding and leeches are rightly
given a prominent place in severe lung and heart disease.
The warnings about poultices are repeated, and the
authors discard them as much as possible.
The anterior fontanelle is dated to close usually about the
18th month, and the care of premature infants is described.
In chap. III. there is a clinical picture of great value on
“ Chronic Dilatation of the Colon,” not before described.
The paragraphs on “Recurrent Vomiting,” “Membranous
Gastritis,” “ Congenital Hypertrophy of the Pylorus,”
“ Geographical Tongue,” “ Diphtheritic Paralysis and Anti¬
toxin,” “ Erysipelas,” “Bronchiectasis,” “Bronchopneu¬
monia,” “Scrofula,” “Tubercular Peritonitis,” “Disease of
the Spleen,” “ Meningitis,” “Posterior Basic Meningitis,”
“Habit Spasm,” “Idiocy and Cretinism,” “Idioglossia,
and Speech Defects,” “Malignant Endocarditis,” “Purpura
Fulminans,” “Achondroplasia,” “Enema Rashes,”
“(Edema,” “Ichthyosis,” and “The Care of Children
with Infantile Paralysis ” are all either quite new or re¬
written ; thus it is obvious the work is much enlarged.
A work like this, gone over separately by each of these
authors, and gone over, as we are told, by both together,
cannot be other than one of our most valuable books on
diseases of children. This we believe it to be, and if asked
42
Reviews and Bibliographical Notices.
to recommend the most convenient, sound, and practical
book on this subject, we should have no hesitation in
naming this volume. It is, moreover, written in beautiful
English, which has always characterised Dr. Goodhart’s
work. In any such book some imperfections are sure to
be found by the critic, and while impressed with the excel¬
lence of the book we are not blind to the fact that one or
two points might perhaps be revised in future editions.
They are, however, very difficult to find, and are of
the most trivial nature. For instance, we should wish
our distinguished authors to be more emphatic in their
denunciation of tubes attached to feeding apparatus, while
perhaps a little more detailed description might be given of
the pathology of “ atrophy ” or “ marasmus,” and of “ rheu¬
matoid arthritis.”
We wish this volume every good fortune, and feel sure
that anyone wishing for a safe and beautifully- written book
on diseases of children could not possibly do better than
trust themselves to the guidance of Drs. Goodhart and
Still. They will not go wrong if they do, and they will
never regret the purchase.
2. These are beautiful volumes, and reflect great credit on
the editor, publisher, and authors. The volumes are brought
up to the chief ideas of present-day medicine amongst
children, especially in the United States, where the study is
eagerly pursued. It seems to have been carefully revised,
and much new material is added. It is particularly good
on the feeding and general care of children, like all Ameri¬
can books on diseases of children, and much valuable infor¬
mation may be found in these chapters. The system is in
some cases a good one of getting separate writers for
separate articles, and they are, on the whole, fairly complete
essays on each subject.
There are, however, some striking omissions in a few of
the chapters, and we venture just to mention one or two of
these, which we hope will be rectified in future editions.
In the chapter on “ Marasmus,” or “Simple Atrophy” as it
is termed, no tru6 pathology is mentioned. The real essence
of the disease, as lucidly described by Dr. Soltau Fenwick
43
Recent Works on Diseases of Children .
and Baginsky, is not touched upon, and the reader is left
with a hazy notion of the actual processes underlying this
affection. Again, “rheumatoid arthritis ” is not successfully
dealt with. It is a rare disease, to be sure, but very familiar
to English authorities on diseases of children, and may be
seen in the London children’s hospitals with its great
peculiarities. Then 4 4 posterior basal meningitis of infants
is not satisfactorily dealt with, and is confounded with
suppurative meningitis. Drs. Gee, Barlow, and Still have
done such excellent work on this disease in London that
now all books on children’s diseases should contain an
account of it.
Another peculiar disease of children, rarely seen, but yet
most interesting, is 44 iaioglossia.” It would, however, be
difficult for an author to describe this affection (or, indeed,
any disease) without having studied examples of it, and
perhaps they have not been yet observed in America. No
mention is made of it.
We would like to have seen Yol. II. commence with
Diseases of the Nervous System, so as to avoid placing the
first short chapter of this branch at the end of Yol. I.
Notwithstanding the above few deficiencies we have the
highest admiration for this fine work, and have no hesita¬
tion in saying that it reflects credit and honour on the
American physicians who have compiled it for their careful
studv of the diseases of children.
t j
It is beautifully printed and illustrated.
3. These Transactions continue well bound, well printed,
and well illustrated. This volume is much enlarged.
Amongst the most interesting papers are the following : —
(1.) 44 On The Arch of the Foot in Infancy and Childhood,”
by John Dane, M.D., Boston, where it is nicely shown
that, instead of young infants having flat feet as some have
taught, the space that in the adult and older child is
bridged over by the arch of the foot is in the infant and
young child, if it is at all fleshy, entirely filled up by a pad
of fat ; it is the impression made upon the paper by this
fat that has misled us into thinking that the foot of the
infant had no arch. In thin children the pad is wanting,
44
Reviews and Bibliographical Notices,
in which case the print of the foot strongly resembles that
of the adult.
(2.) “Epidemic Infantile Paralysis,” by E. G. Brackett,
M.D., of Boston Ten cases are reported, occurring in the
same locality at the same time.
(3.) “Bed Posture as an Etiological Factor in Spinal
Curvature,” by G. W. Eitz, M.D., Cambridge. Here is a
most thoughtful and excellent fragment well dealt with.
It is shown that lateral bed posture curves the spine ; that
these habitual postures tend to fix such curve ; that the
time in bed is long enough to markedly produce it ; and
that bed posture becomes an important factor in both
causation and cure. The spine dips into a curve when
lying down.
(4.) “Deformities of the Chest in Rickets,” by J. S. Stone,
M.D., Boston.
(5.) “ Round Shoulders,” by Robert Lovett, M.D.,
Boston.
(6.) “ On the Treatment of the Kyphosis in Pott’s
Disease,” by P. Redard, M.D., Paris. A remarkable paper,
beautifully illustrated.
The above papers are most instructive.
4. The advice given in this small leaflet is good. It is
issued for the public, or perhaps professional readers also.
The points Mr. Noble Smith draws attention to may be
summarised as follows : — That many deformities develop
during growth; that “postural deformities” often result
from badly-shaped clothes ; that children’s clothes should
have — (a) large, loose, and full chests ; (b) no suspenders
or braces ; (c) no buttons on stays ; (d) belts round the
waist to suspend the nether garments from ; (e) vests and
drawers made separately, as “ combinations ” are apt to
shrink and to cramp the wearer. Boots should have flat
heels, long soles, and straight inner borders.
We agree with Mr. Smith in his views, and the above
are the salient points of the paper.
5. We cannot conceal the fact that whenever we receive
this paper we are disappointed with its printing, paper,
45
Ramsay — Diseases of the Eye.
and binding. The two former have improved of late, but
the appearance of the cover is most unattractive, and we
venture to predict that if the outside and the table of
contents were made more clear, and advertisements placed
second, it would become far more popular.
6. This is the nicest journal on children’s diseases with
which we are acquainted. The papers we would draw
attention to in these numbers are: — “The Urine of
Infants and Children,” in No. 9 ; “ Hospitals for Infants,”
in No. 11; “Whooping-cough,” in Yols. XY. 11, and
XYI 3; “Pneumonia,” in XY. 12 and XYI. 2; also
“ Haemorrhagic Disease ” and “ Tetany,” in XYI. 3.
There is a marked difference between English and
American printing ; on looking into the type, we notice it
lies in the wide spacing between the letters of an American
word, as compared with the closely fitted letters of an
English printed word. This makes the American type
very trying to the eyes of English readers, and accounts
for its unpopularity. We feel it trying ourselves ; but, on
the other hand, we are not blind to the fact that for all
we know our type tries the sight of our brethren across
the water. We would be glad to hear some expression of
opinion on this point.
Atlas of External Diseases of the Eye. By A. Maitland
Bamsay, M.D., with 30 full Coloured Plates, and 18 full-
page Photogravures. Eolio. Pp. 195. Glasgow: James
MacLehose & Sons. 1898.
The plates in this Atlas are, for the most part, executed
from photographs of actual cases, most of which occurred
in connection with the author’s work in the Glasgow
Infirmary, and the author hopes that they may be found
useful to medical men in general practice who may not
have many opportunities of visiting the wrards and clinique
of an ophthalmic institution.
He has endeavoured to make the letterpress which
accompanies each illustration not only descriptive of, but
also complementary to the plate, so as to give as faithful
a clinical picture as possible of all the diseases dealt with.
46
Reviews and Bibliographical Notices.
To make a really satisfactory atlas of external diseases
of the eye is one of the most difficult tasks imaginable, for
each picture represents only one stage of a disease which
varies in appearance daily, often hourly ; but the author of
this Atlas has done better in this respect than most of his
predecessors, and has added sufficient description of the
disease to explain and supplement the illustration, so that
a fairly comprehensive picture can be formed by the reader
of the condition in general.
The photographs are, for the most part, fairly charac¬
teristic and well chosen, and the coloured plates are better,
and more nearly approach the real appearances, than in any
other atlas of the kind which we have come across, though
perfection has not yet been reached, and many obvious
improvements could be made. The book is beautifully
printed, and fills a real want long felt, for though many an
excellent atlas of internal diseases of the eye exists, few
have successfully produced an atlas of the external diseases
of the lids and eyeball.
We therefore congratulate Dr. Maitland Ramsay, though
we think in some of his cases he might have had the picture
taken at a stage more characteristic of the disease than
he has chosen. For instance, those pictures which illus¬
trate the difference between a “Hordeolum” and a
“ Chalazion,” or between “ Blepharitis Marginalis ” and
“ Lachrymal Catarrh,” on Plate 2, might easily be im¬
proved. The book is an expensive one — viz., T3 3s. n'et.
The Essentials of Chemical Physiology for the Use of
Students. By W. D. Halliburton, M.D., F.R.S. Third
Edition. Longmans, Green & Co. 1899. Pp. 199.
This most useful work is now so well known, and its
merits are so universally recognised, that little more
is necessary than to call the attention of our readers
to the appearance of a new edition. The present issue,
however, differs in many respects from those which
have preceded it, as was required by the rapid progress
of the science of physiological chemistry. Some new
sections have been added, notably those on the urinary
Halliburton — Handbook of Physiology . 47
pigments, our knowledge of wliick has become so much
more precise of late years, owing to the labours of
Hopkins, Garrod, and others, and on the crystallisation of
egg albumin as effected by the method of Hopkins. The
chapter on the proteids has been rewritten, and includes
a new section on the protamins, and an extended account
of the nucleins, while in most of the chapters consider¬
able changes will be found. In the section on the coagula¬
tion of the blood a table is given representing the process
of clotting as due to the action of thrombin on fibrinogen ;
thrombin, the perfect fibrin ferment, being itself formed
from a zymogen, prothrombin, by the action of the lime salts.
The principal changes in the text are naturally to be found
in the advanced course. Here we have a coloured plate of
the different oazone crystals, a description and figures of
the ultra violet spectrum of haemoglobin, and some of its
derivatives, and in the appendix is given a description of
Oliver’s methods of estimating the colouring matter of the
blood, and of determining the number of corpuscles. It
will be been that the work is brought well up to date.
As a student’s book it has no equal. It is an essential part
of the equipment of every physiological laboratory.
Handbook of Physiology. By W. D. Halliburton, M.D.,
F.R.S. Fifteenth Edition. London: John Murray.
1899. Pp. 872.
A BOOK which appears in the fifteenth edition may be
considered to have passed the stage of criticism, and there
are very few members of the medical profession who have
not to acknowledge the benefit they have derived at some
stage of their studies from one or other of the numerous
editions of Kirkes’ Physiology. This most admirable text¬
book has evidently entered on a new era of popularity,
thanks to the labours of Professor Halliburton. The book
still has the name of “ Kirkes’ Flandbook ” on the title
page, but none of the old Kirkes remains — the work has
been completely rewritten by its present author. The
first edition of Professor Halliburton’s handbook appeared
only two and a half years ago, but even in such a short
48 Reviews and Bibliographical Notices.
time the marvellous activity of physiological research has
made considerable alteration necessary. The author tells
us that he has endeavoured to incorporate all the important
facts that have been discovered since 1896, and in this
endeavour he appears to have been very successful. The
size of the book is, however, increased by only 21 pages.
In revising the chapter on the circulation of the blood
Professor Halliburton has had the assistance of Dr. Leonard
Hill. A very important alteration is made in the arrange¬
ment of the matter. In the last edition the central nervous
system and the organs of special sense were treated of
before circulation, respiration, digestion, and the other
vegetative functions. This unusual and undesirable
arrangement is now altered, and the brain and cord, with
the senses, are placed at the end. The illustrations have
always been a great feature in Kirkes, and as the text
includes a good deal of histology there is much room for
pictorial effort. In the present edition there are 668 figures
in the text, many of them printed in colours and all
beautifully executed. There is, besides, a good coloured
plate of the principal blood spectra. On the whole we
can most strongly recommend this handbook as containing
within moderate compass a very complete and accurate
account of the present condition of physiological science.
It is a work which well deserves the great success which
it has enjoyed, and which we hope will long attend it.
Elementary Physiology. By BENJAMIN MoOKE, M. A. London:
Longmans, Green & Co. 1899. Pp. 295.
In the preface we are told that “ this book is intended to
give an idea of the structure of the body, and of the
changes which are continually taking place in it during life,
to those who have no previous knowledge of the subject.”
It is written in as elementary a fashion as possible, and
with the smallest possible use of technical terms. It is
meant for the use of junior students as a first introduction
to the subject, and also for general readers, and it is hoped
“ that it may remove some of that deplorable ignorance
49
Moore — E lemen tciry Pliysio lo cjiy .
■which is so often met with, even among fairly well educated
people, as to the general structure of their own bodies,
and the actions which take place within them during life.”
The usefulness of the work is greatly increased by an
appendix of practical exercises well selected, and easy of
performance, and also a list of questions by which the
reader call easily test his knowledge as he goes along.
The arrangement of the matter is simple, and presents
nothing unusual. After a general introduction, an anatomi¬
cal description of the body is given in three chapters —
on the skeleton and its articulations, the muscular system,
and the position of the viscera. We have then chapters
on the circulatory system, the blood, diet, digestion,
absorption and metabolism, respiration, animal heat, excre¬
tion, the nervous system, and the senses.
As wras to be expected from a physiologist and teacher
of Professor Moore’s eminence, the information in each
of these chapters is exact and clearly given, and through¬
out great judgment is shown in separating the essential
matters from those which are of less importance. A
student who reads this little work intelligently, and who
works over the practical exercises, and tests himself with
the questions in the appendix, will know far more physiology
than nine-tenths of the men presenting themselves for
examination do — at least so far as our experience enables
us to judge.
We notice a few errors in the text, evidently due to the
printer. Thus, in the note on p. 216, it is stated that 9
grams of creatinin, 5 grams of uric acid, and 4 grams of
hippuric acid are excreted daily. These numbers should,
of course, be 0*9, 0*5, and 04 respectively. Such slips are,
however, very few.
The text is illustrated by 125 drawings, mostly taken
from “ Quain’s Anatomy,” and Schafer’s “Essentials of
Histology.” There is a good index.
This book, which is the same in plan as Foster and
Shore’s “ Physiology for Beginners,” but somewhat more
comprehensive, will, we think, supply a want which is
largely felt. We feel sure that it will enjoy that wide
popularity which it so well deserves.
D
50
Reviews ancl Bibliographical Notices.
Schoolboys Special Immorality. By Maurice 0. Hime,.
M.A., LL.D., sometime Headmaster of Foyle College,
Londonderry. London : J. & A. Churchill. 1899. Pp. 48.
With much skill and sound judgment Dr. Maurice Hime
deals with a difficult and delicate subject in this booklet of
48 pages. The work is based upon an article written by the
author in the autumn of 1897, which was published in the
Lancet for September 4th of that year. After some intro¬
ductory observations, Dr. Hime insists on the prevalence of
the vice and defines the duty of headmasters regarding it.
Personally, he has found that certain school arrangements
are of use in preventing and checking the vice. These
arrangements are mentioned and explained. First and
chiefly, cubicles he will have none of.
The advantages of moral persuasion are discussed, and
Dr. Hime easily disposes of the objection that plain speaking
may do actual harm to an innocent boy. He says (page 30),
“ good advice, provided that it be given at once, wisely and
affectionately, by an experienced and discreet schoolmaster,
cannot do harm to any boy, good, bad, or indifferent.”
Dr. Hime declares strongly against expulsion of boys
reasonably suspected of, or actually detected in, the offence.
In his opinion, it is “ an absurd, injurious, and most unfair
plan.” His excellent little homily ends with warm-hearted
words of encouragement for boys, masters, and parents alike.
Elements of Alkaloidal Mtiology, introductory to the Study
of Auto-Intoxication in Disease. By A. M. Brown, M.D.
London: Henry Kimpt on. 1899. Pp. 86.
This book is apparently intended to maintain two theses.
First, that most, if not all, diseases are due to auto¬
intoxication. by alkaloidal substances generated in the
body by its metabolism ; and, secondly, that the generally
received views as to the important part played by bacteria
in the causation of disease are erroneous and even ridicu¬
lous. The work appears to be entirely the outcome of the
study, as the author does not record any observations of
his own in support of either of his contentions. We
cannot congratulate him either on the matter or the manner
51
Pedley — The Hygiene of the Mouth.
of his work, either on the value he gives to the statements
on which he relies, or on the tone in which he speaks of
the works of those men who are admitted by all patholo¬
gists to have done most for modern science. Thus, Bou¬
chard’s observations on the toxicity of the urine and on
the antagonism of day and night urine, which have been dis¬
proved by every competent experimenter who has controlled
them, are quoted as if they were fully established, while such
a sentence as the following shows a wilful ignorance of
facts: — “We must insist that the phenomena of disease,
due to the most essential processes, are possible without
the intervention of micro-organisms, bacillar or otherwise.’*
We would ask what disease ? Has the author ever demon¬
strated the absence of the tubercle bacillus in phthisis, of
the typhoid bacillus in typhoid, or the tetanus bacillus in
tetanus'? But perhaps it is idle to speak to a generation
which has read three editions of Dr. Brown’s larger work
on alkaloidal aetiology. For our part the smaller intro¬
ductory work is enough for us, although, as our readers may
remember, we have noticed the first and second editions
of the opus magnum.
In conclusion we would quote the following passage
from the work before us : — “ The speculative groping of
pangermists in general may have added some brilliant
pages to the romance of medicine, but very little to our
knowledge of disease, and still less to its alleviation or
cure.” Those who agree with this statement, and with
the view that no advance in our knowledge of pathology,
“ more particularly pathogenesis,” has been made in the
last thirty years, may find Dr. Brown’s book agreeable
reading. To those who think otherwise we cannot recom¬
mend it.
The Hygiene of the Mouth ; a Guide to the Prevention and
Control of Dental Diseases. By R. Denison Pedley,
I.R.C.S.Ed., L.D.S. Eng. London: J. P. Segg & Co.
The prevalence of dental disease and the ill-consequences to
general health therefrom, together with the belief that more
care on the part of humanity, in what one might term the
52 Reviews and Bibliographical Notices.
toilet of the month, would materially help to mitigate these
evils have, states the writer, prompted him to publish the
pages before us.
On reading, it would strike one that some doubt exists
for whom the author caters — the profession or the public.
To the latter we would say read, mark, learn, &c. ; but from
perusal, the dentist , if a medical man, would be unlikely
to cull much information, apart from having his energies
freshened in the direction of giving advice more assiduously
towards the efficient cleansing of their teeth by his patients,
especially those of tender years.
The author treats his subject as it applies to— (1) child¬
hood, (2) adult life. Speaking under the former division,
the advising young children quill toothpicks to carry about
and use (!) would, we believe, be open to much criticism of
an adverse nature.
Touching upon the much-debated question, whether sweet¬
meats should be allowed young children, the more sensible
view — now taken by not a few foremost practitioners — has
been adopted by the writer, viz., that in moderation, and
when of good quality, such are not to be forbidden, seeing
the amount of nourishment they contain. That school chil¬
dren be compelled to cleanse their teeth daily under super¬
vision is a sound proposition ; and could the author in some
manner bring about a system of “tooth-brushing drill’ —let
us call it — to be adopted in all public schools, &c., there is not
any doubt but that much suffering — nay, more, disappoint¬
ment — in after-life would be anticipated.
A tabulation of reflex troubles having a dental origin,
with clinical records of some such cases, are next gone into,
after which the last forty pages are enriched by some dia¬
grammatic illustrations of various conditions of the human
teeth, together with several formulae for mouth-washes, &c.
That any very striking information awaits the reader
unless a non-professional one — in the ninety pages which go to
complete this publication we cannot state, but, undoubtedly,
sufferers, or those having children in their care, would
derive useful hints from their study. The publishers have
done their part well. A curious fact is the omission of all
mention as to dates of writing, publishing, &c.
PART III.
MEDICAL MISCELLANY.
- -
Reports , Transactions , ancl Scientific Intelligence.
The Rinderpest of 1897 in Cape Colony .a By James Harpur.
In bringing forward this subject I will endeavour to tell as plainly
as I can something of the ravages of the great Rinderpest, or cattle
plague, which invaded Cape Colony in the early months of 1897,
and also something of the exertions put forward in trying to check
its fatal progress.
It cannot be regarded as a disease of recent years. The German
appellation of Rinderpest, the steppe murrain of Russia, and the
cattle plague of England, are now fully recognised as one and the
same disease. It seems to have taken up its abode in Russia.
Every year in that country it carries off cattle to the value of close
on two million pounds sterling.
In this century it appears to have been limited to Russia until
1827, when, in consequence of the invasion of the Turkish
dominions by the Russian army, the area of the disease was
extended into that country. It afterwards penetrated into
Prussia, Saxony, Hungary, and Austria, and committed great
ravages in those countries before it could be extirpated.
In 1841 it was introduced into Egypt, and in three years
destroyed 350,000 head of cattle — in fact, almost all the cattle then
in the country.
It attacked England during the years 1866-67, and the death-
rate amongst the cattle was enormous, rising to over 500 a
day. It is calculated that over 500,000 head were carried off,
besides costing the Government many millions of money.
The evolution of this epidemic in Africa is unique amongst the
epidemics of the world as regards the steady course which it
pursued, and the amount of destruction and ruin, famine and war,
which it left in its trail.
Rinderpest is a specific disease belonging to the class of con-
a Read before the Dublin University Biological Association.
54
The Rinderpest of 1897 in Cape Colony.
iagious fevers. It is conveyed in the excreta from the deceased
animal. How long the virus lasts in the excreta is not known,
nor to what distance it may be diffused. In addition, it may
travel in the hide, horns, hoofs, and intestines of the dead animal,
or in anything that may come in contact with the blood of the
animal. The contagious matter is one of the most subtle and
prolific of any of the known elements of disease.
Belonging to the class of disease termed zymotic, one would
expect to find the period of incubation, then the onset, then the
period of high fever, then the period of local effects, and lastly the
time when the disease tends of itself to get well, and the patient’s
fate depends on one point — has the disease made such havoc that
the patient has strength to recover from it or not ? It must, how¬
ever, be borne in mind that whilst we speak of the different stages
of a zymotic disease, and can always separate them in idea, they
may be all crowded together, constituting what may be termed
the malignant type. To this special type Rinderpest belongs. The
period of incubation is from three to five days, and the animal
usually dies from four to six days after the onset. Recovery,
when it does occur, is very slow, and takes place by lysis. At the
period of onset the first symptom is a marked rise in temperature,
rising from 101° F. to 107—8° F. The animal then gets a dull,
dispirited look, the eyes lose their brightness, the ears hang in a
peculiar fashion. It ceases to ruminate, and leaves off eating.
There is a certain amount of stiffness in the movement of the
animal. The eyes next become bloodshot, and appear sunken in
the head from the oedema of their lids. The inflammation of the
eyes soon leads to secretion of what is at first a mucous, then a
muco-purulent, discharge, which can be seen running down from
the inner canthus, leaving a dirty whitish or greenish streak along
the hair of the face. This is a very characteristic sign of the
disease. The nasal mucous membrane becomes very vascular, and
readily bleeds if roughly handled, as, for instance, in making an
animal open its mouth by inserting the fingers into the nose. The
mucous membrane of the gums and inner side of the lips, and other
parts of the mouth, become excoriated. These excoriations are
of various extent and of irregular shape. Another very early
symptom of the disease is the congestion of the mucous membrane
of the vulva, which becomes reddened, and exhibits abraded spots
similar to those observed in the mouth. The appetite suddenly
fails, and in milch cows the secretion of milk disappears almost
entirely. Purging is another very marked symptom of the disease.
55
The Rinderpest of 1897 in Cape Colony.
On post-mortem examination one finds that the changes produced
by the disease affect chiefly the digestive system. The fourth
stomach presents a congested lining membrane ranging in tint
from a reddish pink to a deep plum colour. The upper part of
the small intestine partakes in the congestion of the fourth stomach,
presenting the same variety of tints. The mucous membrane is
not in an ulcerated condition, nor are the products of inflammation
present.
The congestion is capriciously distributed, more intense in some
places than others. Peyer’s patches are not necessarily affected.
The lungs are slightly emphysematous.
This is a short description of a disease which has engaged the
attention of scientific men at various epochs. The mortality of the
disease has varied slightly in different countries ; in Africa, however,
it approached the enormous fatality of 98 per cent. As might be ex¬
pected, many different lines of treatment were advocated at different
times, but without any evidence of success. I cannot do better than
here quote the words of Dr. Arthur Wynne Foot, of this city,
who, when Rinderpest was raging in England during the years
1866-67, had special opportunities of studying the disease, and who
has written largely and with great accuracy on the subject. He
says : — « The prospect is gloomy in the extreme when we approach
the treatment of an animal actually affected with ‘the cattle
plague,’ for the results of experience almost invariably show that
the percentages of recovery are about equal, whether animals are
medically treated or not, and medicines which succeed in one case
may fail in the next. When the cattle plague first appeared in
England, and those who had observed it in Eastern Europe pro¬
nounced that the poleaxe and isolation were the only remedies to
be employed, and confidently predicted the result of dallying with
the disease in the hopes of exterminating it otherwise, their warning
was not acceptable to the scientific tendency of the age. Yet the
truth of their words is now evident. However mortifying it may
be to the scientific mind of the present day, the fact is yet un¬
pleasantly true and may certainly now be received as established,
that as a general rule treatment of any kind is worse than useless.
Such was the opinion expressed and very generally accepted in
1867. Let us now turn to the methods employed in South Africa
just thirty years later for the purpose of combating this dreadful
disease.
Many months before Rinderpest reached Cape Colony many
measures were discussed in the House of Representatives at Cape
5G The Rinderpest of 1897 in Cape Colony.
Town how best to protect the country from its onslaught. It was
decided to requisition the services of Professor Koch, from Berlin.
He came and at once set up his laboratory at Kimberley, and
began a series of experiments so as to find out some means which
would confer immunity from the disease. After many experiments
with several animals without any tangible result, he at length began
to study the bile contained in the gall-bladder of a beast suffering
from Rinderpest. Efe noticed the gall-bladder was nearly always
over-distended with bile, and also that this bile was, of ail parts of
the animal, the least affected by the disease. The quality of the
bile in different animals, however, varied. In some it was of a
dark green colour, free from blood and decomposing matter, and to
all appearances normal. In others it contained both blood and
elements of decomposition, and was of a dirty yellow or brownish
colour ; in fact these various conditions of the bile seemed to depend
on how much or how little the disease had affected the mucous
lining of the gall-bladder. He now began experimenting with bile
of the first type — namely, dark green in colour, free from blood,
and of normal consistency, taken from a beast suffering from
Rinderpest and in the collapsed condition of the fever. After many
experiments he found that by inoculating a beast which was per¬
fectly healthy with 10 cc. of this bile, he was able to confer on it
immunity from the disease, provided due precautions were taken
during the operation that the animal did not become infected either
by the attendants or the operator. This immunity he also found
did not set in till the fifth day after the inoculation, so that for the
success of the operation it was also necessary that the animal did
not become subject to infection up to that time. Koch now made
known his experiments and the results. Rinderpest, however, had
not as yet broken out in Cape Colony. The Government, after
carefully considering the matter, decided not to introduce Koch’s
method of inoculation, because that measure would not only increase
the risk, but almost inevitably result in the introduction into the
country of the disease. They resolved in the meantime to adopt
Other measures so as to prevent the disease getting into the country.
With this purpose in view, a double line of wire fencing,
enclosing a belt of country two thousand yards in breadth, was
erected. This fence extended along the entire border line of
Cape Colony, and was continued by the Natal Government on the
east, so that there extended across the entire country a fence
reaching from seaboard to seaboard. Thousands of volunteers were
now enrolled at fixed salaries of ten shillings a day for the purpose
57
The Rinderpest of 1897 in Cape Colony .
of guarding and patrolling this fence. One portion of it, about
50 miles in extent, was considered of great importance, and a
a squadron of Cape Mounted Riflemen were appointed to take
charge of it. It was while a member of this squadron that I was
first brought face to face with Rinderpest.
This was the position of affairs at the beginning of 1897. The
huge fence had been erected, and was being patrolled night and
day by thousands of men awaiting attack from this dreaded and
invisible enemy. Step by step the disease approached at the rate
of about one hundred miles a week, and many were the conjectures
as to the possibility of its being stayed. In spite of every precau¬
tion, however, the disease broke out on a farm at the border, on
the Cape Colony side of the fence. On this farm, on which I
happened to be stationed, there were over four hundred and ninety
head of cattle.
The Government now sent up orders that all the cattle on this
farm were to be shot, and also the cattle on any other farms, on
which Rinderpest should happen to break out. This was compulsory
shooting, for which the Government had to pay compensation to
the farmers, to the extent of about two-thirds value of the cattle.
In a week’s time from the first outbreak, four farms had become
infected, and over eight hundred head of cattle had been shot.
The Government now became frightened and sent up another
order cancelling the stamping out policy, and leaving everything
in the hands of the farmers themselves, who were to do the best
they could to prevent Rinderpest from spreading. The farmers now
decided to adopt inoculation as a last hope. The resources of the
Veterinary Department were, as a result, taxed to the uttermost,
because once inoculation was started it had to become more or less
general. Through a friend of mine I was appointed on the staff
for the purpose of carrying out inoculation, and was at once
installed in this district in which, as I have described, Rinderpest
had broken out.
The method of inoculation advocated by the Veterinary Depart¬
ment was the method of Koch. The operation in detail is as
follows : — A beast suffering from Rinderpest, and in the last stages
of the disease, is shot. It is placed with its right side uppermost.
An incision is made into the abdominal cavity along the lower
margin of the ribs. The gall bladder is exposed, and the neck of
it is seized between the fingers and thumb. It is now detached
with a small portion of the liver. The gall bladder is now
thoroughly washed with water, and disinfected with some antiseptic
58 The Rinderpest of 1897 in Cape Colony.
solution. It is now punctured at some non-vascular part, usually
at the bifurcation of a small artery, and the bile is received into
vessels which had been previously sterilised with alcoholic solution.
The Government were very liberal in the supply of Cape brandy
for this purpose. It was also used for other purposes, indeed I
might say principally other. If the bile answered the conditions
laid down by Koch, it was retained for inoculation purposes. Of
the number of cattle shot for the purpose of bile, on the average
only two out of every five rendered bile fit for inoculation. Indeed
no rule seemed to be able to be laid down, as far as experience
wTent, with regard to the animals most likely to furnish bile
answering Koch’s conditions. The next thing that is done is to
repair to some place where every person taking part in the work
of obtaining the bile can be thoroughly fumigated. This is per¬
formed by exposing oneself to the fumes of burning sulphur in a
fumigating box for about twenty minutes. These fumigating
boxes were something like large sentry boxes with three round
holes, one in the roof and two in the sides, for the purpose of
allowing the heads to be put out. The saddlery and other accoutre¬
ments were also fumigated, and the horses had their hoofs washed
and their noses wiped with a solution of Jeyes’ fluid. Having
obtained the means for carrying out the operation, we now proceed
to the actual operation itself.
The cattle are driven together into an enclosed place, called in
South Africa a cattle kraal ; this is usually a rectangular space
surrounded by a wall, about five feet high, built of rough stones.
Fifty or one hundred head are driven into these kraals, according
to their size, and a band of natives, of about ten or twelve, is
employed catching and throwing them. They first lasso the beast
by the horns, which in South African cattle are exceedingly large.
Then a rope is passed round the hind legs, and another round the
fore legs. The horns and the tail are now pulled in one direction,
and the feet in the opposite, and the animal is most expeditiously
brought to the ground. The temperature of the beast is now
taken ; if it be normal, and no other suspicious symptoms be present,
the animal is inoculated in the dew-lap with 10 cc. of bile, having
previously disinfected the surface of the skin where the needle was
inserted. With a handy set of natives it was possible to inoculate
in this way up to two hundred head in a single day. It was,
however, a very hard day’s work, and such as in South Africa
white men are not accustomed to.
Koch’s method of inoculation in South Africa proved a failure.
59
The Rinderpest of 1897 in Cape Colony.
However favourably one may regard the results obtained by him in
the compound at Kimberley, surrounded as he was by skilled
assistants, who had ample means at their disposal for preventing
infection, we cannot overlook the fact that to perform the operation
in the open country, and in a district already infected with the
disease, was a work which had in it many of the elements of
failure.
The first attempt I made with Koch’s method was in a small
herd of fifty-seven. These belonged to a farmer on whose farm
Rinderpest had already broken out, but they were completely
isolated on the top of a mountain from the rest of the cattle on the
farm. These fifty-seven were each inoculated with 10 cc. of bile.
After the inoculation their temperatures went up to 105° and
107° F., but gradually became normal. On the tenth day after the
inoculation the cattle appeared again in perfect health. To prove
that these cattle were now immune from the disease, they were
inoculated again on the twelfth day after the first inoculation with
1 cc. of Rinderpest blood mixed with 9 cc. of salt solution. Their
temperatures again rose, and the animals to all appearance were
suffering from mild Rinderpest, which also passed off in from seven
to ten days.
Of the fifty-seven thus treated, seven succumbed to the second
inoculation, while the remainder remained in perfect health, although
subjected all round to Rinderpest infection. This result made me
for a long time a firm believer in Koch’s method.
Other cases, treated in precisely the same way, gave results
sometimes good and sometimes very bad — in fact the unfavourable
results were so discouraging that already in a great many districts
Koch’s inoculation had been abandoned. If we bear in mind the
fact that in all cases where the gall inoculations of Koch were suc¬
cessful the cattle must have been free from all infection or traces
of Rinderpest, not only at the time of the inoculation but for five
days later, when the period of immunity sets in — if we bear this
in mind I think we will be able to find some good reasons why
Koch’s method of inoculation did not succeed. We have first of all
the method of obtaining the bile. In a disease, the subtlety of
the contagion of which is without a parallel, one must confess that
it is a method involving great risks of infection.
Secondly, the immunity conferred by the bile did not set in till
the fifth day, and if in the meantime any infection should reach a
herd thus inoculated it will generate the disease in a most
disastrous manner.
60 The Rinderpest of 180 / in Cape Colony.
Thirdly, the period of incubation being from three to five days
there was always the great risk in an infected district of herds,
apparently healthy, having already the germs of the disease in the
process of incubation. These three reasons amply account to my
mind for the failure of Koch’s gall inoculation. It was no doubt a
great theory, but practical men could not make use of it with much
prospect of success. While Koch’s method was being tested,
another way of combating the disease was gradually forcing itself
upon the attention of inoculators. It is a very novel method, and
one which I am sure will appeal to all of us. It owes its success
to two French experts, Drs. Dansyx and Bordet, who were experi¬
menting in the Transvaal while Koch was carrying on his experi¬
ments in Kimberley. It is a curative method of treatment as
opposed to Koch’s method of prevention. It is essentially a system
of immune blood treatment. After many experiments with the
blood of animals which had recovered from the disease, they found
that by taking blood from an animal between 30 and 100 days
after its complete recovery and using that blood for the purpose of
inoculating cattle already infected with the disease, they were able
to check the disease, and the animal rapidly recovered, provided
the disease had not gained too much hold. The quantity of blood
used for the inoculation varied from 100 to 200 cc., according to
the progress of the disease.
This is a method for the success attendant on which I am pre¬
pared to vouch. I inoculated many hundreds of cattle already
infected with the disease by this method, and saved 70 per cent.,
those cases that succumbed being invariably cases where the disease
had gone too far. The method of procedure is as follows : — An
animal that has suffered from Rinderpest, and between 30 and 100
days after its complete recovery, is bled from the external jugular
to the extent of about three or four quarts. The wound is closed
up again. The blood is now defibrinated and used for inocu¬
lating purposes. The blood is injected subcutaneously. The
quantity used for one inoculation was usually about 150 cc.
Not having any hypodermic syringe of this size, and being
unable to get one, I used an ordinary enema syringe, one end of
which was inserted in a bottle containing a fixed dose, while to the
other end was attached the needle.
This method of immune blood inoculation eventually proved to
be the means by which Rinderpest was baffled in Cape Colony.
Many improvements have since been made upon the method, which
was first brought before the public by the two French experts,
61
The Rinderpest of 1897 in Cape Colony .
Dansyx and Bordet ; instead of using the blood which had been
previously defibrinated, the serum only need be used. This serum
can also be preserved for an indefinate time in a solution of phenol.
Besides, the curative properties of the serum can be increased by
previously inoculating the animal from which the blood is to be
obtained, with first 100 cc. of Rinderpest blood, followed by
200 cc., then 400 cc., up to 800 and 1,000 cc. of Rinderpest
blood. By this means the curative properties of the serum are
greatly increased, and much smaller quantities of it are sufficient
for inoculation.
Is not this one of the purest experiments that has yet been made
upon the question of the antitoxin treatment, if I may call it so, of
zymotic disease ? We have here the immune blood taken from an
animal of the same species. This is, I think, an important point,
and should not be overlooked, and just as the immune blood taken
from an animal of the same species would contain the cuiative
properties in a greater degree than that taken from an animal of
a different species, so I hold that immune blood taken from an
animal or man of the same family is even better than that taken
from the same species.
Note also that the serum derived from this immune blood can be
preserved for an indefinite time without losing its pioperties, and
so is always available. And again, the curative properties of this
serum can be increased to a wonderful degree. Are not all these
points of practical importance ?
In describing these two methods of inoculation — he ., Koch’s pre¬
ventive and Dansyx and Bordet’s curative — I have not said anything
with regard to the means by which one or other method confers
its immunity. The theories that have been put forward to account
for the action of these and similar methods of antagonising bacterial
diseases are, to my mind, insufficient, and based upon results that
have reacted in individual cases. To have a sound theory one
must be able to observe its workings towards similai results in
very dissimilar objects of application.
M. Pasteur may justly be deemed the first to overtake and
suppress by inoculation a process of specific infection. His theory
of action may be called “ the Theory of Attenuated Virus.”
With regard to this theory, which has deeply permeated the
mind of each one who engages in the study of immunity, I shall
ask this question — has it been proved to be a sound theory by its
successful use in many dissimilar objects of application, or is its
more or less general acceptance due to the success attendant on its
application to hydrophobia ? To my mind we must conscientiously
62 The Rinderpest of 1897 in Cape Colony.
admit, after carefully studying the matter, that it is due to the
latter fact. The success which M. Pasteur obtained in the treat¬
ment of hydrophobia by what he called “ attenuated virus ” can
be explained by a very different theory, and which is in reality but
a part of a more general theory which explains all the various and
subtle processes of inoculation conferring immunity.
The preventive method of vaccination against small-pox, the
so-called attenuated virus methods of inoculation for cholera in
chickens, anthrax in sheep, and hydrophobia in man, the antitoxin
method in diphtheria, and the coming methods in typhoid fever and
tuberculosis, are all brought in this theory very closely together,
and are represented as special examples of the general means by
which immunity is conferred. I do not for several reasons bring
this theory under the fire of criticism in this paper, but merely
show that my views are somewhat opposed to the present expressed
theories as to immunity conferred by inoculation.
Whatever in the future I see, or fancy I see, in store for the
antagonising of disease by inoculation may be mere dim visions,
nevertheless, through whatever medium each one of us may look,
I think you will all agree that there is an extensive field for
interesting observation and research.
ANATOMICAL PROPORTIONS OF DIFFERENT RACES.
Prof. Arthur Thomson, in Knowledge (June, 1899), gives us
an elaborate article on the proportions of the human subject
in various races — trunk to limbs, limbs to limbs, segments of
limbs to each other, and so on. The advantage of this kind of
information is best displayed in graphic form, so that the eye
may pick out the characteristics of each type. He therefore
gives skeleton sketches merely of straight lines. “The long
arms and the long legs of the negro are at once apparent, the
shortness of the upper in contrast with the lower limb in the
white man is very evident, whilst the short trunk, and pro¬
portionately longer lower limbs of the Australian are strikingly
displayed. The proportion of the upper limbs in the Javanese
and Southern Chinamen is almost the same, but the shorter
lower limbs of the latter are readily recognised. It is along
such lines as these that we venture to think progress will be
made. Provided we can obtain the necessary measurements
we can then present the results in a form which will demonstrate
with greater clearness and more lasting effect those minor
differences, on the sum of which racial distinctions depend. ;
ROYAL ACADEMY OF MEDICINE IN IRELAND.
President — Edward H. Bennett, M.D., F.R.C.S.I.
General Secretary — John B. Story, M.B., F.R.C.S.I.
SECTION OF OBSTETRICS.
President — F. W. Kidd, M.D.
Sectional Secretary — J. H. Glenn, M.D.
Friday, February 10, 1899.
The President in the Chair.
Specimens Exhibited.
Dr. E. Winifred Dickson— Small ovarian cyst removed by
laparotomy.
Dr. W. J. Smyly — (a) Four myomatous uteri removed by
cceliotomy; (b) Ectopic gestation removed by coeliotomy.
Dr. F. W. Kidd — Three cases of ovarian multilocular cysts
removed by coeliotomy.
Dr. Purefoy — (a) Quantity of hair from dermoid tumour ;
(b) Case of pyosalpinx removed by coeliotomy ; (c) Foetus arynchus ;
(i d ) Foetus showing procidentia uteri.
Dr. Glenn — (a) Case of dermoid tumour of both ovaries removed
by coeliotomy ; (b) Epithelioma removed by excision from the left
labium majus.
Dr. Alfred Smith— (a) Fibro-myoma of the Fallopian tube ;
( b ) Case of adherent ovary, tube and vermiform appendix removed
by coeliotomy; (c) Two cases of multilocular ovarian cysts.
Discussion on the Rotunda Hospital Obstetrical Report.
Dr. More Madden said the record was most creditable. He
believed this was due to the strict asepsis practised in the hospital.
Dr. Purefoy had set a good example in the use of ergot in post¬
partum haemorrhage. Though it was an old-fashioned treatment it
was most effective.
Dr. W. J. Smyly thought it was a very great gain to have done
away with the plug in the treatment of abortion. In the treatment
of placenta praevia the same method was used at present as during
his tenure of office at the Rotunda Hospital, when there was not
64
Royal Academy of Medicine in Ireland.
one death as the result of haemorrhage from placenta praevia, though
two cases had ended fatally. One of these patients had been
delivered by the old method of version and immediate delivery, and
had died after a short time from haemorrhage and rupture of the
cervix, and the other had died on the 10th day of pulmonary
embolism. Coining to accidental haemorrhage, he considered that
the best treatment was still practised — namely, that if the patient had
not strong labour pains it was a mistake to rupture the membranes,
and if there was external haemorrhage the uterus should be
plugged. In London, students taught at the Rotunda had been
rejected at examinations for not saying that they would rupture
the membranes in such cases. Even the nurses who go up for the
examination of the Obstetrical Society were instructed beforehand
to say, if asked what they would do in a case of accidental
haemorrhage, that they would rupture the membranes, which, he
thought, would be most improper. He objected to the use of the
expression “ the induction of artificial abortion ” in the Report, as
the term had a considerable amount of opprobrium attached to it,
and he considered that it would be better to say that they
accelerated abortion.
Dn. Macan pointed out that the mortality of the internal depart¬
ment was, contrary to what they would expect, twice that of the
external department. He deprecated the time limit of 4 hours as
an indication for the application of the forceps as given in the
Report. Indications on the part of the mother or child were admis¬
sible, but the time indication was ridiculous. He concurred with
Dr. Smyly in objecting to the expression “the induction of artificial
abortion.” He noticed a case of eclampsia which was stated to be
absolutely free from albuminuria, and therefore not capable of
being explained by the ordinary theories. There was a case of
brow presentation above the brim where the forceps had been
applied. He thought that the forceps was contra-indicated in such
a case.
Dr. Kidd referred to the fact that in about 50 per cent, of the
cases of rise of temperature after delivery no explanation of the
cause of this rise could be given. Surely they did not return to
the old idea that it was due to milk fever, and that the poison was
not of sufficient intensity to exhibit itself in the vaginal discharge.
Dr. Purefoy, Master of the Rotunda, in reply said that, with
regard to the use of ergot in post-partum haemorrhage, it was need¬
less to say that they used it only when the placenta was absent.
They employed Squibb’s preparation of ergot, and he commended
its use as it had given satisfactory results. One possible explanation
65
Section of Surgery.
of the fact that the mortality was greater in the internal than in
the external department was, of course, that the bad cases in the
external maternity were admitted into the hospital. The 4 hour
limit was only one and the least important indication in the use of
the forceps. The other indications on the part of the mother and
the child were also taken into account. He agreed that it was
unsatisfactory not to be able to assign a cause to the cases of rise
of temperature which Dr. Kidd had referred to, but the fact
remained that they were unable to give a tangible cause for the
elevation, as a large number were not interfered with, even to the
extent of a vaginal examination.
The Section then adjourned.
SECTION OF SURGERY.
President — R. L. Swan, President of the Royal College of Surgeons
Sectional Secretary — John Lentaigne, F.R.C.S.I.
Friday , March 3, 1899.
The President in the Chair.
Living Exhibit.
Mr. John Lentaigne — Case of arthrectomy for tubercular
disease of knee-joint eight weeks after operation.
Diseases of the Foot.
Mr. W. I. De Courcy Wheeler read a paper on some diseases
of the foot. Having described the anatomical points bearing upon
the subject, and entered fully into the distribution of the synovial
membranes, he detailed five cases of complete excision of the os
calcis, followed by the most satisfactory results ; one case of
excision of the os calcis and astragalus, with portions of the tibia
and fibula ; 13 cases of medio-tarsal operation, or Chopart’s opera¬
tion, all showing as favourable results as the patient (exhibited at
the Society) on whom he performed this operation twenty years
ago ; also three cases of complete excision of the astragalus for
disease, besides others for compound dislocation. There was a
brief record of 39 cases after Symes’ operation, also results after
Iripiers operation, which Mr. Wheeler was of opinion had as
many advantages over the subastragaloid operation as Chopart’s
had, but it has not the advantages claimed over the medio-tarsal
operation, except with those who believe that in Chopart’s opera¬
tion the astragalus is thrown forwards against the scar, which is
E
66 Royal Academy of Medicine in Ireland.
quite preventable in a properly executed medio-tarsal operation,
and does not occur when the plantar flap is made sufficiently long.
After a record of the excisions of various bones of the foot, and
six resections of the first metatarso-phalangeal articulation, the
paper concluded by a description of metatarsalgia, Madura foot, and
two cases of podal coma, so graphically described by Professor
Miller. One case completely recovered, the second had a recur¬
rence of the disease. There was no history of any constitutional
or predisposing cause why the patient’s foot- — a male about thirty-
two years of age — should be attacked by this painful disease,
except in Miller’s words, his u system was weak and miserable.”
His parents were both alive, and remarkably healthy.
A discussion followed, in which Mr. H. G. Croly, Mr. T. Myles,
the President, Dr. Henry Fitzgibbon, Mr. Chance, and Sir
Francis Cruise took part.
Mr. Wheeler, in reply, said that excision of the os calcis was
favourable, because the synovial sac is limited, thus preventing
rapid extension. The sooner the bone is removed the better, and
he did not approve of the gouge in removal, because it was difficult
to say whether one was in healthy or unhealthy tissue, and still
more, in strumous patients the use of the gouge might set up
inflammatory action which would produce more carious disease.
The podal coma he had seen was the same as that described by
Miller.
Perforating Gastric Ulcer.
Mr. T. Myles read a paper on “ Perforating Gastric Ulcer,’
and mentioned a number of cases on which he had operated. .
Amongst the most interesting of these was that of a gentleman
aged 72, who after the reduction of an umbilical hernia, developed
symptoms of perforation. The patient was under the care of Sir
Francis Cruise and Dr. Moran. When Mr. Myles was called in
the patient was sinking rapidly, with great pain and tenderness,
persistent vomiting of black tarry matter, evidently blood, complete
absence of liver dulness, tympany, &c. Operation seemed hope¬
less, but was undertaken in consequence of the dreadful agony
patient was suffering. The perforation was easily found, sutured,
and abdomen freely douched with hot saline. Patient [made a
complete recovery. The author pointed out that thej ease with
which an anterior perforation wTas found and handled contrasted
markedly with what happened when the perforation was behind,
and extravasation occurred into the sac of the peritoneum.
A number of interesting cases were detailed, and some illustrated
clearly the great difficulty of accurate diagnosis.
67
Section of Pathology.
Sir F. Cruise bore out all Mr. Myles said in his paper. He
had learnt from the case nil desperandum. The patient was almost
pulseless at the commencement of the administration of the chloro¬
form ; the pulse became much better when the chloroform was
changed to ether. The result of the operation was most extra¬
ordinary.
Mr. Wheeler congratulated Mr. Myles on the excellent result,
which showed that early operation offers better chances of recovery
than delayed operation. He preferred swabbing out the abdomen
to douching. He had seen saline solution revive a patient on
whom he operated for tubercular peritonitis. It depended on the
position of the perforation of the stomach whether the operation
could be rapidly done or done at all.
Mr. Chance mentioned the case of a young woman with gastric
ulcer who suddenly became collapsed with symptoms of perforation.
Laparotomy was at once performed, but thorough examination of
the stomach revealed nothing. The abdomen was closed, and
recovery followed. In another case, that of a woman, he opened
the abdominal cavity, and found in an abscess a small cavity, a
good deal of flocculent material, and a considerable quantity of
undigested food. He drained the abscess, and recovery followed.
The mortality of stomach operations seemed very high according
to statistics, because the operation was done for malignant disease.
Mr. Myles replied.
The Section then adjourned.
SECTION OF PATHOLOGY.
President — J. M. Purser, M.D.
Sectional Secretary — E. J. McWeeney, M.D.
Friday, February 24, 1899.
The President in the Chair.
Pneumococcal Septiccemia vcith Ulcerative Endocarditis consecutive
to Croupous Pneumonia .
Dr. McWeeney communicated this observation. The patient, a
man aged thirty-seven, was admitted on the 5th of December, 1898,
to the Mater Hospital, under the care of Dr. Murphy, with right
apical pneumonia. Crisis occurred on the ninth day, and was
attended with a good deal of collapse. Ten days afterwards patient
was allowed up one evening and got very weak. On January 1st,
68
Royal Academy of Medicine in Ireland.
an aortic systolic murmur developed, which became very bad ;
patient became prostrate and delirious, the temperature curve
assumed a pyaemic type, and death ensued on the 5th of January.
On the 2nd blood was taken, with strict precautions, from the finger,
and inoculated by means of a pipette on several tubes of oblique
glycerine agar. After twenty-four hours incubation at 37°, one of
these tubes presented a few extremely minute dewdrop-like colonies,
which proved to consist of Frankel’s pneumococcus. The other
tubes remained sterile as far as could be seen. At the autopsy
(forty-eight hours after) blood was aspirated from the right
auricle into a sterile bulbed pipette, and inoculated on agar tubes.
Owing to the solid coagulation, but little liquid could be obtained.
The incubated tubes showed numerous large circular colonies, like
discs of porcelain (probably the Bacillus coli ) but also very
many minute whitish, very delicately fringed colonies, which proved
to be the pneumococcus. A broth culture from one of them,
after twenty-four hours at 37°, was scarcely turbid, yet 1 c.c.
injected intraperitoneally into a rabbit caused death in seventeen
hours. Pneumococci with typical capsules were in the blood of
every organ examined. The other post mortem results were,
briefly: pericardium universally obliterated by recent adhesions,
parietal layer being readily stripped off ; myocardium of auricles soft
and friable like wet blotting paper. Right posterior cusp of aortic
valve presented a mass of vegetations as big as a cherry — colour,
greyish green where not covered with clot ; behind this the cusp
perforated, hole would admit an ordinary pen handle. Grey
hepatisation of most of the right lung. Spleen twice the natural
size, infarcted throughout. Embolus in primary branch of splenic
artery, fibrinous, crammed with pneumococci.
Case of Hodgkin’s 'Disease.
Dr. J. B. Coleman read a communication on the subject of
Hodgkin’s disease, and related a case of the disease which was re¬
markable for the acute clinical course, and for the widespread
distribution of the lesions. The patient, a labourer, aged fifty, had
enjoyed good health up to eleven weeks before his death. He gave
no history of alcoholism or syphilis. Glandular enlargements first
appeared in the left cervical and axillary regions. On admission
to hospital, three weeks before his death, he was somewhat
emaciated, but not anaemic ; skin dry and scurfy ; pulse and tem¬
perature normal ; all the superficial glands were considerably
enlarged, and there was evidence of enlargement of the thoracic
and abdominal glands also ; the glands were soft, freely movable,
Section of Pathology . G9
and painless ; spleen was easily palpable and liver dulness increased.
Examination of the blood showed haemoglobin and red cells
normal, the white cells 11,200 per cubic m.m. ; 40 per cent, of the
white cells being lymphocytes ; the blood contained no micro¬
organisms. The patient rapidly became more and more prostrate,
temperature was usually normal or subnormal, but on three oc¬
casions in three weeks it mounted to 100*5° ; his appetite failed, he
became delirious, and died with symptoms of toxaemia eleven weeks
from the onset of the disease. The necropsy disclosed universal
enlargement of the superficial lymphatic glands, as well as of the
mediastinal, retroperitoneal and mesenteric glands ; adenoid
nodules were present in kidneys, spleen, liver, and intestines ; the
spleen was greatly enlarged, and growing from its capsule, as well
as from that of the liver, were large masses of adenoid material ;
below the liver the retroperitoneal glands were enlarged and massed
into a tumour, which surrounded the aorta and involved the
adrenals. Cultural and inoculation experiments were carried out
with the assistance of Dr. McWeeney with negative results. Dr.
Coleman mentioned the arguments in favour of Hodgkin’s disease
being of an infective nature, and pointed out that numerous
observers had found micro-organisms in the diseased glands. He
also contrasted the disease with leucocythsemia, and said that
Cohnheim regarded Hodgkin’s disease as an aleuksemic Vorstadium
of leukaemia, whilst numerous observers had noted the transition of
the one disease into the other.
Dr. E. J. McWeeney said that he had received the organs in
this case in a fresh state, and, along with Dr. Coleman, had made
an exhaustive bacteriological examination. A great number of
tubes were inoculated, including serum of the ordinary kind and
glycerine serum. Inoculation was also done on a rabbit intra-
peritoneally with about two or three grams of the lymphoid material
ground up in an aseptic mortar. Examination of the rabbit a
month later showed no trace of the cellular material. Nothing
whatever grew upon any of the substrata. Therefore, he thought
that this well-marked case of Hodgkin’s disease was not dependent
upon any micro-organism capable of being made to grow in the
ordinary way. If shown the sections from the liver and kidney as
a fresh case, he should describe them as having the histological
characters of a small round-celled sarcoma, rapidly infiltrating and
destroying the specific tissue of each of the organs. The characters
were more like those of indifferentiated embryonic tissue rather
than the differentiated lymphoid structure of lymphatic glands and
spleen. It undoubtedly spread along the portal canals in the liver,
70 Royal Academy of Medicine in Ireland.
and along the large blood vessels in the kidney. The specific
tissue of the organs literally seemed to melt away before the ad¬
vancing army of the new cells. Mitoses were not found to any¬
thing like the extent that one would expect from the rapid
neoplastic process. A very remarkable feature was the occurrence
of localised amyloid degeneration in the vascular apparatus of the
affected organs. He asked Dr. Coleman if there was any history
of suppuration, syphilis, or tuberculosis to account for the lardaceous
disease. In the absence of these, the lardaceous chancre must be
considered part and parcel of the morbid appearances. One of the
cardinal symptoms of Hodgkin’s disease was absent in this case —
viz., oligocythcemia rubra.
Brigade Surgeon-Lieut.-Col. Burke said when at Gibraltar
and Malta he had seen many specimens of amyloid degeneration,
and the liver specimens now exhibited were very like those he had
seen due to syphilitic disease.
Dr. Coleman, in reply, said that there was no history of
syphilis or long-continued suppuration. Regarding the cardinal
symptom of anmmia, he said that anaemia is not necessarily a part of
Hodgkin’s disease, and only becomes marked as the case progresses.
Anaemia has been noted absent in undoubtedly true cases of the
disease.
Epithelioma of Lip from Youth Eighteen Years Old.
Mr. G. Jameson Johnston read the notes and exhibited micro¬
scopical sections of a case of epithelioma of the lip in a youth
eighteen years of age. The case had been reported in the British
Medical Journal in October, 1898, and the report elicited several
communications doubting the diagnosis. The microscopical ap¬
pearances were so obvious to him that he proposed merely to
submit the specimens for the examination of the members of the
Academy.
Breast containing New Growth removed from Youth Seventeen Years
Old , with Microscopic Sections.
Mr. Johnston also exhibited the left breast of a male patient,
containing a new growth in the left upper quadrant, about the
size of a large walnut ; radiating processes of the growth extended
in every direction into the gland substance ; the consistence of the
mass was quite firm, and to naked-eye examination very like
scirrhus. It had been steadily growing for three months in spite
of medical treatment, causing some slight discomfort, not actual
pain * there was no retraction of the nipple or dimpling of the skin ;
71
Section of Pathology.
the glands along the lesser pectoral were palpable before operation.
No history of injury could be obtained. The whole breast and
connective tissues and glands along the pectoralis minor were
removed. The wound healed by first intention. At the present
time (twelve hours after operation) no recurrence can be seen or
any enlarged glands felt. Microscopical examination showed the
growth to be mainly fibrous tissue, with what appears to be a few
short columns of gland cells here and there. Mr. Johnston felt a
difficulty in classifying the growth, and asked for expressions of
opinion as to whether it shouid be described as chronic inflammatory,
fibro-adenomatous or otherwise.
Dr. A. C. O’Sullivan thought that no one could doubt that
the first section was a squamous cancer. The breast section in
some places showed nothing but fibrous tissue, in other places it
showed a certain quantity of glandular structure. He was inclined
to speak of it as a fibro-adenoma.
Dr. E. H. Bennett said that a similar case of epithelioma of
lip in a youth of eighteen had been described in Pott’s works.
Dr. E. J. McWeeney considered the epitheliomatous nature of
the lip tumour most typical. The breast tumour appeared to him
to be chiefly fibromatous, if not exclusively so. There were some
tract-like structures composed of cells in elongated bands or strips
throughout, but the high power showed them to be more of the
nature of small thick-walled arteries running in the connective
tissue rather than glandular structures. However, there were also
some large oval spaces packed with cells which might indeed be of
glandular origin, perhaps of new formation, perhaps atrophic
portions of the mammary gland. He quite recently saw a breast
tumour removed by Mr, Hayes with exactly the same microscopical
structure as Mr. Johnston’s, but its naked-eye appearance was that
of scirrhus, except that it did not present any of the little yellowish
masses of fatty degenerated epithelial cells commonly seen.
Mr. Gr. J. Johnston, in reply, said that although he felt very
much inclined to agree with Dr. O’Sullivan from his description of
the structure of the breast tumour, still he was not inclined to
accept his naming it a fibro-adenoma. This tumour was absolutely
non-encapsuled. He doubted if the tumour of the lip recorded by
Pott as epitheliomatous was really epitheliomatous in the absence
of pathological investigation like that of the present day.
Sarcoma of the Suprarenals and Secondarily of the Lung.
Dr. J. Magee Finny showed the left lung and the right and
left suprarenals, which were the seat of sarcoma, with micro-
72 Royal Academy of Medicine in Ireland.
scopical sections of the lung made and explained by Dr. O’Sullivan,
Lecturer in Pathology, Trinity College, Dublin. The patient was a
man of sixty-six years, who was admitted to Sir Patrick Dun’s
Hospital, October, 1898, suffering from great prostration and
cough, and pain in the left side. The only well-marked signs he
possessed were those of encysted left pleural effusion, without dis¬
placement of the heart, and on exploration the diagnosis was
confirmed and the fluid found to be bloody. This character and
his constitutional cachexia made the diagnosis to be cancerous
pleurisy. The patient’s colour was very dark, but without the
characteristics of Addison’s melasma, while the sputum was free
from tubercle bacilli, and the urine from albumen. Death from
exhaustion took place March 20th, 1898. The morbid specimens
showed the left suprarenal to be converted into a mass of bloody
sarcoma the size of a goose egg— -the natural tissue of the gland
was obliterated, and the sarcoma, which was unencapsuled, rested
on and partly invaded the top of the left kidney, and was in
intimate relation to the renal vein ; from this vein a branch passed
directly into the sarcoma. The right suprarenal was also converted
into a sarcoma of similar character, but it was the size of a small
hen’s egg. The left pleura was greatly thickened and rough, and
contained a quantity of bloody exudation which was strictly
encysted, as had been mapped out during life ; the layer of pleura
pulmonalis was equally thick, and completely separated the
effusion from the pulmonary tissue. The centre of the lower lobe
of the left lung was a mass of soft broken-down sarcoma which
seemed to pass at different depths into the surrounding healthy
lung tissue. The microscopical character .of sections of the left
kidney and of the lung showed sarcoma of a mixed character, and,
what was most remarkable and strange, a number of giant,
polynuclear, or myeloid cells — containing as many as twelve or
fourteen nuclei cells, which resembled exactly those found in sarcoma
springing from the periosteum or ends of bone. The case presented
therefore the rare peculiarity — not unknown in the life-history of
sarcoma — of reproducing cells of connective tissue type, which is
not that of the matrix from which it grew, inasmuch as there
was a complete absence of any bone disease. The other point of
interest lay in the sequence of the diseased organs. From the
rarity of sarcoma being a primary disease of the lungs, and the
frequency of the suprarenals being the first affected, it is not im¬
probable, as Dr. O’Sullivan suggested, that the disease originated
in the connective tissue or vessels of the left adrenal, that by the
open vein it passed through the left renal vein into the circulation,
73
Section of Pathology.
and directly affected the right adrenal, and by embolic infarction it
found its final resting place in the substance of the left lung. The
most careful examination failed to show any extension from the
adrenals to, or through, the diaphragm.
Dr. E. J. McWeeney said that some of the sections showed a
very marked resemblance to tissue which he found in the kidney
as the result of an aberrant suprarenal growth originating from an
aberrant fragment of suprarenal. The curious thing seen in the
section was the presence of enormous giant cells, entirely like the
myeloid cells of bone.
Melanotic Sarcoma of Chorioid.
Dr. E. J. McWeeney (for Dr. Cole Baker) showed a melanotic
sarcoma of chorioid.
Pathological Fibulae and Patellce .
Dr. Knott demonstrated a series.
The Section then adjourned.
literary intelligence.
Some of the new books to be issued at an early date by Messrs.
J. and A. Churchill are as follows : — A work on “ Medical Elec¬
tricity for the Use of Students and Practitioners,” by Dr. W. S.
Hedley, Physician in Charge of the Electro-Therapeutic
Department of the London Hospital; “The Pathologists’
Handbook : A Manual for the Post-Mortem Room,” by Dr.
T. N. Kelyneck, Demonstrator in Morbid Anatomy at Owens
College, Manchester;’ “ A Text-Book of Physics,” by Professor
Andrew Gray, F.R.S., Professor of Physics in the University
College of N. Wales ; the book will be issued in three parts,
the first to come out being that on Dynamics, Properties of
Matter ; “A Handbook on Chemistry and Physics for Students
preparing for the first examination of the Conjoint Board,”
under the joint authorship of Messrs. Corlin and Stewart ; the
sixth edition of Dr. Eustace Smith’s “ On the Wasting Diseases
of Infants and Children;” the third and enlarged edition of
Dr. Bezley Thorne’s “ Schott Methods of the Treatment of
Chronic Diseases of the Heart ; ” “ Notes on Folkestone,” with
a Map of the Town, by Dr. Larking. The foregoing books will
in “almost every case be very fully illustrated.
SANITARY AND METEOROLOGICAL NOTES.
Compiled by J. W. Moore, B.A., M.D. Univ. Dubl. ;
P.R.C.P.I. ; F. R. Met. Soc. ;
Biplomate in State Medicine and ex-Sch. Trin. Coll. Dubl.
Vital Statistics
For four Weeks ending Saturday , May 20, 1899.
The deaths registered in each of the four weeks in the twenty-
three principal Town Districts of Ireland, alphabetically arranged,
corresponded to the following annual rates per 1,000 : —
Towns,
Ac.
Week ending
Aver¬
age
Towns,
Ac.
Week ending
.
Aver¬
age
April
29
May
6
May
13
May
20
Rate
for 4
weeks
April
29
May
6
May
1 o
lt>
May
20
Rate
for 4
weeks
23 Town
26-3
231
22-9
24-0
241
Limerick
30-9
_____
8-4
18-2
—
Districts
181
Armagh. -
21-4
21-4
21-4
14-3
19-6
Lisburn
42-6
21-3
o-o
8-5
Ballymena
5'6
22-5
28-2
11-3
16-9
Londonderry
28-3
11*0
17-3
20-4
19-3
Belfast
22-5
241
24-6
25-6
24*2
Lurgan
31-9
22*8
13-7
22-8
22-8
Carrickfer-
40-9
17-5
17-5
17-5
23*4
Newry
52-3
8T
8T
121
20-2
gus
45*4
26-9
Clonmel -
14-6
19-5
39-0
24-3
24-3
Newtown-
ards
5-7
39-7
17*0
Cork
31-8
22-8
18-0
23-5
24-0
Portadown -
12-4
37T
6-2
30-9
21*7
Drogheda -
45*6
11-4
41-8
38-0
34-2
Queenstown
5-7
17-2
11*5
34-4
17-2
Dublin
29-4
24-3
26-0
25-5
26-3
Sligo
60-9
10-2
15-2
20-3
26-6
(Reg. Area)
19-6
Dundalk -
16-8
16-8
29-3
4*2
16*8
Tralee
o-o
33-6
28-0
16-8
Galway
11*3
26-4
34-0
11-3
20-8
Waterford -
23-9
21-9
19-9
23-9
22-4
Kilkenny -
9-4
42-5
4-7
28-3
21-2
Wexford
1ST
9*0
1ST
4-5
12-4
In the week ending Saturday, May 20, 1899, the mortality
in thirty-three large English towns, including London (in which the
rate was 16*3), was equal to an average annual death-rate of 17*6
per 1,000 persons living. The average rate for eight principal
towns of Scotland was 19*0 per 1,000. In Glasgow the rate was
20*5. In Edinburgh it was 18*4.
Sanitary and Meteorological Notes. 75
The average annual death-rate represented by the deaths regis¬
tered during the same week in the Dublin Registration Area and
in the twenty-two principal provincial Urban Districts of Ireland
was 24*0 per 1,000 of their aggregate population, which, for the
purpose of this return, is estimated at 1,053,188.
The deaths from the principal zymotic diseases in the twenty-
three districts were equal to an annual rate of 1*6 per 1,000, the
rates varying from 0*0 in sixteen of the districts to 5*6 in
Tralee — the 3 deaths from all causes registered in that district
comprising one from diphtheria. Among the 172 deaths from all
causes registered in Belfast are 6 from measles, 3 from whooping-
cough, one from diphtheria, one from simple continued fever,
6 from enteric fever, and one from diarrhoea. The 34 deaths in
Cork comprise one from each of the following '.—Measles, whooping-
cough, and enteric fever. Among the 13 deaths in Limerick are
one from enteric fever and one from diarrhoea. The 12 deaths in
Waterford comprise 2 from measles.
In the Dublin Registration Area the births registered during the
week amounted to 182 — 86 boys and 96 girls ; and the deaths to
180 — 88 males and 92 females.
The deaths, which are 7 over the average number for the
corresponding week of the last ten years, represent an annual rate
of mortality of 26*8 in every 1,000 of the population. Omitting
the deaths (numbering 9) of persons admitted into public institutions
from localities outside the Area, the rate was 25*5 per 1,000.
During the twenty weeks ending with Saturday, May 20, the
death-rate averaged 29*4, and was 1*3 under the mean rate for the
corresponding portions of the ten years 1889-1898.
Nineteen deaths from zymotic diseases were registered during
the week, being one in excess of the average for the corresponding
week of the last ten years, and also one over the number for the
previous week. They comprise 2 from measles, one from scarlet
fever (scarlatina), 11 from influenza and its complications, 3 from
whooping-cough, and one from diphtheria.
As in the week preceding 17 cases of scarlatina were admitted
to hospital; 9 scarlatina patients were discharged, and 77 remained
under treatment on Saturday, May 20, being 8 over the number in
hospital on that day week.
The number of cases of enteric fever admitted to hospital was
8, being 3 under the admissions in the preceding week, and 2 under
the number for the week ended May 6. Eleven patients were
discharged, and 55 remained under treatment on Saturday, May 20?
76 Sanitary and Meteorological Notes.
being 3 under the number in hospital at the close of the preceding
week.
Six cases of diphtheria were admitted to hospital, being 4 over
the admissions in the preceding week, but one under the number
for the week ended May 6th ; 8 patients were discharged, one died,
and 20 remained under treatment on Saturday, May 20, being 3
under the number in hospital on that day week.
Thirty-six deaths from diseases of the respiratory system were
registered, being equal to the number for the preceding week, and 7
over the average for the 20th week of the last ten years. They
comprise 21 from bronchitis and 14 from pneumonia.
Meteorology.
Abstract of Observations made in the City of Dublin , Dat . 53° 20'
W., Long. 6° If/ W.^for the Month of May , 1899.
Mean. Height of Barometer, - 30*001 inches.
Maximal Height of Barometer (28th, 1 p.m.), 30*538 „
Minimal Height of Barometer (loth, 8 p.m.), - 29*334 ,,
Mean Dry-bulb Temperature, - - 51*0°.
Mean Wet-bulb Temperature, - - 47*5°.
Mean Dew-point Temperature, - - 44*0°.
Mean Elastic Force (Tension) of Aqueous Vapour, *288 inch.
Mean Humidity, - 78*2 percent.
Highest Temperature in Shade (on 31st), - 69*6°.
Lowest Temperature in Shade (on 27th), - 38*0°.
Lowest Temperature on Grass (Radiation) (on
6th), - - • - - 33*0°.
Mean Amount of Cloud,
Rainfall (on 16 days),
Greatest Daily Rainfall (on 17th).
General Directions of Wind, -
- 53*4 per cent.
- 2*095 inches.
- 0*358 inch.
N.E., E., W.S.W.
Remarks.
Both at the beginning and at the close fair anticyclonic weather
prevailed, calm, cold nights alternatingwithbright, sunny, and some¬
times warm days. During the central fortnight conditions were
cyclonic, and the weather was very disturbed, rainy and cold.
Rain fell daily from the 11th to the 24th inclusive, the total fall
being a little over the average.
In Dublin the arithmetical mean temperature (51*8°) was slightly
77
Sanitary and Meteorological Notes.
below the average (52*0°) ; the mean dry-bulb readings at 9 a.m. and
9 p.m. were 51*0°. In the thirty-four years ending with 1898,
May was coldest in 1869 (M. T.=48-2°), and warmest in 1893
(M. T.r=56-7°). In 1898 the M. T. was 51-2°.
The mean height of the barometer was 30*001 inches, or 0*012
inch above the corrected average value for May — namely, 29*989
inches. The mercury rose to 30*538 inches at 1 p.m. on the 28th,
and fell to 29*334 inches at 8 p.m. on the 15th. The observed
range of atmospheric pressure was, therefore, 1*204 inches.
The mean temperature deduced from daily readings of the dry-bulb
thermometer at 9 a.m. and 9 p.m. was ol*0°, or 3*/ above the
value for April, 1899, 47*3°. Using the formula, Mean Temp.—
Min. + {max. — min. x *47), the value was 51*4°, or 0*2° below the
average mean temperature for May, calculated in the same way,
in the twenty-five years, 1865—89, inclusive (51*6°). The arith¬
metical mean of the maximal and minimal readings was 51*8°,
compared with a twenty-five years’ average of 52*0°. On the
31st the thermometer in the screen rose to 69*6° — wind, E. On
the 27th the temperature fell to 38*0° — wind, W. The minimum
on the grass was 33*0° on the 6th.
The rainfall amounted to 2-095 inches, distributed over 16 days.
The average rainfall for May in the twenty-five years, 1865-89,
inclusive, was 2*030 inches, and the average number of rainy days
was 15*4. The rainfall and the rainy days were thus somewhat
above the average. In 1886 the rainfall in May was very large —
5*472 inches on 21 days; in 1869, also, 5*414 inches fell on 19
days. On the other hand, in 1895, only *177 inch was measured
on but 3 days. In 1896 the fall was only *190 inch on 7 days.
In 1898 as much as 3*332 inches fell on 20 days.
A lunar corona was seen on the 20th ; solar halos appeared
on the 1st, 17th and 29th. High winds were noted on 6 days,
but did not attain the force of a gale on any occasion. The
atmosphere was slightly foggy on the 10th, 12th, and 29th. Hail
fell on the 16th Thunder was heard on the 15tli.
During the month the thermometer did not fall below 32° in the
screen or on the grass. The mean minimal temperature on the
grass was 40*6°, compared with 4'2*9° in 1898, 40*9° in 1897,
43*1° in 1896, 41*8° in 1895, 37*6° in 1894, 45*6° in 1893, 41*3°
in 1892, 37*7° in 1891, 42*2° in 1890, 42*4° in 1889, and 37*5° in
1888. The maximum exceeded 60° on 10 days, but never fell
short of 50°.
The rainfall in Dublin during the five months ending May 31st
amounted to 9*652 inches on 87 days, compared with 10*568
78
Sanitary and Meteorological Notes .
inches on 84 days in 1898, 10*693 inches on 93 days in 1897,
5*971 inches on 70 days in 1896, 10*410 inches on 68 days in
1895, 12*709 inches on 90 days in 1894, 7*908 inches on 66 days
in 1893, 10*099 inches on 80 days in 1892, only 5*995 inches on
63 days in 1891, and a twenty-five years’ average of 10*496 inches
on 81*6 days.
At Knockdolian, Greystones, Co. Wicklow, the rainfall was
3*095 inches distributed over 16 days— *555 inch falling on the
17th and *500 inch on the 13th. The total fall since January 1st,
1899, equals 15*475 inches on 86 days, compared with 12*445
inches on 78 days in 1898, 14*120 inches on 90 days in 1897,
5*716 inches on 52 days in 1896, 12*845 inches on 58 days in 1895,
15*696 inches on 85 days in 1894, and 9*565 inches on 65 days in 1 893.
The rainfall at Cloneevin, Killiney, was 2*13 inches on 14 days,
*36 inch being measured on the 17th. The average rainfall in
May at this station during the 14 years 1885-1898, inclusive, was
2*063 inches on 13*4 days. Since January 1st, 1899, 11*15 inches
of rain have fallen at Cloneevin on 79 days. This compares with
a 14 years’ average of 9*685 inches on 71*8 days.
At the National Hospital for Consumption Newcastle, Co.
Wicklow, the rainfall in May was 2*240 inches on 16 days, compared
with 3*251 inches on 19 days in 1898, and 0*802 inch on 11 days
in 1897. The maximal fall in 24 hours was *550 inch on the
17th. Since January 1, 14*891 inches of rain have fallen at this
station on 83 days, compared with 12*459 inches on 74 days in the
corresponding 5 months of 1898. The maximum shade tempera¬
ture was 67*7° on the 30th, the minimum was 36*5° on the 6th,
15th and 27th.
PERISCOPE.
THE MICROBE AND THE APPLE TART.
Mr. G. Clarke Nuttall, B.Sc., in the June number of Knowledge ,
selects for his theme the change of colour from white to> reddish,
and then a dirty brown, which cut apples undergo as they lie
piled up in slices in the dish waiting for their covering of
paste — a change of colour forming a Gordian knot, which many
have attempted in vain to untie, and which even yet is not
altogether free. “ The latest and most thorough explanation
is one lately put forward by a chemist named Lindet. . . .
Within the cells of the tissues which make up the fleshy part of
the apple — the part that is eaten — there is produced in their
jelly-like contents a certain product to which the name malase
or laccase has been variously given ; and this product belongs
to a curious class of substances known as enzymes.
79
New Preparations and Scientific Inventions.
Now, an enzyme is a. production of the activity of the cell which
has the unique power of influencing other substances in its
neighbourhood, and yet remaining unaltered in any way itself.
It can exert influence without apparently being affected by
doing so. Its own constitution is stable, but it possesses
power to act, even at a distance, on certain of its surroundings,
and produce great effects on the constitution of other matter,
in some way not yet thoroughly comprehended.”
ELEMENTARY CHEMISTRY.
The Lancet (May 20, 1899) says that at a recent meeting of the
Chemical Society Professor Harold B. Dixon detailed the results
of some simple experiments, and they proved interesting. Thus,
in dealing with the combustion of carbon disulphide he found
that the vapour undergoes a, phosphorescent combustion in air
similar to that of phosphorus and sulphur. In the combustion
of carbon disulphide, in spite of the presence of an excess of
oxygen, small quantities of unaltered carbon disulphide as well as
oxysulphide and monoxide of carbon remain. In another paper
Professor Dixon showed that in the combustion of carbon it is
not strictly true that the formation of carbon dioxide is due to
a single and direct action between carbon and oxygen. It has
been accepted that carbon monoxide is only formed by a secon¬
dary action between carbon dioxide and carbon. On the other
hand, experiment s would seem to make it very probable that
in the combustion of carbon the incomplete product carbon
monoxide is first formed. This should throw some light on
the conditions; ensuring the perfect combustion of coal and coal
gas, and thus directly affect, the question of smoke abatement.
It is now well known, further, that in the products of the spon¬
taneous oxidation of coal at ordinary temperatures deadly carbon
monoxide occurs which would injuriously affect the health of
miners.
NEW PKEPARATIONS AND SCIENTIFIC INVENTIONS.
Hydrochloride of Heroin.
“Heroin” was introduced by Messrs. Friedr. Bayer & Co., of
Elberfeld, Prussia, in the autumn of last year, as a sedative in
affections of the air-passages. An account of the drug will be
found in the number of this Journal for February, 1899 (Vol.
CVII., p. 160). The wish for a neutral heroin salt, easily soluble
in water, and suitable for subcutaneous injection, has been frequently
expressed. This desire on the part of physicians the firm of
Messrs. Bayer have complied with by introducing the hydrochloric
acid salt of heroin, under the name of “Hydrochloride of Heroin.”
80 New Preparations and Scientific Inventions .
Hydrochloride of heroin is a white crystalline powder, melting
point 230°-231°, easily soluble in water (1-1*7), and also easily
soluble in alcohol. The aqueous solution is of neutral reaction,
and gives no reaction with perchloride of iron. The dose for
subcutaneous injection is the same as that of heroin itself — viz.,
one-twelfth to one-sixth of a grain. It is advisable, however, in the
case of a first injection to reduce these doses by one-half — viz.,
one-twenty-fourth to one-twelfth of a grain.
“ Tabloid” Effervescent Medicines.
Messrs. Burroughs, Wellcome & Co. have submitted to us
specimen tubes of “tabloid” caffe'in citrate effervescent, B.P.,
gr. 60, and “tabloid” effervescent sodium sulphate, gr. 60. These
preparations are typical of the new series of “ tabloid ” effervescent
preparations which the firm have introduced, and which includes : —
“Tabloid” caffe'in citrate effervescent, B.P., gr. 60; “tabloid”
lithium bitartrate (effervescent), gr. 5 ; “ tabloid ” lithium citrate
effervescent, B.P., gr. 60 ; “ tabloid ” lithium citrate (effervescent),
gr. 4; “tabloid” magnesium citrate (true, effervescent), gr. 60;
“tabloid” magnesium sulphate effervescent, B.P., gr. 60; “tabloid”
magnesium sulphate compound (effervescent) ; “ tabloid ” piperazin
(effervescent), gr. 5 ; “ tabloid ” potassium citrate (effervescent),
gr. 15; “tabloid” sodium phosphate effervescent, B.P., gr. 60;
“tabloid” sodium salicylate (effervescent), gr. 5 ; “tabloid” sodium
sulphate effervescent, B.P., gr. 60. In comparison with ordinary
granular effervescing preparations the effervescent “ tabloids ” are
wonderfully compact, portable, and convenient, whilst they offer
a much smaller surface for deterioration by damp or exposure.
They achieve an accuracy in dosage impossible with loose granular
preparations, and this exactness is independent of weighing or
measuring of any kind on the part of the patient. In water they
produce effervescing draughts of the various drugs at the moment
they are required. The purity of their constituents is of that high
standard characteristic of all “tabloid” drugs. The specimens
which we have received are as follows : — “ Tabloid ” caffe'in citrate
effervescent, B.P., gr. 60 (3*89 gm.). This preparation represents
the effervescent caffe'in citrate of the B.P., 1898, and contains
two grains of caffe'in citrate iu each drachm. One or two may
be added to half a tumbler of water. “Tabloid” sodium sulphate
effervescent, B.P., gr. 60 (3*89 gm.), represents the official prepara¬
tion. This last is a useful and convenient form for the regular
administration of sodium sulphate in constipation associated with
gouty and hepatic disorders.
THE DUBLIN JOURNAL
OF
MEDICAL SCIENCE.
AUGUST 1, 1899.
PART I.
ORIGINAL COMMUNICATIONS.
Art. V. — Diphtheria. Analysis of One Hundred Cases ,
By John Marshall Day, M.D. Univ. Dublin; Resi¬
dent Medical Officer, Cork-street Fever Hospital.
During the year 1898-9 we admitted into1 Cork-street
Hospital one hundred cases of diphtheria, amongst whom the
death-rate was 18 per cent. This is the largest number of
admissions and the lowest death-rate recorded in any year.
Of these cases we find 63 were females and 3T males.
The greater proportion of cases of diphtheria are under ten
years of age, sixty-six per cent, of the cases being under that
age, and for that reason we will lay most stress on the
diagnosis in young persons.
Me may lay down as a rule, first, that nearly all cases1 of
diphtheria, excluding wound diphtheria, are primarily
tonsillitic, and by extension invade the larynx and nasal
tract.
In diagnosticating diphtheria in children, four kinds of
sore throat must be kept in mind, viz. : — Scarlatinal, rheu¬
matic, diphtheritic, and septic, due to pus in the oral cavity,
as aphthae, &c.
The term membranous sore throat is now used only as a
loop-hole of escape for the over-cautious.
Scarlatina without a rash is not a disease of childhood. If
the throat symptoms be severe the rash is present in propor-
VOL. CVIII. — NO. 332, THIRD SERIES. F
82
Diphtheria .
tion, and well-marked, or there will be the diagnostic brown¬
ing at the flexures and red spots on the extremities, and
characteristic tongue. When the two diseases co-exist the
diphtheria nearly always takes on a nasal type in addition to
the formation of membrane on the tonsils. Also one gene¬
rally notices that in scarlatina the child looks heavier and
collapses much earlier than in diphtheria. One must always
bear in mind that the two diseases may co-exist, and when
the throat symptoms are suspicious make a bacteriological
examination.
Rheumatic sore throat is nearly always accompanied by
pains in the muscles of the neck or vague pains in the body,
sweating skin, redness of palate, pharynx and tonsils, deep
injection in spots, and often a rheumatic history and a
rheumatic purpura.
There is, I believe, greater difficulty in diagnosticating
pysemic throat from diphtheria, as it often presents very
similar appearances ; swabbing is the only true guide.
In the sore throat which arises from constipation the appear¬
ances are different. They are more like those of follicular
tonsillitis — one has not the enlarged glands, but a foul,
coated tongue, soft sweating skin, and faecal breath ; and
the patient is far more oppressed than is usual in diph¬
theria in the early stage.
The diagnosis of diphtheria is made by the presence of
membrane, enlarged glands under the angle of the. jaw,
temperature most frequently raised,* but sometimes sub¬
normal or normal ; a peculiar and very characteristic
f 03 tor often present, frequently with well-defined patches of
greyish or whitish hue on the tonsils, and often in the soft
palate ; these may be so large as to simulate a mushroom and
completely hide the back of the throat. These patches are
more or less adherent, will not come away with a cotton wool
swab, or if removed leave a bleeding surface ; or the mem¬
brane will be a soft pultaceous looking matter, darker iii
colour and more offensive. Sometimes one may see round
holes dug out with jagged, sloughing edges, easily distin¬
guished from the empty abscess cavity, or an irregular ulce¬
rated surface with greyish purulent matter adhering ; some¬
times one can see only congealed blood and sloughing throat
with intense foetor. This is a very fatal form ; therefore, one
83
By Dr. J. M. Day.
may conclude that, when a child suffers from a sore throat
with membrane which will not wipe off easily, or ragged
ulceration with foetor, enlarged glands, especially if accom¬
panied by nasal discharge, and husky voice, one should bear
diphtheria in mind, and, failing to put it under any other
heading, treat it as diphtheria,, and inject at once and swab
(before applying anything else to the throat), so as to con¬
firm the diagnosis. Injections do not cost much, are not
painful, do not require the services of a surgeon, and may in
an emergency be administered with an ordinary hypo¬
dermic needle, and so far as our present knowledge goes, are
free from any injurious effects even when the case proves
not to be diphtheria.
If the patient has been in contact with infected persons,
the throat may be simply red, though not much swollen, and
no membrane visible. This absence of membrane has not
been noticed in children (cases with a large quantity of
membrane often do very well, and the converse also holds).
One cannot base a prognosis on the quantity of membrane,
but finds wdiere the membrane is well defined and raised the
cases do well, also when the temperature is over 101° on the
second or third day the prognosis is mostly favourable.
What strikes one most about the disease is its insidious
nature, and the frequency with which it is present in the
throat without the patient making any complaint.,
As is seen in scarlatina often when the throat is much
engaged the patient swallows well, the membrane or secre¬
tion acting like a glove, and deadening sensation.
The first symptoms of diphtheria in a child are generally
vomiting, headache, lassitude, and sometimes pains in the
bones. On examination one notices the enlarged glands
under the angle of the jaw, the tired facial expression, and
a peculiar foetor from the breath, which is diagnostic, as
is the foetor of typhus. The tongue as a rule is very
dirty. There is more or less membrane on the toiisils, palate
and pharynx, which presents the various appearances de¬
scribed above.
Prognosis — The earlier a case comes under treatment the
better the prognosis. When we analyse the 100 cases we
find 48 entered as having been only one or two days ill. Of
these six died — death-rate 12*50. Four died of laryngeal
84
Diphtheria-
symptoms, within ten hours of admission, two had nasal
discharge and died on the fourteenth day. I think we aie
correct in assuming that these cases were longer ill than
stated — he., that the membrane had been present on the
throat for several days before the larynx and nostrils
became engaged. Nineteen were three days ill. Of these
five died, showing a death-rate of 26 per cent. Four died on
the seventh, and one on the fourteenth day. Twelve were
suffering from scarlatina, of whom four died, showing a
death-rate of 33*3 per cent.
The cases under treatment varied greatly in severity at
different periods. Sometimes there would be a run of severe
cases, and sometimes of slight, so that prognosis could, to a,
certain extent, be based on the prevailing type.
We can classify diphtheria into tonsillitic, nasal, and
laryngeal. There were 6T of the first class with two deaths,
27 nasal with ten deaths, and 16 with laryngeal symptoms,
with six deaths.
One may lay down the axiom that the earlier the nasal
discharge appears and the more foetid it is, the worse the
prognosis ; one also finds that in scarlatina, the nasal type is
most common at the early stage, and the laryngeal type in
the convalescent stage.
The insidious nature of the disease is one of its most
dangerous characteristics — for instance, a woman brought in
an infant early one morning which had died on the way to
hospital, and the history she gave was that it “ got bad with
its breathing in the middle of the night.” Examination
showed that it was a case of diphtheria probably of several
days’ duration, and on questioning her about the other chil¬
dren she stated that they were quite well, and going to
school, but we found on examination that the mother and
two children were suffering from diphtheria, the children
eventually recovering after a very severe attack.
I have seen a child playing about the garden, and, on
examination, found liis throat, covered with membrane.
The period of dying is distinctive. Most of the cases die
on the 7th, 14th, or 21st day of illness. Some die quickly of
the intensity of the poison, with all the symptoms of intense
blood destruction, evidenced by hcemorrhagic purpura,
diarrhoea, vomiting, collapse, with putrid nasal discharge ;
85
By Dr. J. M. Day.
some of laryngeal obstruction and pneumonia; some of
•cardiac failure ; and lastly, of prolonged fever, diarrhoea,
and exhaustion. One may see grave cardiac paralysis
come on about ten days after very slight throat symptoms.
The treatment we have found most successful is, the
injection of 750 to 1,000 units of antitoxin into the thigh or
behind the shoulder with simple antiseptic precautions
(when we injected into the abdominal walls we found that
diarrhoea ensued in several cases). This may be repeated
next day, but we have not found it of much avail in severe
cases where the nasal trouble has been long present. Much
larger doses are sometimes given, but I think it is of
greater importance to get a reliable antitoxin, and give
calomel, grains 1 or 2 every hour or two hours until the
bowels be well moved. This seems to me to be of particular
benefit in laryngeal cases. Dry the throat with cotton wool,
and apply Loeffkr’s solution to the parts, holding the swab
for a minute, if possible against the membrane ; spray the
throat frequently with paroleine in which 10 grains each of
salol and menthol have been dissolved. Tf there be much
tonsillitic swelling we sometimes apply poultices to the neck,
bringing them up above the ears, we use internally a
mixture of liq. ferri liydrochlori. and quinine, in doses suitable to
the age of the patient. For the nasal discharge we use warm
solution of carbolic acid, one in 40, with bread soda, 60
grains to the 6 ounces as a douche. With older patients if
they complain of pain in swallowing, a Kelson’s inhaler with
carbolic acid solution is used. We seldom order stimulants
in the early stages, as alcohol vitiates the action of anti¬
toxin, and there is no need as a rule. Ko case developed
laryngeal symptoms after admission, and only one died of
cardiac failure, a girl aged 7 years, on the fourteenth day of
a severe attack with nasal discharge.
We have nothing special to report in reference to the
kidneys, as none of the cases developed nephritis.
Eight convalescents had paralytic symptoms which called
for special treatment, several others showed slight transient
paralysis of the palate or eye muscles.
The length of time the throat may remain infectious after
an attack is very variable. We never discharge a patient
until all redness has disappeared, and when after rest for
86
Diphtheria.
twenty-four hours from all treatment, the swab gives a
negative culture. We have found in one case the bacilli
present a month after all membrane had disappeared, and
in another which had slight redness of the throat five weeks
later. Of course we do not consider a case safe till the
mucous membrane of the nostrils is normal : in two cases
the membrane reappeared ; in one on the 19th and in the
other on the 14th day after injection of 750 units.
In the Metropolitan Asylum Board’s Report, we find that
diphtheria is most prevalent in the winter months. With
us most of the cases were admitted in July and August, and
September and October. We also find that their death-
rate is 20*9 per cent, with serum treatment, which accords
with ours of 18 per cent.
On looking back over the cases there is not one in which
we regret having withheld operative interference, as those
cases classified as laryngeal which died, did not die as a rule
of dyspnoea, and all its accompanying distress, but of
diarrhoea and pneumonia, and in some cases so soon after
admission that interference was not possible.
As regards operation, the ideal cases would be where the
laryngeal symptoms supervene after the child has come
under treatment. In such cases the rule to follow is, so long as
the patient sleeps it is best to wait, but if the patient becomes
restless, or is becoming comatose, operate at once. I believe
in several cases the laryngeal symptoms were due not to
membrane but to swelling of the vocal cords, with a certain
amount of spasm, which generally passes off without opera¬
tion.
Unfortunately our statistics of operation cases show bad
results. Of the two cases in which we operated imme¬
diately after admission, one died in the night suddenly from
obstruction of the tube, and the other slowly from extension
of the membrane down to and below the bifurcation of the
trachea. Is such cases one can only promise to give relief
and produce a condition of euthanasia, but naturally the
prognosis is very grave.
Since writing the above we have had a successful case
after tracheotomy, which was done eighteen hours after the
patient’s admission, a child aged two years. In this case
the patient was becoming rapidly comatose.
The Hot Air Bath.
8T
Art. VI. — Some Theoretical and Practical Remarks on
the Hot Air Bath. By Dr. M. Altdorfer, Wiesbaden;
late Resident Physician at St. Ann’s Hill Hydropathic
Establishment, Cork.
During the time of my connection with St. Ann’s Hill
Hydropathic Establishment, Cork, it has often astonished
me that the views of the medical profession with regard to
the value of the hot air or Turkish bath should vary so
very much, as they do. Some physicians, it is true, are
very enthusiastic about this method of treatment, and
recommend it freely to their patients; but, on the other
hand, there are a number of practitioners who are still pre¬
judiced against it, and consider it their duty to warn
everybody of the dangers lurking behind the walls of this
bath. Now, as I have been living for over twelve years
under the most favourable conditions for watching the
action of the hot air bath at close quarters, mixing freely
with the patients in the bath, and having them under my
observation during the whole day, perhaps the conclusions
arrived at under these circumstances may be of some
general interest.
St. Ann’s Hill, the birthplace of the Turkish bath as
used at present, is frequented by a good many persons
who have been devoted to the bath since its introduction
into Western Europe, and, consequently, the atmosphere
is' charged with an enthusiasm not found anywhere else.
You meet there people who will tell you in all seriousness
that as long as you only stick to your Turkish bath you
may live just as you please — you may eat and drink what
you like, wear whatever you wish, expose yourself to
colds, draughts, or any kind of infection ; in fact, you may
break every known hygienic law with impunity. The
bath is sure to protect you from every harm. Now,
although we need not go so far as these enthusiasts, there
still remains a good deal to be said for the therapeutical
value of the hot air bath, which we shall understand better
when we see how close an imitation the bath is of the
means which nature herself employs in dealing with
disease.
The Hot Air Bath.
88
Recent researches have shown, on the one hand, that
in bacterial diseases the noxious element is not so much
the micro-organisms themselves as their metabolic products,
the “ toxins,” and, on the other, that the morbid symptoms
in a great many other pathological conditions are due to
the presence of certain animal alkaloids in the blood, pro¬
duced within the body through faulty action of the cells,
which have been called by Gautier “ leucomai'ns,” and
are now generally known as “ autotoxins ” (Brieger and
Fraenkel). The accumulation of these deleterious sub¬
stances is held to be the direct cause of the “ constitu¬
tional” diseases, of which rheumatism, gout, diabetes and
anaemia are representatives, as well as of a great many
“functional” diseases of the nervous system, such as
neurasthenia, Graves’ disease, Addison’s disease, and cer¬
tain mental affections, in which autotoxins have been
elaborated through morbid metabolism of the nerve cells.
Moreover, the autotoxins are indirectly harmful, since they
weaken the power of resistance of the body, and cause the
u disposition” to infective diseases by preparing a suitable
soil for the growing of the bacilli and the development of
their products, the toxins. Now, as we know that these
organic bases — toxins as well autotoxins — are soluble in
the blood, which is proved by the fact that they are found
in the urine and that they are highly oxidisable,a the most
rational therapeutics in these pathological conditions would
be to destroy these deleterious substances by endeavouring
to increase the physiological eliminations and oxidations
within the body. In this we should only follow the ways
of nature, who works by such means with regard to pre¬
vention as well as to cure. Gautier holds that poisonous
alkaloids are continuously being formed in healthy men
and animals by the metabolism which occurs during the
functional activities of life, but that there are two physio¬
logical inodes or vital mechanisms constantly at work in
our bodies to protect us against auto-infection — viz.,
“I., the elimination of the toxic products as excretions by
the various emunctories — the liver, the kidneys, the skin,
a Dr. A. M. Brown : “ Treatise on Animal Alkaloids.” London. 1887.
Preface by Gautier. P. 28.
89
By Dr. M. Altdorfer.
the lungs, and the intestinal mucous membranes ; II., the
destruction of the toxic products by oxygenation, which
consists in a continuous combustion of the leucomains by
the oxygen of the blood, in which they are burned or con¬
sumed in its current, or partially in the tissues and organs.” a
These physiological processes are quite sufficient in a
normal state of health, but when owing to some patholo¬
gical conditions an accumulation of toxins or autotoxins
has taken place, then it becomes necessary that all the
vital functions, more especially the eliminations and the
oxidations, should be roused to greater activity in defence
of the organism. A more thorough elimination will be
effected either by copious discharges of the bowels, or by
profuse perspiration and increased action of the kidneys.
In the stools of typhoid fever, and in the urines of patients
suffering from typhoid and pneumonia, the presence of
alkaloids has been detected by Sequin, Guerin, Lauder
Brunton and others, and with regard to perspiration Prof.
Queirolo, of Genoa, b has made some interesting experiments.
He injected into rabbits the sweat of patients suffering
from various fevers — such as small-pox, malaria, rheumatic
fever — and checked the results obtained by other experi¬
ments, in which the perspiration of healthy persons was
used. He eventually found that all the animals which had
received a sufficient dose of the sweat of fever patients
died after from two to forty-eight hours, whilst the animals
into which the same or even a larger quantity of the
healthy perspiration had been injected were in no way
affected. The results of these experiments have been
corroborated by Ziegelroth and others, who have also
discovered bacilli in pathological perspirations. As to
oxidations, it has often been proved experimentally that
during the pathological storm which we call “fever” the
processes of oxidation within the body are considerably
increased, the excretion of C02 being raised by from 70 to 80
per cent. Finklerc has ascertained that in guinea-pigs
not only the excretion of C02, but also the absorption of
a Sir W. Aitken : “On the Animal Alkaloids.” London. 1887. P. 18.
b Brit. Med. Journal. 7 July, 1888.
c Pinkler: “Ueber das Fieber.” Pflueger’s Archiv., vol. XXIX.
90
The Hot Air Bath.
O into the blood, was augmented during fever by from 10
to 16 per cent., and Kraus a has found that the absorp¬
tion of O in men was increased by 20 per cent, during
acute feverish diseases. At the same time the view that
high temperatures in themselves are not only not neces¬
sarily injurious — the well-known “aseptic ” fever of Volck-
mann being a case in point — but that they even have a
beneficial effect, is gaining ground more and more. Loewy
and Richter*3 have shown that the resistance of rabbits to
the virus of pneumonia, diphtheria and hog cholera is
greatly increased if before inoculating with the virus the
temperature be raised by injuring the corpus striatum, and
Kast,c who has experimented with the bacilli of typhoid
fever on rabbits, has arrived at similar conclusions. With
regard to the effect of fever on the human constitution, it
has been observed that, if a diabetic is attacked with
fever — for example typhoid — sugar may temporarily dis¬
appear from the urine, the excess of sugar in the system
being presumably burnt off, and H. Campbell d has pub¬
lished a series of cases in which febrile disorders have
had a curative effect on other maladies, such as rheu¬
matism, dyspepsia, anaemia, rhinoscleroma, and mental
diseases.
In addition to increased eliminations and oxidations I
must mention another means of defence employed by the
organism, which has been studied more closely of late —
viz., leucocytosis, which is always found to be present
in acute febrile diseases (Riegel and Bockmanne). It is
presumed by Brieger, Kitasato, and others, that the leuco¬
cytes play a prominent part in destroying the toxins in the
body by forming antitoxins, and this view is borne
out by clinical observations which show that diseases
with a pronounced leucocytosis take a more favourable
course than those in which this symptom is wanting.
Experimentally the very striking fact has been discovered
a Landois : “ Physiologic.’ ’ 1896. P.427.
b Deutsche med. Wochenschrift. 1895. No. 15.
c Verhandlungen des Congresses f. innere Medicia. 1896.
d Brit. Med. Journal. April 30, 1898.
e Landois, loc. eit., p. 35.
91
By Dr. M. Altdorfer.
by Loewy and Bichtera tbat animals in which by injection
of spermin an artificial leucocytosis bad been produced
could stand witb impunity from three to four times the
dose of the virus of pneumonia, which would have been
fatal under ordinary circumstances. All these observations
certainly seem to support the old theory that fever is a
defensive mechanism of the body, a determined effort on
the part of the constitution to overcome the disease.
Now, if we look about us for a means of imitating the
ways of nature in her struggle with disease, we shall not
be able to find anything better than the hot air bath.
The beneficial action of this bath in removing effete and
noxious substances, and even micro-organisms from the
blood through the free perspiration it produces has been
known for a long time, and in addition to this its 'physical
effects have been dwelt upon by observers like I rey and
Heiligenthal,b Coley, and others, in particular, the temporary
dilatation of the small blood vessels of the surface of the
body by which the blood pressure is altered, the work of
the heart relieved, the circulation quickened, congestion
of internal organs removed, and the general tissue change
promoted. In a paper published in 18b8c I have myself
drawn attention to the chemical action of the different
processes which make up a Turkish bath, more especially
to the efiect on the gas exchange — the excretion of C02 and
absorption of 0 by the human body. I have pointed out
that, whereas under ordinary circumstances the respiratory
activity of the skin is very slight, it has been proved that
the excretion of C02 is increased by raising the surround¬
ing temperature, “in fact it may be doubled” (Landois).
In the hot room of the Turkish bath, when a great amount
of blood is circulating in the widely dilated cutaneous blood
vessels, when after the desquamation of the superficial
epithelial layers the partition between air and blood is
a Loewy and Richter: “Ueber den Einfluss von Eieber and Leucocytose auf
den Verlauf von Infection s-krankheiten.” Deutsche med. Wochenschrift.
11 April, 1895.
b Frey and Ileiligenthal : “Die heissen Luft und Dampfbseder. Leipzig,
1887.
0 The Hot Air Bath in Relation to Ptomains and Leucomains. Medical
Press. May, 1888.
m
The ITot Air Bath.
very thin, when the skin is covered with perspiration —
the gas exchange through this organ must be greatly
facilitated, the endosmosis of oxygen highly favoured.
The bather is, therefore, somewhat in a similar position to
animals with a thin, moist epidermis, and it is a well-estab¬
lished fact that in frogs the exchange of gas through the
skin is so great that this organ may partly replace the lungs
functionally, from two-thirds to three-fourths oi all the
excreted C02 being yielded by the skin (Landois). In the
following stage of the bath, when the exposure of the
body to hot air is followed by the external application of
cold water in the form of a plunge bath or douche, the
gas exchange and the interstitial oxidations are even
more powerfully influenced. Landois, speaking of warm¬
blooded animals, states that, 4 4 as the cold of the surround¬
ing medium increases, the processes of oxidation within
the body are increased through some as yet unknown
reflex mechanism. On passing suddenly from a warm to
a cold medium the amount of C02 and the absorption of 0
is considerably augmented,” as Finkler has proved by
experiments on rabbits. It has always to be borne in
mind that excretion of C02 is the primary process in the
gas exchange, and that only by promoting the intercellular
oxidations and the excretion of CCL we can increase the
absorption of 0, which is dependent on, if not parallel to,
the former process. Winternitz has always emphasised
the fact that by such thermal stimuli as we use in hydro¬
therapeutics we are enabled to powerfully influence the
intercellular oxidations, and even the morphological com¬
position of the blood. According to this authority the
effect of cold water applications is not only a considerable
increase in the excretion of 002 and absorption of O, but
also a greater alkalinity of the blood, and a very remarkable
leucocytosis, the apparent increase of the white corpuscles
being probably due to a stirring up and a better distribu¬
tion through the general circulation of those cellular
elements which have been stagnant in such places as spleen
and spinal cord.a We always finish the process of bathing
in the cooling room by resting for some time in a cool
a Winternitz and Strasser: “ Hydrotherapie.” Berlin. 1898. P.72.
93
By Dr, M. Altdorfer.
atmosphere, and here the stimulus given to intercellular
oxidations and absorption of oxygen is still kept up. “In
animals with the temperature of the surroundings at 46° I .
the C02 given off was one-third greater than with the
temperature at 100*4° F.” (Landois).
If in addition to the above considerations we think of
the fact that the blood after the great loss of fluid is more
concentrated and, therefore, allows the blood corpuscles
charged with oxygen to come into closer contact with the
microbes, and that by the moderately -raised temperature
of the blood the cells, especially the phagocytes, are
roused to greater activity, it seems evident that by resort¬
ing to the use of the hot air bath we have it in our power
to give a valuable assistance to the cells of the body in
their struggle with microbes, toxins, autotoxins, and
other enemies. We are , in fact, working on the lines of real
cellular therapeutics. In another paper* I have pointed out
the striking similarity between the effects of fever and of
the hot air bath on the human organism. In both condi¬
tions we find increase of temperature , up to 101 and 102 1 .,
of pulse, respiration , excretion of urea ancl uric acid, alkalinity
of the hloocl, excretion of C02, absorption of 0, and of general
leucocytosis. Now, if we observe that acute diseases
accompanied by fever generally take a rapid course, whilst
the chronic ailments are most frequently very lingering,
we should be glad to have at our disposal a means of
imitating the action of fever in a manner perfectly harmless
for the constitution, which has this advantage over the
artificial fevers caused by injection of erysipelas virus (as
recommended by Fmmerich and others), that we can
interrupt the process at any time and bring the body back
to normal conditions, and that no consumption of the
tissues is caused by it.
All these theoretical reflections must lead to certain
practical consequences with regard to the working of the
Turkish bath. If we consider the gas exchange and the
processes of interstitial oxidations of such importance in the
therapeutical action of the bath, it follows, as a matter of
a “ Heilfieber und Heissluftbad, ein Vergleich.” Deutsche Med. Ztg. 1888.
Nos. 76, 77.
94
The Hot Air Bath.
course, that, in the first place, we have to pay special
attention to an abundant supply of pure air and fresh
oxygen. On this account it is desirable that the Tuikish
bath should be situated in a locality where abundance of
ozone and no pollution of the air by organic substances is
to be found, if possible in the country. Free access of
oxygen to the bather being of the utmost importance the
ventilation of the different chambers of the bath should be
well looked after, and in connection with the question of
ventilation I should like to emphasise the necessity that in
the hot room the ventilators or foul air conduits should be
placed at the floor level , for the air becomes laden with
carbonic acid and other poisonous exhalations from the
lungs of the bathers, and as the normal temperature of the
body rises but a few points in the hot chamber these
exhalations in addition to being heavier than air are very
much below the average temperature of the sudatory
chamber, consequently they fall and must be extracted at
the floor level. Since we know that effete matters,
particles of waste tissue and possibly even the germs of
disease, are continually being given off by the perspiring
bathers, which must be prevented from finding a lodgment,
it follows that the employment of porous and absorbent
materials should be guarded against thoughout the sudatory
chambers. For this reason I prefer the old-fashioned
wooden clogs for the feet to the soft carpet in these rooms.
With regard to the plunge bath or douche I hold that the
application of water in this form should be of short dura¬
tion but as cold as can be borne, except in cases in which
special caution is indicated on account of some constitu¬
tional weakness. Experience has shown that the more
intense the thermal stimulus, which means the greater the
difference in the temperatures of the media employed, the
more lively the oxidations within the body will be by re¬
flex action. The cooling room ought to be really cool and
not warm as is very often the case. Cool air, in addition to
stimulating general metabolism, has the advantage that it
restores the tone of the skin much quicker than warm air,
which means saving of time and a more buoyant feeling
of health after the bath. If, as we have seen above, the
95
By Dr. M. Altdorfer.
increase in tlie gas exchange through the skin and lungs,
started in the first two stages of the bath, is continued in
the cooling room it must be a great mistake to wrap the
body in sheets or blankets as the process of breathing
through the skin can be best facilitated by exposing the un¬
covered body as much as possible to the surrounding air,
and vitiating the air of this room by tobacco smoke
becomes, of course, from a hygienic point of view, a sheer
absurdity.
All these observations go to show that we have in the
hot air bath a very important curative agent, but if we
wish to get the full value out of it — that is, if by its use we
want to counteract efficiently the formation of a virus or
the development of a bacillus in the body — the bath should
be taken much more frequently than is usually done. As
a luxury it may be taken once a week, but for therapeuti¬
cal purposes this is not sufficient, at least two baths daily
ought to be the rule. The fear that this would be
“ lowering ” to the constitution is quite groundless. I
have had ample opportunity of observing the good results
of two or even three Turkish baths daily, which are not
weakening because the perspiration set up by heat applied
from without causes no wasting, (It is, of course, very
different in the case of the spontaneous sweating of the
consumptive, when the lost heat has to be supplied from
within.) The chief use of these baths in the training of
athletes, jockeys, &c., consists in the beneficial effect they
have on the relief of muscular fatigue by removing the
waste products of the muscles’ own activity and by sup¬
plying them with fresh oxygen, not in keeping the weight
down. Other things being equal a course of Turkish
baths rather tends to a gain in weight than to a loss, the
appetite being improved and the digestion as wrell as
the assimilation of food greatly promoted. An increase of
two pounds per week is quite a usual occurrence, and I
have known people who took two baths daily to put on as
much as five pounds in a week. To reduce a person by
Turkish baths only is much more difficult, and it can only
be done by modifying the process of bathing in such a
way that heat is only employed for a short time and that
96
The Hot Air Bath.
liberal use is made of cold water applications by repeated
and prolonged douches or plunge baths, the loss of heat
being made good by the burning up of the superfluous
adipose tissue.
From my own observations I am bound to say that I
consider the hot air bath a greater boon to the feeble and
delicate than for the strong and robust, who by all kinds
of bodily exercise are able to occasionally raise the tem¬
perature of their bodies and to stimulate all the vital
functions of the different organs. The vicarious relation
in which this bath stands to exercise gives it a value
hardly to be exaggerated in the management of such
cases as, whether through simple lack of strength or the
disablements of disease, have become incapacitated from
complying with a condition of health so fundamental and
far-reaching as physical exercise, and it has the additional
recommendation that it can be resorted to at all seasons
and under all climatological conditions. Over the customary
cold tub it has this advantage— -that by the heating of the
body before the application of cold water the necessary
reaction is secured, and that thus even those people are
enabled to use cold water who otherwise would be
deprived of the benefit of this bracing element.
Taken all in all, I am strongly of opinion that the hot
air bath is one of the best “ tonics'’’ known on account of
its action on blood and nerves, and that, consequently, .not
only is the use of it in health very advisable to give the
cells of the body a real training which will stand them in
good stead in the hour of battle, but that it also should be
freely resorted to in debilitating diseases. I for one cannot
agree with some high authorities who deprecate its use in
rheumatoid arthritis, for, although I am perfectly well
aware that rheumatoid or osteo-arthritis in an incurable
disease, the relief obtained in such cases is considerable,
and I have known patients of this class to come to St.
Ann’s Hill year after year in the firm belief that only by
means of the Turkish baths were they able to keep their
ailment within bounds and to prevent its progressing.
With regard to the therapeutical indications I need not
say much of the use of the hot air bath in gouty and rheu-
T7
By Dr. M. Altdorfer.
matic affections or other conditions caused by deficient
oxidations and auto -intoxications, such as diabetes, anaemia,
obesity, &c., as the good effect in such cases is well known
and generally admitted. But I should like to point out
some morbid conditions in which the beneficial action of
the bath has not yet received the general attention it
undoubtedly deserves.
The first disease I would mention is tuberculosis. After
the excellent results I have met with in consumptive
patients I am fully convinced that the hot-air bath is the
most powerful remedy at our disposal in the incipient stage
of phthisis, and that it very often will turn the scale in
favour of the organism in the struggle for existence
between the cells and the invading bacilli by mobilising,
as it were, a greater number of leucocytes (“ calling out
the reserves”), stimulating all the cells and destroying the
toxins produced by the bacilli. We generally find that
the application of our baths in such cases is followed by
increased appetite, gain in weight, ceasing of night per¬
spirations, and improvement of general health as well as
of local symptoms, that, in fact, the progress of the disease
has been completely arrested. In the paper mentioned
above I have described some cases with very satisfactory
results.
Another class of diseases very favourably influenced by
these baths are the nervous disorders, more especially the
general neuroses, such as neurasthenia, &c. In these cases
it is to be presumed that on the one hand the stimulation
of the cutaneous nerves by the thermal applications reacts
on the nerve-centres, rousing them to healthful energy,
and that on the other the toxins elaborated through the
faulty metabolism in the nervous system are removed from
the blood by the increased eliminations and oxidations.
Even in the treatment of mental diseases the Turkish baths
are highly spoken of. T. S. (Houston says in his <e Clinical
Lectures on Mental Diseases,” in the chapter on mental
depression, “ baths are most useful, especially Turkish
baths. I have seen many chronic melancholics much im¬
proved, and some cured by a course of Turkish baths.”
In such cases, however, no cold douche should be applied
Gr
98
The Hot Air Bath.
to the head, as the following reaction would be very risky
for the patient. If there are any signs of congestion of the
head, putting the feet in cold water for a minute or so is
the best remedy.
The mere mechanical action of the hot air bath has a
favourable influence in diseases of the heart and circulation —
diseases in which the use of this bath has been vigorously
forbidden by some authorities. I, myself, however, must
concur in the view expressed by Dr. Frey, of Baden-Baden,
that the condition of the heart and circulation is always
improved by a judicious use of the bath, and this is not
surprising if we reflect how much the work of the heart
must be lightened by the general dilatation of the capil¬
laries in the skin, and the consequent lowering of the blood-
pressure. Of course the precaution must be taken not to
throw cold water suddenly on the bather, as this abrupt
contrast in the temperature would put a strain on the heart
which might be too great for a weak organ, but to cool the
body by gradually reducing the temperature of the douches-
or shower baths.
That in the dilatation of the vessels of the surface
of the bod}^ we have a means of lessening pain depend¬
ing on congestion of internal organs, and of preventing
congestion, from going to inflammation, must be evident
to everybody. The strikingly beneficial action of the
hot air bath in cases of cholelithiasis has become more
intelligible since the publication of the researches of Kow¬
alski,9' who has found by experiments on dogs that thermal
stimuli of a short duration and of a low temperature favour
the removal of bile from the body, and that high tempera¬
tures stimulate the functional activity of the liver, and in¬
crease the amount of bile which it forms. Both conditions
being present in the hot chamber and the cold douche, the
hot air bath must act as a cholegogue as well as a hepatic
stimulant.
I have referred already to the better absorption and
assimilation of food, but it seems that in a similar way the
absorption and assimilation of certain drugs which we wish to
a “Ueber den Einfluss von ansseren hydrotherapeutisclien Procedural auf die
GaUensecretion.” Blatter f. klin. Hydrotlierapie. 1898. No. 11.
Verruca or “ Warts V
99
incorporate into the system is greatly promoted. That
mercury acts more potently in syphilis in conjunction with
Turkish baths has been stated by many authorities,
amongst others by Prof. Neisser, of Breslau; and as to other
drugs I have myself very often observed that these baths
intensify the action of iron in chlorosis. Some milder cases
will be cured by Turkish baths without iron, but in the
severer forms of the disease the therapeutical action of the
baths alone is not sufficient. I remember the very striking
case of a young lady who had taken iron in different forms
off and on during a period of six years without being able
to get rid of the chlorosis she suffered from. A course of
Turkish baths improved her condition somewhat, but the
real cure was effected only by resorting to Bland’s Pills
again, the iron acting almost like a charm after the con¬
stitution had been prepared by the baths for the better
absorption and assimilation of the drug. I may add that
this lady has been quite well now for over four years, and
that I have seen several similar cases since.
It has not been my intention to deal at all exhaustively
with the therapeutics of the hot air bath ; I have only-
mentioned some of those indications for its use which are
not, as a rule, found in treatises on this bath, but I think
that enough has been said to prove that this method of
treatment deserves the closest attention of the medical
world.
Art. VII.— Note on Verruca or u Warts V By II. S.
Purdon, M.D. ; Consulting Physician, Belfast Hospital
for Skin Diseases, &c.
It may seem unnecessary to make any remarks on so well-
known and trivial an affection of the skin as warts. However,
those — especially young ladies — who suffer from these growths
do not think lightly of their cutaneous trouble, or that their
presence is an ornament to the hands or fingers, and are only
too ready and glad to be free from these little out-growths
of skin. Globular in appearance ; seldom exceeding a line or
two in breadth or elevation ; an undesirable addition on any
exposed part consisting of hypertrophied papillae, the central
100
Verruca or “ Warts.”
portion of which is penetrated by a single vascular loop ; hence
when the wart is cut or irritated it bleeds readily, and the
blood from same is said by many lay people to propagate others.
The hardness to touch of a wart is due to the horny tissue ot
the epiderma, whilst the redness observed in some depends
on the increased vascularity of their bases. Warts occur
more frequently in children and young persons. In adults
they are usually met with on the scalp, often associated with
seborrhoea and slight loss of hair. On the hands, however,
it is the dorsal surfaces which are usually attacked, either
singly or in clusters, and again, warty bands are occasionally
met with in various parts of the body, being merely groups
of agglomerated warts, from 8 lines to several inches in
breadth.
Fanciful names have been given to warts, as V-plana,
V-cylindrica, V-pedunculata, &c.
As for venereal warts they may in some cases be non¬
specific, but generally are the result of sexual irritation, and
vary from the small pedunculated wart to those of larger
size, called cauliflower excrescences. Prepucial warts are
troublesome; for trivial cases the old-fashioned powder of
equal parts of acetate of copper and powdered savin, dusted
two or three times a day on the warts, the affected place to be
washed occasionally with an astringent lotion, such as that of
sulphate of zinc, is generally sufficient ; however, in obstinate
cases, after deadening sensibility with cocain, the application
of a stick of potassa cum calce is a “ sure ” remedy, oil or
water being afterwards used on the affected parts.
The flat wart occurring on the scalp I have always shaved
off with a sharp knife, and then “ punched ” the raw surface
freely with a piece of tough nitrate of silver, using Johnson
and Son’s “ tough lunar caustic ” for the purpose.
For warts on the finders or hands the usual remedies are
strong nitric acid, acetic acid, chromic acid, or removal by
the knife. My experience of the acids is that they usually
irritate and often spread the warty growth, so for several
years I have adopted the following method, and always with
success.
Some 8 or 9 years ago in driving a nail into a piece of
wood, in place of hitting the nail I struck my left thumb
101
By Dr. II. S. Purdon.
with the hammer; result — continuous pain, followed by a
warty growth several lines in length and breadth. I followed
the usual routine plan of “ burning” the wart with nitric and
other acids for some weeks, and succeeded in spreading the
attack. After thinking the matter over I obtained an india-
rubber finger-stall, similar to a glove finger, and wore the
same night and day. It was sufficiently tight to make gentle
pressure on the warts, which, moreover, were kept constantly
in a moist and “ macerated ” condition owing to retained
perspiration. In six weeks the warts had disappeared. I
have frequently since then recommended this plan, and
always with success. If the wart^ be on the hands or feet
then a bit of an indiarubber bandage can be used, and will
be found “ curative.”
In cases where there are a large number of warts some
dermatologists recommend arsenic to be given, and this is
useful in such diseases as psoriasis and verruca, where there
is a hypertrophous condition of the papillae.
The peasants and poorer classes still believe in “ charms
for warts, usually a gold ring and some mystic words.
Another is that mentioned by Lady Wilde a “ steal a piece
of meat and apply it raw to the w^arts, then bury it in the
ground and as the meat decays the warts will disappear.”
Professor Kaposi, of Yienna, in his book on diseases of
the skin, translated by Dr. Johnston, of U.S.A., recom¬
mends excision of warts with the knife ; whilst Dr. Norman
Walker, of Edinburgh, in his recently published work on
dermatology, and which I may be allowed to say does him
infinite credit, advises that warts be snipped off with scissors.
Both these plans leave slight marks. Young ladies as a rule
do not like “ cutting.” Mv method avoids all this.
a Ancient Cures, Charms, &c., of Ireland.
Jf ' » * ? . ' r>
PART II.
REVIEWS AND BIBLIOGRAPHICAL NOTICES.
. - - -
Twentieth Century Practice . An International Encyclopedia
, of Modern Medical Science by Leading Authorities of
Europe and America. Edited by Thomas L. Stedmaix,
M.D., New York City. In Twenty Volumes. Volume
XVI. Infectious Diseases. London : Sampson Low,
Marston & Company, Limited. 1899. 8vo. Pp. 785.
It will be remembered that the publication of this volume
was delayed, and that, in consequence, Volume XVII.
appeared in advance. Now that Volume XVI. has been
issued, all wre can say is that it was wrell worth waiting for.
Whether regard is had to the matter or the manner, this
volume deserves close attention.
The “ infectious diseases” discussed in its 785 pages are* —
lobar pneumonia, cerebrospinal meningitis, dysentery, yaws,
erysipelas, simple continued fever, relapsing fever, and the
ever-attr active typhoid fever.
Somewhat curiously, a dissertation on “ Inflammation,” by
Dr. Ernst Ziegler, of Freiburg, has crept into the centre of
the volume. With some propriety it precedes the admirable
account of erysipelas, which comes front the pen of Dr. Otto
Gr. T. Kiliani, attending surgeon to the German Hospital,
New York.
The opening article is on “Lobar Pneumonia,” by Dr.
Andrew H. Smith, attending physician, Presbyterian Hos¬
pital, New York. But why “lobar? ” We know what the
author means, for his definition speaks of “ an acute disease
in which a specific parasite invades the air-cells of one or
more pulmonary lobes,” &c. Yet, surely the clinical and
pathological experience of the past ten years should once
and for all time dispose of the fiction that acute pneumonia
is generally confined to a lobe. In young children the
lobular distribution of fibrinous pneumonia has long been
recognised. The author himself draws attention to this fact
Stedman — Twentieth Century Practice. 103
in the following words : “ The lesion of croupous pneumonia
does not observe the boundaries of the lobes nearly so accu¬
rately in children as in adults ” (page 131). In adults a
.multilobar or lobular distribution has become relatively
common since the first pandemic of influenza in 1889.
Dr. Smith cannot accept the view that pneumonia is
primarily a general infection with a secondary local lesion oi
varying intensity and importance, or which may remain
absent altogether. No, he says that “it seems impossible
from a careful consideration of all the phenomena to resist
the conviction that the disease begins in the lungs’’ (page 7).
Hence his definition : “ Lobar pneAmonia is an acute dis¬
ease in which a specific parasite invades the air-cells of one
or more pulmonary lobes, where it grows in a fibrinous
medium exuded from the functional capillaries and generates
a toxin that infects the system at large.”
The author does not believe in the doctrine that pneumonia
is a multiple infection. He is essentially an “ unicist.” For
him the pneumococcus alone is the causa causans of the dis¬
ease, and so this is the way in which he puts it — “ Other
infectious diseases seem often to open the way to infection
by the pneumococcus. The specific fevers — typhus and
typhoid, measles, erysipelas, dysentery — each is a frequent
forerunner of pneumonia, and holds a causal relation to it.
In these cases the pneumonia is modified by the pre-existing
disease, and seldom follows the regular clinical course. It
is apt to assume a wandering form, appearing in patches in
different parts of the lungs, presenting irregular and fluctu¬
ating temperatures, lacking a definite crisis, &c.” Surely
his accurate observation of these atypical or abnormal pneu¬
monias should have suggested to Dr. Smith that perhaps
the lung affection in such cases was a secondary local mani¬
festation of the primary disease, whether that was erysipelas,
measles, or typhoid fever.
Again, sewer-gas or pythogenic pneumonia finds no place
in his category, and the literature of the subject is ignored.
This is the more to be wondered at, since his observations on
•climate as a predisposing cause of pneumonia show that he
is in search of some other predisposing cause to explain the
remarkable fact that pneumonia occurs more frequently in
104
Reviews and Bibliographical Notices.
the southern than in the northern and colder portion of the
United States of America. “ Thus,” he says (page 83), “it
is evident that it is not a question of temperature, but of
some other influence, the nature of which is not yet under¬
stood, but which probably has a relation to the life-history
of the specific microbe.”
Professor A. Netter, physician to the Hopital Trousseau,
Paris, gives us an excellent account of epidemic cerebro¬
spinal meningitis. He studies this terrible malady under the
headings — history and geographical distribution, clinical
study, bacteriology and epidemiology. In a brief list of
works which may most profitably be consulted he can cite
only those authors “who excel on various points.” In this
exclusive list we are glad to find “ in Ireland a remarkable
report of Collins.” It may be of interest to recall the fact
that Dr. Edward W. Collins’s “ Report upon Epidemic Cere¬
brospinal Fever” appeared in the forty-sixth volume of
the Dublin Quarterly Journal of Medical Science
(August, 1868, page 170).
Dr. Netter’ s article is worthy of all praise. From a
diagnostic standpoint he attaches much importance to the
value of Kernig’s sign. When patients suffering from menin¬
gitis of any kind are placed in the dorsal decubitus, we do
not ordinarily find any contractures of the lower extremities,
these being readily flexed or extended in any direction by the
hand of the examiner. But if we make the patients sit up
we find that there is a certain degree of flexion of the knees,
and on attempting to extend the limbs a slight contraction
of the flexors prevents this movement being carried to its
full extent. Of course, having determined the existence of
cerebrospinal meningitis by Kernig’s sign, we have still to
ascertain its exact nature. A very interesting point is the
intimate connection which seems to exist between epidemic
cerebrospinal meningitis and pneumonia. This is fully dis¬
cussed at pages 215-221. Dr. Netter, in the section on
bacteriology, shows that relations of which we do not yet
know the precise importance undoubtedly exist between the
pneumococcus and the Diplococcns intracellular is meningitidis
( Meningococcus ) described by Weichselbaum in 1887.
The section on “Treatment” curiously enough inune-
Stedman — Twentieth Century Practice. 105
diately precedes that on “ Pathological Anatomy” — absit
omen ! Among the drugs mentioned with approval is per¬
manganate of potassium. Although Dr. Netter has had no
personal experience with it in meningitis, yet he has em¬
ployed it with good results in certain cases of auto-intoxication,
and he thinks it is very possible that it would equally modify
the poison elaborated by the pathogenic agent of meningitis.
It doubtless acts by oxidising. Isaac Kay obtained a cure
in three cases out of four in which he gave permanganate of
potassium, a tablespoonful every hour of a solution of one
grain to the ounce.
The editor of the Brazil Medico, Professor A. A. de
Azevedo Sodre, of Rio de Janeiro, contributes an exhaustive
article on Dysentery, including a full account of the amoebic
aetiology of the disease, first established by Losch, of St.
Petersburg, in 1875. To Councilman we owe the name
Amoeba dysenteries , a much more significant term than the
name Amoeba coli given by Losch. The presence of the
amoeba in the contents of tropical abscess of the liver is, in
Professor Sodre’s opinion, one of the most powerful argu¬
ments in favour of the amoebic origin of dysentery.
To Dr. H. A. Alford Nicholls, C.M.G., Dominica, W.I.,
we are indebted for an excellent account of Yaws, for which
the author accepts the term “ granuloma tropicum ” as the
most suitable Latin equivalent. Dr. Nicholls writes with
authority, for he formerly served as Her Majesty s Special
Yaws Commissioner in the West Indies.
That Dr. Kilianbs article on Erysipelas is thoroughly up
to date will be evident from his definition of the affection
(page 409) — a Erysipelas in man is caused by the action of
the chain coccus, identical with Streptococcus pyogenes ,
which causes suppuration in various parts of the body, from
a simple abscess of the skin to fatal peritonitis, and which
may also be the cause of septicemia without suppuration.”
A short article on “ Simple Continued Fever,” by Dr.
Landon B. Edwards, of Richmond, Virginia, is followed by
an elaborate monograph on Relapsing Fever, by Dr. Leo
Popoff, Professor at the Imperial Military Academy in St.
Petersburg. It is curious to note that all the earlier
authorities on the disease are either British or Irish physi-
106 Reviews and Bibliographical Notices.
yians, Dr. Jolm Rutty, of Dublin, heading the list under
date 1770.
At page 457 we meet with the following not very compli¬
mentary, and not — we venture to add — very accurate, para¬
graph : — “It was always Ireland which in the great epidemics
that prevailed in the United Kingdom in 1868 and 1873,
and also previous to this date, remained the centre whence
the disease spread throughout Great Britain. It was Ireland
again which was the source whence this scourge passed
beyond the British Isles, and invaded other parts of the
world, such as America.” We were fairly aghast when we
read this astounding statement. We rubbed our eyes and
asked ourselves, metaphorically, whether we were dreaming
or no. Our medical memory goes back further than 1868 —
“Eheu! fugaces, Postume, Postume,
Labuntur anni ” —
and, certainly, we can recall no epidemic of relapsing fever
which could be termed “great.” In support of his state¬
ment Dr. Popoff apparently quotes, as his authority, Mur¬
chison and “ his classical work on 4 The Continued Fevers of
Great Britain ’ (1862).” How could any author, writing in
1862, describe epidemics stated to have prevailed in 1868
or 1873? There were no such epidemics in Ireland. In his
history of relapsing fever Murchison, writing in 1873, of
course mentions the great Irish epidemics of 1817-1819 and
1846-1849, and he does state that most of the British
epidemics have been of Irish origin. He tells us also that
,in 1868 relapsing fever reappeared in Britain, but when an
outbreak did occur that year in London he adds, 44 there was
no relapsing fever in Ireland, there was no evidence of any
of the patients having come recently from Ireland, and
throughout the epidemic less than nine per cent, of the
patients were of Irish birth.” Murchison likewise shows
that the Scotch epidemic of 1843 originated in Scotland,
and scarcely, if at all, implicated Ireland. Murchison, there¬
fore, is not responsible for the sweeping charge made against
Ireland by the Russian professor, Popoff, in the inaccurate
and very misleading sentences we have quoted from his
monograph. Popoff seems really to have drawn his informa¬
tion from Hirsch’s Geographical and Historical Pathology *
Stedman — Twentieth Century Practice. 107
Hirsch, writing on Relapsing Fever, says, “ Another series
of outbreaks occurred in 1868-73. There are no particulars
of that epidemic for Ireland .” Quite so, because there was
no epidemic in Ireland — at all events, the Registrar-General
for Ireland is silent on the subject.
Our Russian friend returns to the charge at page 460,
when he writes — “ Coming to America, and especially the
United States, we find that relapsing fever was imported
into Philadelphia by Irish immigrants in 1844.” How could
this be, since there was no relapsing fever in Ireland at that
time? Here is what Hirsch says on this subject: — “It
showed itself first in 1844 at Philadelphia among emigrants
who had arrived from Liverpool, there being a few cases
also among those in charge of them.” Hirscli’s authority is
Dr. Clymer (New York Medical Becord , Feb., 1870, page
575).
We confess that Professor Popoff’s vague and inaccurate
statements have shaken our faith in his account of relapsing
fever.
More than 200 pages of this volume are devoted to a
study of Typhoid Fever in two monographs. The first is on
the aetiology and pathology of the disease by Dr. John S.
Thacher, Pathologist to the Presbyterian Hospital, Hew
York. The second article discusses the symptomatology and
treatment. It is written by Dr. John Winters Brannan, of
New York, who is well qualified for his task, being Clinical
Lecturer on Infectious Diseases in Columbia University, as
well as Visiting Physician to the Bellevue Hospital and to
the Hospitals of the Health Department of the City of New
York. -
The definition of typhoid fever with which the first article
opens is apparently the handiwork of both authors. It is
peculiarly happy, succinct, and to the point — “ Typhoid fever
is a state of infection by the typhoid bacillus. A profound
intoxication is commonly produced as well as certain ana¬
tomical lesions.” (Page 551.)
Both articles form a very creditable piece of work, and
together present a faithful review of our present knowledge
of typhoid fever. It would naturally have gratified us had
Dr. Thacher, in particular, expressed more recognition of
108 Reviews and Bibliographical Notices.
the recent work done by Irish physicians in this special field
of research. Surely Dr. Wallace Beatty’s case of typhoid
fever without intestinal lesions might have been quoted,
seeing the diagnosis had been scientifically verified by the
application of Widal’s test. Also Sir George Duffcy’s
classical case of perichondritis laryngea deserved mention, as
did also Dr. Colpoys Tweedy’s excellent paper on Periostitis
following Enteric Fever, which was published in the Trans¬
actions of the Academy of Medicine in Ireland for 1886.
There is an interesting section (at page 744) on the
“ Specific Treatment with Bacterial Cultures or Serum.”
Dr. Brannan explains that the term “ Specific Treatment ”
is now applied to the method of treatment by inoculation of
attenuated bacterial cultures, or of antitoxic or bactericidal
serum derived from them. But surely there was no “ specific
treatment before this, and we must traverse the accuracy of
the statement that “ the term ‘ specific ’ was formerly applied
to the treatment of typhoid fever by carbolic acid and other
agents, which, by virtue of their antiseptic power, were
believed to exert a specific or antidotal action on the
disease.”
From the foregoing criticism it will be seen that Volume
XVI. of “Twentieth Century Practice” is replete with
interest.
An Introduction to the Study of Materia Medica. By
Henry G. Greenish, F.I.C., F.L.S.; Professor of
Materia Medica and Pharmacy to the Pharmaceutical
Society of Great Britain. London : J. & A. Churchill.
1899. Pp. 511.
This handsome volume is described by its author as being
a short account of the most important crude drugs of
vegetable and animal origin. It is designed for students
of pharmacy and medicine, and is based on the subject-
matter of the lectures delivered by Professor Greenish to
his class. The crude “ organised ” drugs are treated of in
ten sections, arranged in accordance with the organs from
which they are furnished — e.g., leaves, flowers, fruits,
barks, &c. Under “ unorganised ” drugs are considered
Morris — Hainan Anatomy. 109
the products of plants, such as extracts, gums, resins, oils,
&c. ; and a section is also devoted to animal substances.
After an account of the source, and, in most cases, a brief
history of each drug, a full description is furnished of it,
and particular attention is directed to its diagnostic
characters, which are categorically stated. In this way
the student is encouraged to use his power of observation,
and is aided in his capability of recognising the genuine
article and in detecting adulteration of, or substitute for, it.
The constituents of the drug are also given, as well as a
very brief account of its uses. A large number of illus¬
trations are scattered through the work, and many of
these, especially some of those of leaves, barks, and roots
taken from photographs, are extremely good. There are
also numerous illustrations of the structure of different
parts of plants as seen on microscopical examination.
The book is one chiefly for pharmaceutical students,
and will doubtless deservedly become a standard text-book
with them. Its general usefulness would be increased if
among the numerous drugs described those which are
official were indicated ; and if the preparations of such
that are contained in the last issue of the British Phar¬
macopoeia were also specified.
A Treatise on Human Anatomy. By Various Authors.
Edited by Henry Morris, M.A., M.B. Bond. Second
Edition, revised and enlarged. London : J. & A.
Churchill. 1898. Pp. 1274.
The second edition of Morris’s Anatomy is in every
respect an excellent work — a sound, sensible, and healthy
anatomy. Sound, because the work has been entrusted to
tried men of considerable experience, who have produced
a correct and trustworthy account of the parts with which
they deal ; sensible, because, as a rule, much of the padding
which one finds in such works, many of the trivialities of
the subject, useless and troublesome, have been left out,
and in their place we find many additions in the direction
of applied anatomy which are most useful both for the
student and the practising medical man ; and healthy
110 Reviews and Bibliographical Notices.
because the whole tone of the book is good, and generally
in accordance with the present-day views on anatomy,
combining, as it does, not only ordinary anatomy, but, in
addition, such views on the morphology of the various
parts as are necessary to make their true significance
intelligible.
The contributors to the volume are — (1) Mr. Bland
Sutton, who takes charge of the Osteology, and if we may
be allowed to select a section for special commendation, it
would be this one, which the author has treated in his
usual masterly style. (2) Mr. Henry Morris, the editor,
has written the Joints, which, needless to say, are done in
a- most thorough fashion, but to our mind much simpler
and less elaborate descriptions would be better for the
average student. (3) Mr. Davies-Colley has treated the
Muscles very completely, but perhaps a little extravagantly
as regards space. (4) Mr. W. J. Walsham has done ample
justice to the Blood-vessels and Lymphatics, and gives us
an excellent article, illustrated, as regards the lymphatics,
by very ingenious diagrams after Hr. Sherwood. (5) The
Neurology was written for the first edition by JDr. St. John
Brooks, and has been revised by Dr. Arthur Bobinson for
the present issue, the resulting article being both accurate,
complete, and readable. (6) The Eye has been success¬
fully rendered by Mr. Marcus Gunn. (7) The Ear, Nose,
Larynx, Heart, Respiratory Organs, and Tongue are the
work of the late Mr. Hensman, revised for the present
edition by Dr. Arthur Robinson ; and of all we can speak
in terms of praise. (8) The Digestive Organs above the
diaphragm are by the same authors, and might, we think,
be a little more thorough in certain regards — e.g., mouth,
palate, naso-pharynx, &c. (9) The remainder of the
Digestive System is the work of Mr. Frederick Treves,
and although the peritoneum and its development are
handled in a most thorough and successful manner, the
treatment of the viscera we do not consider so satisfactory —
in fact they are not quite up to date ; nor do we like the
method of giving the relations of an organ by drawing a
square with the name of the organ printed within it, and
the names of the various relations around. Students try
Morris — Human Anatomy. Ill
to get this off by heart without trying to understand the
relations, which is objectionable. (10) The Urinary and
Generative Organs and the Skin are from the pen of
Mr. William Anderson, and are very successfully treated.
(11) A useful section of 120 pages on Applied Anatomy
comes from the hand of Mr. W. H. Jacobson. (12) A
short but interesting article on Vestigial and Abnormal
Structures by Dr. Kobinson winds up the book.
While we are able to express a very high opinion on the
general merits of the work, there are some minor points
with which wre do not quite agred For instance, the
attachments of the rectus anticus minor, of the scalenus
medius, and of the pectoralis minor and latissimus, shown
in Figs. 82, 109, and 120 respectively, the attachment of
the subscapularis in Fig. 123, of the shoulder capsule in
Figs. 124 and 125, of the extensor indicis in 130, of the
anterior crucial ligament, and the anterior fasciculus of the
external lateral ligament (which is put where the posterior
fasciculus is usually attached) in Fig. 163, the posterior
fasciculus of the external ligament and the posterior crucial
ligament in 164. The radius has no outer border, although
referred to in connection with the insertion of the pronator
quadratus, page 321. We do not like the insertion of the
gluteus medius on page 353 ; it is incomplete. There is
no reference to the origin of the obturator externus from
the body of the pubes on page 362. The old and objec¬
tionable name, transverse portion of the arch of the aorta,
is retained (page 467 and elsewhere) for a structure that is
in no sense transverse. We are at a' loss to understand the
second diagram on the next page, 468 ; surely the right pul¬
monary vein lies in front of, and then crosses over, its
artery, and not the reverse. We object very much to the
shape of the arch of the aorta in the Figure 323 on the
following page, even though it be a diagram ; nor do we
like the diagrams on page 474, which are too regardless of
strict accuracy. On page 502 we remark that the name
tarsal cartilages is still preserved — not wisely we think.
The pancreatico-duodenal arteries are not correctly de¬
scribed ; they do not run in the groove between the pan¬
creas and duodenum. The true relation of the pancreas
112 Reviews and Bibliographical Notices.
to the superior mesenteric artery should be given on page
558. We doubt the statement, often made, that more
than half of the superior cava lies inside the pericardium.
The lateral sinus does not run horizontally outwards from
the occipital protuberance, as stated ; its course is arched
(page 621) . The account and picture of the end of the right
suprarenal vein on page 632 does not agree with our
experience. The line of reflection of the peiitoneum at
the left side of the spigelian lobe is not correct in Fig.
581. There is no good picture of the suprarenals, &c.
But, after all, these are minor matters, and represent
simply some of the inaccuracies which will always creep
into such a large work. Taking the whole book, it is well
written, well illustrated, well printed and turned out, and,
most important of all, it is good, sound anatomy — the kind
of a book that a student or a practitioner should always
have by him.
Laboratory Work in Bacteriology. By Frederick G.
Novy, Sc.D., M.D. ; Junior Professor of Hygiene and
Physiological Chemistry, University of Michigan. Second
Edition. Ann Arbor : George Walir. 1899.
Despite the continuous multiplication of text books of
bacteriology, the merits of Dr. Novy’s manual have caused
its very general adoption in the United States, and have
gained for it so assured a place that a second edition has just
appeared. Although it has not been our practice to deal at
any length in this department of the Dublin Medical J onrnal
with second or subsequent editions, we nevertheless con¬
sider it only right to devote to Professor Novy’s book
something more than a mere passing allusion — and this
for two reasons. In the first place, the work being printed
and published in America is of necessity but little known
on this side of the Atlantic ; in the second place, its merits
are so great and the thoroughness of the work is so admir¬
able that we think the second edition may well be ranked
in point of convenience and utility with the very best
practical manuals at present used in British laboratories.
Before a writer can hope to convince others he must
113
Novy — Laboratory Work in Bacteriology.
first of all convince himself, or at any rate appear to have
done so. Dr. Novy complies to the full with this first
condition, and boldly claims for bacteriology a fuller
measure of recognition in the medical curriculum than it
has hitherto received, on this side of the water at any rate.
Let us hear him plead his own case : — “ A thorough course
of laboratory instruction in bacteriology is absolutely
essential to the proper education of the medical student of
the present day. The practical knowledge thus acquired
in the methods of handling bacteria, in the precautions
necessary to the prevention of personal infection, and in
the methods for the recognition and for the distinction of
disease-producing organisms is fundamental and invaluable.
Such information is directly useful as a means of diagnosis ;
it is essential to the successful performance of antiseptic
operations, and is indispensable to the proper execution
and understanding of the common hygienic measures for
the prevention of communicable diseases. It is, therefore,
evident that the course in bacteriology should not be
inferior either in length or in the character of the instruc¬
tion to any other laboratory course offered in the medical
curriculum.”
There is much force in this pleading, and despite the
efforts of those who would pare down the work arid cut
down the fees of medical schools to the uttermost, with the
immediate object of “lightening the burden” cast upon the
“ unfortunate ” student, but with the ultimate result of
throwing open the portals of our profession to the swarm of
needy, half-educated struggle-for-lifers, we cannot help
thinking that the tendency of the time is rather in favour
of the scientific teaching so vigorously pleaded for by Dr.
Novy. “Bacteriology,” he goes on to say, “as an educa¬
tional measure of the first importance belongs to the first
or, at the latest, the second year of a medical course. The
student is thus enabled to make use of his knowledge in
connection with his clinical studies. The spirit of scientific
investigation and not mere book-reading must be fostered
in the student from the outstart, since it is this that leads
to progress in medicine, and serves to distinguish the true
physician from those bound down by blind faith, com-
H
114
Reviews and Bibliographical Notices .
mercialism, or ignorance.” Nor is Professor Novy meiely
the voice of one crying in the wilderness. “ Duiing tho
past ten years,” he says, “ three laboratory courses in
bacteriology have been given annually in the hygienic
laboratory of the University of Michigan. Uach course
covers a period of twelve weeks of daily work, to which
the entire afternoon is devoted. Inasmuch as this labora-
tory work is recpiired of all medical students the numbei
of students which (sic) annually take the course at times
exceeds two hundred/’ Here we must leave off quoting
textually from our author with the remark that if two
hundred students are annually put through a course of
practical bacteriology, such as is sketched out in this book,
in one single American university, then we are about to
assist at a very interesting object-lesson on the effect pro¬
duced upon the profession in America by the early adminis¬
tration of full doses of high-class scientific instruction.
Will they be the better of it? Qui vivra, verra.
Now for some details about the contents of the book and
their arrangement.
The initial chapters are devoted to such a theoretical
description of the form, classification, and life-history of
the bacteria as may serve to render intelligible the ensuing
practical demonstrations. The author’s style is not always
beyond reproach. Thus, on the very first page he tells us
that “ inasmuch as bacteria belong to the lowest and
simplest forms of life it cannot be expected that they will
show any marked differentiation into plants . In
their characteristics of growth, multiplication, and repro¬
duction they resemble the group of algce more than any
other group of living beings , and it is this general relation¬
ship rather than any one peculiarity which has led to their
being placed in the vegetable kingdom.” [The italics are
ours.] Apart altogether from the ambiguity of the second
italicised passage the accuracy of the statement it conveys
may fairly be questioned. Then, again, a few lines lower
down the writer speaks of “ moulds or fungi as though
the two classes were co-extensive. On page 35 we find it
stated that the bacilli are, as a rule, motile (!), and a little
lower down — “ certain bacteria scarcely show real motion
115
No VY — Laboratory Work in Bacteriology.
at the ordinary room temperature, because of the presence
of a slimy secretion. AVhen placed, however, at the
temperature of the body the motion becomes well marked.”
To what bacteria does the author allude? In didactic
works the use of the word certain instead of specific names
is much to be deprecated.
A point Avhich cannot fail to strike the British reader is
the prominence given by the author to the structures
which he calls “ giant-whips.” These are enormous (up
to 132g long) spindle-shaped, spiral bodies which are said
to abound in the condensation watefr of agar cultures of
motile bacilli. Though derived apparently from detached
flagella they are immensely larger than the very organisms
•on which the flagella occur. Though first observed by
Loffler and subsequently described by Sakharoff and
A. Fischer, “ giant-' whips ” do not seem to have excited
much attention on this side of the Atlantic, and Dr. Novy’s
surprising figure (7) is the first representation we have
seen of these strange objects.
Illustrations of the various species of bacteria are omitted
and blank pages are left to be filled in by the student from
his own cultures and microscopic preparations.
The last few chapters are for the advanced worker the
most interesting. In chapter XIII., on the examination of
water, soil, and air, we note that Dr. Novy includes traces
of nitrous acid amongst the constituents of a “good”
water supply. On the same page we find an amusing
printer’s “devil” — * — , “the chlorine, nitrates, nitrites, and
ammonia are in themselves harmless and can be taken
with impurity (sic) in relatively large doses.” Apropos of
the examination for typhoid and pseudo-typhoid bacilli,
Dr. Novy makes no allusion to the useful methods of
Parietti and Abba, nor yet to the method of plating-out
the Berkefield-filter-residue in carbol-gelatine. On the
other hand, we find complete instructions for the prepara¬
tion of Eisner’s medium and for making Stoddart’s gelatine-
agar. With regard to the last-named its utility is far from
clear to the present writer. It would appear to be a
method of demonstrating the superior mobility of Eberth’s
bacillus, but why “ direct microscopic examination or the
116
Reviews and Bibliographical Notices.
staining of flagella will not give a satisfactory indication
of the mobility ” is precisely what we should like to know
and what Dr. Novy fails to explain. The veriest tyro will
not mistake the lazy movement of typical B. coli for the
waggling and darting of typical B. typhosus ; it is the
actively mobile coli-form ” and pseudo-typhoid forms
that are liable to give rise to error in diagnosis, and how
such error is to be avoided by the use of Stoddart’s medium
is far from obvious.
We have left ourselves no space in which to deal with
what is perhaps the most useful feature in the whole work —
viz., the fulness of detail with which certain of the more
difficult bacteriological procedures are described. W e may
instance the preparation of toxins, the filtration of bacterial
liquids, the testing of antitoxins, and above all the making
of collodion-sacs, the use of which has yielded, more
especially in the hands of the Pasteur school, such impor¬
tant results. We know of no such complete treatment in the
English language of these technical parts of the subject.
There is j’ust one final observation which occurs to us with
regard to the author’s somewhat meagre account of agglu¬
tination. He directs that the drops of diluted serum be
“ inoculated with a minute portion of agar culture of the
Eberth bacillus.” Surely no more certain method of pro¬
ducing pseudo-reactions could well be devised ! These
errors in matters of detail are, however, more than counter¬
balanced by the merits of the work, and we can safely
congratulate Professor Novy on having made a very
valuable addition to the literature of bacteriology.
The Edinburgh Medical Journal. Edited by G. A. Gibsox,
M.D., F.B.C.P. Ed. New Series. Yol. Y. Edinburgh
and London : Young J. Pentland. ’ 1899. 8vo. Pp.
648.
All that need be said of the fifth volume of the new series
of this old-established monthly medical journal is that,
under the able editorship of Dr. G. A. Gibson, it maintains
the high literary standard reached by its predecessors.
There are no fewer than thirty-five original articles in
117
Hbie — An Apology for the Intermediates.
this volume, several of them written by the foremost men
in the profession in Scotland.
The other contents are full of interest, consisting of
reviews of British and foreign literature, reports of societies,
reports on recent advances in the various branches of
medical science, analytical reports, and monthly notes on
meteorology and vital statistics.
An Apology for the Intermediates ( for Boys). By Maurice
C. Hime, M.A., LL.D., some time Aead-Master of Foyle
College, Londonderry. London ; Simpkin, Marshall,
Hamilton, Kent & Co. Dublin: William M‘Gree. 1899.
In his preface Dr. Hime says, 44 I have tried to imagine
myself, throughout my 4 Apology,’ a witness being orally
examined by the Commissioners, answering their questions,
and, when necessary, explaining my answers.”
To the question, 44 Is it not a fact that boys’ health has
been injured, their eyes in particular, by the amount of study
necessitated by these examinations ? ” he replies, 44 Certainly
not. I have never known of a child’s general health, or eyes
in particular, being injured by reading for the Intermediates.”
He admits that he has known of two instances of children
whose general health, and one whose eyes were affected
temporarily by overstudy, but this occurred at a school which
did not prepare pupils for the Intermediates, and where the
daily school and study hours were longer, and the time
allowed for play less, than at Foyle College, or any other
Intermediate school with the working of which he was
acquainted.
To the next question: 44 But have not several distinguished
oculists lately asserted that preparation for the Intermediates
actually does injure the eyesight ? ” he replies, 44 Yes, asserted
this they certainly have, but assertion is not proof.” Precisely
so, and the same applies equally to Dr. Hime’s very positive
assertion in reply to the former question, an assertion grounded
almost exclusively, as most of his very assertive answers are,
upon his experience as Head-Master of Foyle College, where
very exceptional attention appears to have been bestowed
upon the hours of study and of recreation. But surely
118 Reviews and Bibliographical Notices.
Dr. Hime does not suppose that all the Roman Catholic and
Protestant schools and colleges throughout Ireland are
managed on the same lines as Foyle College.
In the evidence before the Commission it was freely
admitted that a deterioration of eyesight was inseparable
from the spread of civilisation and education. That had
been proved long ago by the very exhaustive investigations
made in Germany, America, and England, and the result has
been that of late years a great deal of attention has been
devoted to the question of school hygiene, with the object
of securing as far as possible a mitigation of the evils which
are a necessary consequence of educational progress. The
charge brought against the present Intermediate system is
that by the payment of results fees and prizes it offers a
premium for over-pressure, and notwithstanding all Dr.
Hime’s assertions to the contrary we maintain that this is
so. It is simply incredible that the leading oculists through¬
out Ireland, and a number of the chief medical authorities
in Dublin, should have voluntarily testified to the disastrous
results of this system from their own experience in their
practice, if the evidence had not been overwhelming.
It is an established fact, says Dr. Hime, that parents u pay
far more attention now-a-days to their children’s eyes, even
as they do to their teeth, than they used to do formerly, and
oculists and dentists alike are consulted far more frequently
than they used to be, parents recognising more and more the
importance of having their children’s teeth and eyes properly
attended to. How strange that dentists have not also been
brought prominently forward to prove that children’s teeth
are going from bad to worse in consequence of the Inter¬
mediate system.” We have very little doubt that had the
attention of the members of the dental profession been
directed to the matter, and their opinion asked, it would
have amply corroborated the other medical testimony.
It could scarcely be otherwise — that is to say, in cases where
there has been a break down of the general health, for what¬
ever will cause an impairment of the general state of the
system will be pretty sure to lead to dental trouble. It is
obvious that the attention of dentists would not be so directly
drawn to the connection between over-pressure at school and
H are — Progressive Medicine. 119
tlie condition of tlie teeth, as in the case of the general health
or eyesight.
Undoubtedly parents do bestow a great deal more care
upon the eyes and teeth of their children, for the spread of
education has forced it upon them, besides knowledge has
made great strides as regards the errors of refraction and
dental maladies, and their connection with the general state
of the health. The testimony of -parents is an important
factor in proving the truth of the charge against the Inter¬
mediates, and little difficulty would hakre been experienced
in finding witnesses to corroborate the medical evidence.
One most important point as regards the medical evidence
is of course excluded from Dr. Hime’s “ Apology,” and that is,
the deleterious effects of the Intermediate system upon the
general health and eyesight of girls. Looking at the whole
question from the medical point of view it is absurd to
exclude this and to attempt to answer the objections brought
forward by assertive contradictions.
Progressive Medicine: A Quarterly Digest of Advances ,
Discoveries , and Improvements in the Medical and Surgical
Sciences. Edited by Hobart Amory Hare, M.D. ; Pro¬
fessor of Therapeutics and Materia Medica in the J efferson
Medical College of Philadelphia ; Physician to the J efferson
Medical College Hospital; Laureate of the Eoyal Academy
of Medicine in Belgium, of the Medical Society of London ;
Corresponding F ellow of the Sociedad Espahola de Higiene
of Madrid ; Member of the Association of American Phy¬
sicians, &c. Volume I. — Surgery of the Head, Neck,
and Chest; Diseases of Children; Pathology; Infectious
Diseases, including Croupous Pneumonia; Laryngology
and Rhinology ; Otology. March, 1899. London: Henry
Kimpton.
As the editor very truly and very graphically observes in his
preface, “the state of the progressive medical man of to-day
is that of a man who, while hungry for food, has thrust
upon him such a mass of pabulum, prepared in so many
forms by so many cooks, that it is possible for him to get not
a taste of many dishes from which he might obtain much
120
Reviews and Bibliographical Notices.
pleasure and strength if he but knew their real value and
design. Often the technical appearance of an article staggers
his mental digestion, and he casts it from him as being too
difficult a morsel for him to assimilate. There are at the
present time numerous 4 annuals ’ or 4 year-books ’ published
• with the object of recording in condensed form the greater
part of the medical literature of the year, but in nearly all
of them the process of boiling down has been practised with¬
out first sifting the useful from the useless, with the result
that the physician has presented to him a mass, concentrated,
it is true, but so varying in quality that the good can only
be separated from the bad by a process as difficult as that
needed for the utilisation of the crude material. What the
young physician needs to-day is a well-told tale of medical
progress in all its lines of thought, told in each line by one
well qualified to cull only that matter which is worthy of his
attention and necessary to his success.”
Such is the raison d'etre of the present beautifully-printed
volume of 490 pages. The character of paper, type, and
illustrations makes it a real pleasure to turn over the leaves
of this book ; and the matter of the text is thoroughly worthy
of the dress in which it has been placed by the combined
good tastes of printer and publisher. We cordially congra¬
tulate the editor on the matter and manner of his new and
arduous enterprise. As he tells us, 44 every contributor to
the pages of Progressive Medicine has been asked to say
what he has to say in a narrative form, and, equally impor¬
tant, to place his hall-mark on the text, so that it will be a
story which bears a personal imprint, and will express not
only the views of the authors cited, but the opinion of the
contributor as well.”
The text is arranged under six heads — mentioned in the title.
Of these, the first has been contributed by J. Chalmers Da
Costa, M.D. ; the second by Alexander D. Blackader, M.D. ;
the third by Ludvig Hektoen, M.D. ; the fourth by William
Sydney Frazer, M.D.; the fifth by A. Logan Turner, M.D.
(Edin), F.R.C.S. Edinburgh ; and the sixth by Robert L.
Randolph, M.D. The last ten pages of the volume are
occupied by an excellent index.
We have carefully examined the pages of this new
Dowse — Treatment of Disease by Physical Methods. 121
“ Quarterly,” and have jealously scrutinised tlie paits which
deal with the special departments in the literature and piac-
tice of which we have recently been most deeply engaged, and
we can fully congratulate the various authors on the conscien¬
tious thoroughness with which they have performed their
respective tasks. We cordially recommend it to every medical
man as a most reliable summary of the professional progress
of its period.
- - - - - - i - -
Treatment of Disease by Physical Methods. By Thomas
Stretch Dowse, M.D.Abd.; F.R.C.P.Ed.; formerly
Physician-Superintendent, Central London Sick Asylum :
President, North London Medical Society; Member of
Council and Secretary for Foreign Correspondence,
Medical Society of London; Physician to the North
London Hospital for Consumption and Diseases of the
Chest, to the North-West London Hospital, and to the
West- End Hospital for Epilepsy and Diseases of the
Nervous Svstem ; Associate Member of the Neurological
Society of" New York, &c. Bristol : John Wright & Co.
London : Simpkin, Marshall, Hamilton, Kent & Co., Ltd. ;
Hirschfeld Brothers. 1898.
This portly and handsome octavo of 412 pages gives a \ei}
good practical summary of the existing state of our rapidly
progressive knowledge of the treatment of disease by physical
manipulations of various kinds. The author is a well-known
expert in the medical applications of electricity, massage, &c.,
and gives us, in these pages, the advantages of a cleai
mental reflex of many years’ experience in one of the most
important departments of medical knowledge.
When so vast a domain has to be surveyed the application
of detailed criticism is nearly always idle, except for the
purpose of pointing out gross errors, or expressing the pro¬
nounced divergence of the reviewer s opinions. In the
present instance we have neither of these excuses to advance.
We have read Dr. Dowse’s book with attentive care from
beginning to end, and unhesitatingly recommend it to our
readers as the best introductory text-book we know to the
122
Reviews and Bibliographical Notices.
study of the theory and practice of the physical methods
of treating disease, which he has himself so successfully
practised.
Notes on Surgery for Nurses. By Joseph Bell, M.D.,
F.R.C.S. Edin. ; Consulting Surgeon to the Royal Infir¬
mary and to the Boyal Edinburgh Hospital for Sick
Children. Fifth Edition, thoroughly revised. Edinburgh:
Oliver & Boyd. London : Simpkin, Marshall, Hamilton,
Kent & Co., Ltd. 1899.
To this new issue the author has 46 added an Appendix
treating of the important and interesting question raised as
to the Relation of the Trained Nurse to the Profession and
the Public.” The fact that this neat little volume is a fifth
edition represents the most convincing testimony that could
well be offered of the fact that the author’s work has been
appreciated by the public, and was originally needed for the
supply of an existing want. We have no doubt whatever
that the present issue will retain the popularity which was
so well deserved by its predecessors. Detailed criticism of
fifth editions constitutes a waste of time and energy. W e
will only say that the author has done his duty by the
present volume in bringing it thoroughly up to date.
A Primer of Psychology and Mental Disease for Use in
Training-schools for Attendants and Nurses and in
Medical Glasses. By C. B. Bukr, M.D. ; Medical
Director of Oak Grove Hospital for Nervous and Mental
Diseases, Flint, Mich. ; Formerly Medical Superinten¬
dent of the Eastern Michigan Asylum ; Member of the
American Medico-Psychological Association, &c. Second
Edition, thoroughly revised. Philadelphia : The E. A.
Davis Co. Pp. ix+116. 1898.
This little work is mainly intended for asylum attendants,
though it is said to have been found useful for medical
students also.
A brief glossary is followed by a section (Part I.) devoted
to a short but very readable account of normal psychology.
123
Burr — A Primer of Psychology.
Although not wanting in certain loosenesses of statement,
to say the least, this might serve as an introduction to the
subject for a medical student who proposed to correct his
impressions by subsequent reading, but we entirely fail to
see the usefulness of burdening asylum attendants with a
mass of purely theoretical considerations, which, indeed,
unless in America attendants are much better educated as a
class than, in this country, will be very imperfectly under¬
stood, and whether understood or not, have little bearing on
their everyday work.
The second part is devoted to the consideration of
insanity, and in the opening paragraphs stress is rightly laid
on the importance of comparing a patient’s “ present with
his former habits of thinking, feeling, and anting. The
causes of insanity are classified into (1) direct physical
causes ; (2) indirect physical and emotional causes ;
(3) vicious habits ; and (4) constitutional and evolutional
causes, amongst the last being pubescence and adolescence,
the adolescent period being given as from 30 to 35,
which must surely be an misprint. Passing over one or two
points which are open to criticism, we may accept this as
a passable rough arrangement ; but we are not at all
disposed to admit the usefulness of the author’s division of
the insanities, while his description of individual varieties
seems to us far too difficult for the class of readers for
whom it is mainly intended. Thus, we altogether doubt
the existence of “ hystero-mania” and “ hystero-melan-
cholia ” as varieties of sufficient importance to merit
separate names, while the term “ dementia ” is used in a
loose manner which cannot fail to give rise to confusion.
We note that paranoia is described as if in all cases
following the course of symptoms termed by Magnan
“megalomania,” and though we do not agree with this,
the description, it must be admitted, is well done. On the
whole, this section suffers from elaboration of theoretical
detail at the expense of practical utility.
The third section, however — on the “ Management of
Cases of Insanity ” — deserves nothing but praise, and we
do not think it possible to find a better arranged or more
concise, clear, and judicious short account of the proper
124
Reviews and Bibliographical Notices.
lines of treatment to follow in mental disease. Even
asylum physicians may pick up useful “wrinkles” from
this admirably-written section, which is worth all the rest
of the book together. We may particularly commend the
caution as to the danger of over-feeding patients where
food has to be administered mechanically.
Part IV., which is simply the reprint of an address by
the author on the duties of asylum attendants, written in
rather a high-faluting style, could very well have been
spared here, however suitable it may have been for its
original purpose. Had: the space taken up by this and by
discussion of purely psychological points being devoted to
such an account of elementary anatomy and physiology as
would assist attendants to understand their duties, it
would, we think, have been far more to the purpose.
The inadequacy of the book is the more to be regretted
that it is well written and readable, and, like most Ameri¬
can medical works, excellently printed and got up.
The Origin , Growth , and Fate of the Corpus Lutemn , as
observed in the Ovary of the Pig and Man. By J . G. CLARKE,
M.D. Baltimore: The Johns Hopkins Press. 1898.
Pp. 40.
This able paper forms the fourth number of the seventh
volume of the “ Johns Hopkins Hospital Reports.” It
records the results of work done by the author in Leipzig
under the direction of Professor Spalteholtz, and has
already been published in German. A thorough investi¬
gation of the different stages in the development and
decline of the corpora lutea in the ovary of the pig was
carried out by means of parallel sections, some of which
were stained by a modified v. Gieson method, and some
of which were submitted to the valuable digestive method
of Spalteholtz and Iioehl. These two methods control
one another, and allow of more exact conclusions than
either alone. The results got from the pig were compared
with those derived from a less complete series of human
ovaries, and a very definite theory of the function of the
125
Clarke — The Corpus Luteum.
corpus luteum is given. It is best to give the author’s
conclusions in his own words : —
“ 1. The lutein cells are specialised connective- tissue cells, which
appear in the inner layers of the follicle wall at the time when it
begins to show a differentiation into the theca interna and externa,
and gradually increase in size and number until the period of
maturity, when they have assumed all of the characteristics which
cause them to be designated lutein cells. The corpus luteum is,
therefore, not an epithelial but a connective-tissue structure.
u2. In the growing follicles the lutein celfe are increased at the
expense of the ordinary connective tissue cells until the latter are
represented by only a few cells and a fine reticulum in the mature
follicle. This reticulum forms a fine vreb, stretching from the
theca externa among the lutein cells, beyond which it is woven
into a more or less fine line known as the membrana propria.
“ 3. At the time of the rupture of the follicle, the membrana
propria is broken through in places by the advancing lutein cells
and blood-vessels, but quickly reforms a connective-tissue line in
front of the lutein cells, which push it towards the centre, where
it finally forms a dense core of interlacing fibres.
“ 4. After the rupture of the follicle the lutein cells (connective-
tissue cells) show a remarkable activity in growth, increasing both
in size and numbers until the empty cavity is completely filled in,
after which they begin to undergo degeneration.
“ 5. The fine reticulum between the lutein cells of the mature
follicle is the antecedent of the connective-tissue cells, which are
quite sparse in the first stage of the growth of the corpus luteum,
but become the predominating structure at the height of its
development.
“ 6. The degeneration of the lutein cells is probably induced
through the increasing density of the connective tissue surrounding
them.
“ 7. The retrogression of the corpus luteum is characterised
first by the fatty degeneration of the lutein cells, followed by the
shrinking of the connective-tissue net into a compact body (corpus
fibrosum), after which it is gradually removed through hyaline
changes until a very fine scar-tissue is left, which is, at last, lost
in the ovarian stroma.
u 8. The blood-vessels of the corpus luteum are quite resistant,
and the larger ones are among the last structures to give way in
the process of retrogression.
“ 9. The office of the corpus luteum is that of a preserver of
126
Reviews and Bibliographical Notices.
the ovarian circulation, which exercises its function almost per¬
fectly in the younger woman, but which at last, with the increasing
density of the stroma, begins to fail in its activity, its remains
being slowly or imperfectly absorbed uQtil these deposits finally
exert the opposite influence and hasten the laming of the circulation.
a 10. Cessation of ovulation is induced, not through the disap¬
pearance of follicles per se , but through a densification of the
ovarian stroma and a destruction of the peripheral circulation
which prevents their development.”
Two beautifully-executed plates, containing 17 partly-
coloured figures, illustrate the descriptions given in the text.
RECENT WORKS ON DISEASES OF CHILDREN .
1. The Diseases of Children, a Clinical Handbook . By
Geobge Elder, M.D., E.R.C.P. Ed., and J. S. Eowleb,
M.B., E.R.C.P. Ed ; Clinical Tutors, Edinburgh Royal
Infirmary. London : Charles Griffin & Co. 1899.
2. Aids to the Treatment of Diseases of Children . By
John M‘Caw, M.D., E.R.C.P. ; Senior Physician to
the Belfast Hospital for Sick Children. Second edition.
London : Bailliere & Co. 1899.
3. The Care of the Baby. A Manual for Mothers and
Nurses, containing practical directions for the manage¬
ment of infancy and childhood in health and disease.
By J. P. Cbozieb Gbiffith, M.D. ; Clinical Professor
of Diseases of Children in the University of Pennsyl¬
vania. Second edition. Philadelphia. 1899.
4. Transactions of the American Pediatric Society. Tenth
Session. Yol. X. 1899. Reprinted from the “ Archives
of Pediatrics, 1898.”
5. Archives of Pediatrics. Yol. XYI. Nos. 1-6. 1899.
6. Pediatrics. Yol. YII. Nos. 1-12. 1899.
1. This is an attractive-looking volume. It has been pre¬
pared with some trouble and not altogether without success.
For a volume compiled, as we are told, exclusively from
the works of others, it has been fairly well done. The
authors have put together much information from many
sources, but we much prefer original clinical observations,
however small they may be, provided they be accurate.
127
Recent Works on Diseases of Children.
Objecting, as we do, to gain anything second-hand when
it can be gathered fresh from the original, we cannot com¬
mend the compilation of such volumes as these, as they
tend to encumber the literature without increasing know¬
ledge. It is convenient in size and shape, but the print is
too small for comfortable reading, and the paper is not
good. There is no description of Friedreich’s disease,
thrombosis of the cerebral sinuses, or those most interest¬
ing cases of functional ataxy.
2. We are, despite many omissions and some obsolete or
erroneous views, favourably impressed with this little
handbook. With some revision or, perhaps, “ co-editing ”
with some other authoritv on diseases of children, it is
capable of being made into a very useful book for senior
students. There is no description of “rheumatoid
arthritis,” “functional ataxy,” “posterior basal men¬
ingitis,” “ thrombosis of cerebral sinuses,” “ habit spasm,”
“ purpura fulminans,” “Friedreich’s disease,” or “spastic
paraplegia,” or “ empyema.”
It is difficult to treat all diseases concisely and yet cor¬
rectly, and we think Dr. M‘Caw has made the best attempt
at such a book with which we are acquainted.
3. This is intended to be a guide to mothers and nurses
on all that pertains to young children in health and dis¬
ease ! — a title sufficient to ruin any book from the magni¬
tude of its scope. The first half of the book is suitable to
the purpose, but we must condemn in the strongest manner
any wholesale popular treatment of such a subject in this
way. The author says it is not intended to supplant the
physician, but he does so, and we believe books of this
nature may do incalculable harm. The second half of the
book is a small practice of medicine, and we believe a most
dangerous book to place in the hands of either mothers or
nurses. Directions as to the care and nursing of sick
children is one thing, but directions for treating and dis¬
tinguishing dangerous diseases one from the other is
grossly mischievous and ridiculous, considering neither
mother nor nurse can possess the knowledge to even
recognise them.
128 Reviews and Bibliographical Notices.
4. These Transactions are useful publications, and the
present volume can be consulted with profit on the follow¬
ing subjects “ Hospitals for Infants,” by Emmett Holt ;
“ Infantile Scurvy,” “The Heating of Milk for Infant
Feeding,” “ Laryngeal Diphtheria,” and “ The Anaemias
of Infancy.” They are beautifully reprinted from The
Archives of Pediatrics,” and most capably edited by Dr.
Floyd Crandall.
5. This journal continues to please its readers, and we
venture to again remind the publishers that with a little
alteration it would surely still more delight its subscribers
and keep far ahead of any other journal on children & dis¬
eases which we know. I*Ve allude to advertisements on
th e, front cover. These should be totally expunged. These
numbers contain some very interesting papers, amongst
them being the following subjects : — Tetany, whooping-
cough, incontinence of urine, Friedreich s disease, croup
(laryngeal diphtheria), opium in children, sudden deaths in
children, chorea, laryngismus, rickets, night terrors, and
syphilis. It is printed on good paper, and but for two
advertisements the front cover is attractive. Dr. Floyd
Crandall is to be congratulated warmly on the continued
success of this journal, and also the publication of the
Pediatric Society’s Transactions.
6. There is some improvement in the cover of. this
magazine, and we hope it will continue. Its appeaiance
has formerly been against it. There are some interesting
papers in this volume, amongst which may be mentioned
those on whooping-cough, tuberculosis, syphilis, laryn¬
gitis and laryngeal spasm, convulsions, and diphtheritic
paralysis.
The Great Eastern Railway Company' s Tourist Guide to
the Continent. Edited by Percy Lindlei. Illustrated
and with Maps. London: 30 Fleet-street. 1899. 8vo.
Pp. 158.
At this holiday season of the year information as to pleasant
Continental trips is bound to be grateful to the jaded o\er-
Sir W. It. Gowers — Diseases of the Nervous System. 129
worked members of our profession who seek rest and recrea¬
tion. The publishers have been good enough to place in our
hands an advance press copy of the Gt. Eastern (England)
Railway Company’s “ Tourist Guide to the Continent,”
published at the price of sixpence. Among its fresh features
are particulars of the New Express Service to Norway,
Denmark, and Sweden, via the Royal Mail Harwich-Hook-
of-Holland route, of new tours in the Luther country and
Thuringian and Hartz Mountains, a series of Continental
maps, and a chapter, “ Dull, Useful Information,” giving
particulars as to the cost of Continental travel. The editor,
Mr. Percy Lindley, has done his part of the work right well,
and the guide is a marvel of cheapness as well as a mine of
information.
A Manual of Diseases of the Nervous System. By SlR W. R.
Gowers, M.D., F.R.S. Third Edition. Edited by Sir
W. R. Gowers and James Taylor, M.D. Vol. 1. — Diseases
of the Nerves and Spinal Cord. London : J. & A.
Churchill. 1899. Royal 8vo. Pp. 692.
It is with sincere pleasure that we welcome a new edition
of this truly classical book. Among works on the diseases
of the nervous system it has no superior, and very few
equals. In the preparation of the present edition Sir
W. R. Gowers has had the assistance of Dr. James Taylor,
Assistant Physician to the National Hospital for the
Paralysed and Epileptic, who is himself a very distinguished
neurologist. The editors have, they tell us, carefully
revised every chapter, and added much new matter. This
is apparent even to the most casual reader. The general
arrangement of the work remains as in the previous
editions ; but to the first part, which treats of general
symptomatology, is appended a new section on the general
constitution of the nervous system, in which a short account
is given of the modern views of the structure of the nervous
organs. The nervous element or neuron is described;
the want of structural continuity between the different
neurons is pointed out ; the fibrillar structure of the pro¬
cesses of the the ganglion cells, both axon and dendrites,
i
130 Reviews and Bibliographical Notices .
is insisted on, and the important alterations in our ideas of
the origination of nervous processes, which are necessitated
by the discovery that the fibrils of the axis cylinders do
not terminate in the nerve cells, but merely pass through
them, are clearly shown.
In the second part, on the diseases of the nerves, we
find admirable chapters on some affections little known
and very difficult of diagnosis, as brachial neuritis, general
crural neuritis, and rheumatic neuro-myositis. In an appen¬
dix to the chapter on the last-named disease we note the
following passage : — “ It should be noted that the influence
of gout, including ancestral gout, is a subject on which
the young practitioner starts with a high degree of scep¬
ticism regarding the teaching of his seniors. But year by
year his doubts become fewer, as they are rubbed away,
or removed more sharply by contact with facts.5’
T he chapter on multiple neuritis is considerably extended,
and gives a masterly account of this class of affections.
The third part, on the diseases of the spinal cord, opens
with an excellent account of the structure of this organ.
The antero-lateral ascending tract, or tract of Gowers, as
it is commonly called after its discoverer, is traced to the
cerebellum, while some fibres, running in the same position,
pass up near the fillet and end in the corpora quadrigemina
or optic thalamus. These correspond to the crossed efferent
tract of E dinger. The matter is, however, not yet quite
clear in the case of man, although experiments on monkeys
leave little doubt as to the cerebellar destination of
Gowers’ tract in these animals, for Rossolimo has, in a case
of tumour of the cord, traced Gowers’ tract into the
posterior corpora quadrigemina, the substantia nigra, and
the globus pallidus.
The section on the functions of the cord is a succinct
and in every way admirable treatise on the physiology of
this part of the nervous system. Conduction of touch and
of impulse from the muscles takes place in the posterior
columns, and of pain, and probably of temperature, in the
grey matter. Head’s diagrams of the sensory areas of
skin corresponding to the different spinal segments are
given, with a most valuable table showing the approximate
Stimson — Fractures and Dislocations. 131
relations to the spinal nerves of the motor and reflex
functions of the spinal cord.
In the descriptions of the special diseases of the cord
which follow, we everywhere meet with those additions
and alterations which the advance of knowledge has made
necessary. In particular we would point to the chapter
on the muscular dystrophies as an example of the lucid
and complete treatment which the most difficult subjects
receive. ,
In an appendix, Dr. F. E. Batten gives a description of
the muscle spindle, a curious structure, long known, since it
was first described by Kolliker in 1862, but whose real
import has only recently been shown by Sherrington, who
has proved experimentally that it is a terminal sensory
organ.
The volume ends with a good index. The text is
illustrated by 192 figures. The printing and binding
leave nothing to desire.
A Treatise on Fractures and Dislocations. For Students
and Practitioners. By Lewis A. Stimson, B.A., M.D. ;
Professor of Surgery in Cornell University Medical
College, New York. In one octavo volume of 828
pages, with 321 engravings and 20 full-page plates.
The new edition of Professor Stimson’s work, issued in a
single volume, is a decided gain both for the student and
the practitioner. It renders reference to the work much '
easier than was the case while the Fractures and Disloca¬
tions were in separate volumes, and now the information
furnished is brought down to date for both subjects. The
work has had its chief use in the range and accuracy of
its bibliographical references, and naturally the writing of
these down to date is a great advantage for the student.
In many points relating to classification of fractures we
notice statements to which one might well take exception —
points, too, which, examined from a restricted power of
view, embarrass the student. There is no subject more
likely to confuse his mind than that of spontaneous frac¬
ture, and here we find the well-known study by Trousseau.
132 Reviews and 1 Bibliographical Notices.
and others of the rickets of infancy, of adult age, and of
old age ignored in the following passage : — “ Friability
due to rachitis is found only in childhood, for the disease
is one that involves the bones only during their period of
growth, and consists essentially in the prolongation and
exaggeration of the embryonal or developmental condition
of the shaft, in consequence of which its strength and the
firmness of its union with the epiphyses are diminished.”
In the immediate context the varieties of osteoporosis,
other than the rickets of childhood, are discussed, without
a hint at the possibility of there being any close patho¬
logical relation of the diseases, nor any suggestion from
the side of treatment that the diseases are controllable by
the same drug — i.e., cod-liver oil. In the passage we have
quoted there is a suggestion which we think is erroneous
namely, that the fractures of infantile rickets are apt to
occur at the junction of the diaphyses with the epiphyses,
which is not the fact. It is hard to discover the good of
the author’s new departure, for which he takes especial
credit in his preface, with regard to fractures of the skull.
We read : — “ The portion treating of fractures has been
almost wholly rewritten, the most marked change in
classification and arrangement being that made in the
chapter on fractures of the skull, in which for the former
classification — as fractures of the base and vault that of
circumscribed fractures of the vault, and fissured fractures
with injury of the brain, has been substituted. "W e can¬
not imagine any lecturer on surgery introducing the subject
to a class intelligibly with such a grouping, nor can we
recommend this chapter of Professor Stimson s to either
student or practitioner. In addition to objections on the
score of classification, we are forced to examine one of the
author’s theoretical discussions : —
“ The mechanism by which the fracture (Colles’) is pro¬
duced has been and still is the subject of much discussion.
Three theories have been advanced : — (1) Fracture by splitting
or crushing ; the cancellous tissue is crushed or comminuted
between the carpus and the diaphysis. (2) Fracture as in
other bones by decomposition of the force and yielding at the
weakest point. (3) Fracture by cross-strain exerted through
Stimson — Fractures and Dislocations. 133
the anterior ligament in exaggerated and forced dorsal flexion
(hyperextension) of the hand. I believe that almost all these
fractures are produced according to one or the other of the first
two ways, and that the third is rarely seen. In the first the weight
of the body is received on the ball of the hand — the carpus —
directly in the line of the long axis of the radius, and the inner
end of the scaphoid or the semilunar splits the end of the radius
like a wedge. This is shown by many specimens, and appears
to be especially frequent in the elderly.
“ In the second the line of the force is slightly inclined from
the long axis of the radius, making an angle open anteriorly.
The arm is outstretched, and not directly in the line of the falh
The force is decomposed as usual, part being taken up by the
resistance of the long axis, and part acting transversely to break
the bone.”
We have quoted a sufficient length of the discussion on
the mode of production of Colies’ fracture to illustrate
some of the faults of the text, which render the detailed
study of any injury very irksome and tedious — e.g.,
“ forced dorsal flexion (hyperextension) of the hand.”
Why cannot the author be content with the ordinary
language of surgery and of anatomy, and use the term ex¬
tension instead of “ dorsal flexion ” ? Again, “ between the
carpus and the diaphysis ; ” surely the term diaphysis is
not correctly used when the author writes about the bone
of which the growth is completed, and to describe the
inferior articular surface of the bone. Lastly, “ an angle
open anteriorly,” where the writer means “ open pos¬
teriorly.”
Faults of this kind are to be found in all parts of the
work. The descriptions of the lesions of the elbow, both
fractures and dislocations, are most difficult to follow until
one has mastered the varied meanings attaching to the
terms condyle, epicondyle, epitrochlea, which the author
uses in a style quite peculiar to himself.
We cannot close this notice without quoting the caution
expressed by the author with regard to the unbounded
faith with which some would receive the readings of the
X-rays: — “ While the X-rays have been of interest and
value in showing details of certain fractures — especially
at the wrist, elbow, and ankle — yet it cannot fairly be said
134 Reviews and Bibliographical Notices.
that they have yielded much information of practical
value which could not be obtained by palpation.
“ Probably their usefulness will be increased by improve¬
ments in methods and apparatus, but at present the infor¬
mation which they give needs to be sifted with great care
from among many misleading appearances.”
Prom the observations made above it will be clear to
our readers that we regard this book with very mixed feel¬
ings. We cannot but praise its excellence as a very com¬
plete bibliographical reference, and as furnishing very
good illustrations of almost all important fractures. Here
our praise must stop, for the text is replete with the
kinds of imperfections of which we have quoted enough
examples.
Hygiene and Public Health. By B. Arthur White-
legge, M.D. Seventh Thousand. London: Cassell
& Co., Ltd. 1899. Pp. 588.
The new edition of this excellent and popular handbook
has all its statistics brought down to date. It contains
information as to recent improvements in disinfectants,
and deals fully with recent vaccination legislation, and
practice. It is a thoroughly reliable and useful handbook.
B. Bradshaw' s Dictionary of Bathing Places, Climatic
Health Resorts, Mineral Waters, Sea Baths, and Hydro¬
pathic Establishments. London: Kegan Paul, Trench,
Triibner, & Co., Ltd. 1899. Pp. 372.
This well known handbook purports to be kept accurate
by annual revision. So far as the Irish entries are con¬
cerned there is need for further correction. It contains
not only an alphabetical list, with particulars, of health
resorts, &c., but has other useful chapters, such as that on
how to reach each place, with the cost and time occupied.
The good taste of the editor has not yet induced him to
omit the “ Explanations and Translations of Technical
Terms and Phrases.”
PART III.
MEDICAL MISCELLANY.
- -
Reports , Transactions , ancl Scientific Intelligence.
- -
Accidental Rupture of the Small Intestine A By J. Nash.
J. S., aged twenty-seven, on the 16th inst. partook of a full meal
of corned beef and cabbage about 3 o’clock, followed at 4 30 by
some soup, bread, and other solids. He then went out to exercise
on a horizontal bar. Whilst doing so, with his arms resting on the
bar behind his back, he was about to raise himself up when his feet
slipped and he fell forward on another bar lying close to the ground.
This bar struck him above the junction of his epigastric and
umbilical regions. The distance of the fall was about two feet.
He immediately felt pain in his abdomen, became faint, and vomited.
The vomit consisted of the contents of his stomach and showed no
trace of blood.
The faintness soon passed off, but the pain persisted, and soon
became more intense, being of a colicky nature. Some hours after he
applied to the infirmary of the Mater Hospital, where he got two
purgative pills and was poulticed over the abdomen. He took one
of the pills, which was promptly rejected by the stomach, as was
also some hot milk. The poultice relieved the pain somewhat, but
the patient passed a very unquiet night. When seen by Dr. Blaney
he stated he felt somewhat easier and had no pain except when he
turned in bed. His aspect was good ; pulse 120, small, hard, and
wiry ; temperature 101° E., and he was suffering from intense thirst.
Examination of the abdomen showed it to be much distended and
tympantic, with liver dulness almost completely abolished. There
was an area of marked tenderness situated above the umbilicus.
His bowels had not moved since the time of the accident (about 17-J
hours), nor had he passed any flatus per anum. On considering his
symptoms Dr. Blaney came to the conclusion that he had ruptured
some part of his intestinal canal, probably somewhere in the
neighbourhood of the duodenum, and suggested the patient’s removal
to hospital for immediate operation, which was agreed to.
a Read before the Medical and Scientific Society of the Catholic University
Medical School, May 8, 1899.
1B6 Rupture of the Small Intestine.
The operation was begun about twenty-four hours after the
accident. Ether having been administered, an incision was made
about 7 inches long in the middle line round the left of um¬
bilicus, and terminating at a level slightly below this. There was
a very thick layer of subcutaneous fat and much subperitoneal fat
also. When the peritoneum was opened the transverse colon
immediately protruded ; this was pulled down, and the stomach was
examined, and was found to be normal. The omentum was then
raised up, and the small intestine examined. On pulling out a few
coils it was found that they were much distended. Tracing these
in the direction of the distension caused a flow of a slightly turbid
fluid, which was received on sponges, and several masses of
whitish-yellow lymph were now seen adherent to and gluing
together different coils of intestine. On gently separating
these, a perforation was found on a portion of the jejunum
lying to the left of the middle line, and apparently close to the
duodenum. The small intestine all round showed here and there
masses of whitish-yellow lymph, was much injected with blood, and
greatly dilated, so much so that Mr. Lentaigne, who was standing
by, remarked that “ it looked more like large intestine than small/’
The rupture was transverse in direction, |- in. long, and running up
to the termination of the mesenteric border. The mucous membrane
was prolapsed into the aperture, which had a rounded outline.
Already well-marked peritonitis had set in, and the intestine
had probably to a certain extent become paralysed. The
margins of the rupture were washed with 1 in 20 carbolic, which
was then flushed away with sterilised saline solution. A double
row of Lembert sutures was inserted, and then the intestines and
mesentery in the neighbourhood were flushed with saline solution.
The wound was then closed. Three silver wire sutures, passing
through the whole thickness of the abdominal wall, and including
peritoneum were first inserted, and fishing-gut was used to approxi¬
mate skin and muscle. A good deal of time was taken up by this,
as the abdominal walls were very tense, and the intestines tended
to protrude, and in addition the silver wire broke two or three
times. Half an hour after the operation, when the effect of the
ether had to a great extent passed off, his pulse was about 14.0,
but otherwise he looked and felt well. He got a pint of hot saline
solution by the rectum, which he retained, and a 7 min. hypodermic
of strychnin. Otherwise his treatment consisted of occasional sips
of hot water. At 6 o’clock that evening his temperature was 100° F. ;
pulse, 140 ; respiration, 40. He complained of the tightness of
137
Rupture of the Small Intestine ,
the bandage and some slight pain in the wound. He was somewhat
restless during the night, complained much of thirst; about 1 30 a.m.
he vomited a large quantity (about two pints) of dark brown fluid.
However, later on he was much improved — temperature, normal ;
pulse, 120 ; respiration, 34 ; he had no pain, and his aspect was
extremely good. He had not vomited any more, and altogether
seemed doing well ; he had not, however, passed any flatus per anum.
He continued fairly well during the next day, but about 6 o’clock
temperature rose to 105° F. ; pulse, 130 ; respiration, 32 ; it fell
again to normal in a couple of hours. About 1 o’clock he
again vomited about half a pint of dark brown fluid, and again
at 5 o’clock about one ounce. Next morning he was still
looking pretty well — temperature, 99° ; pulse, 134 ; respiration,
31. As he had passed nothing per anurn since the operation
a turpentine enema was ordered ; this brought away a consider¬
able amount of formed foeces, emptying apparently the sigmoid
flexure. Towards 4 o’clock he began to vomit, and the vomiting
became more and more frequent, until at last it occurred
every ten minutes. About 5 45 he was looking much worse •
pulse, 140 ; vomiting frequently. The vomited matter regurgi¬
tated from the stomach without any effort on the part of
the patient, appearing, according to him, to come from his throat;
it was almost black in colour and of sour smell — the vomit of
acute obstruction; temperature was 100°, and he complained of
feeling very weak and exhausted by the vomiting. Dr. Blaney
and Mr. Coppinger resolved, on consultation, to re-open the abdomen,
as it was plainly evident that he was dying as it was. Accordingly
about 7 he was again anaesthetised and the wound re-opened, the
vomiting continuing during the operation. The intestines were in
much the same condition as at the last operation ; there was abso¬
lutely no fluid now in the peritoneum, but the intestines on the
left side of the abdomen were much distended and adherent to
each other; one place was slightly kinked, but the intestine was
distended equally below as well as above the spot. On exposing
the site of rupture it was found securely sealed. 1 racing the
intestine downwards towards the caecum it was found to become
gradually smaller and smaller till it reached its normal size. It
was collapsed here, but otherwise looked healthy. It was decided
that the symptoms depended on acute obstruction, owing to the
paralytic distension of the small intestine. There was no moie, oi
scarcely as much, peritonitis as at the first operation. Io relieve
the distension a trocar and canula were introduced into the distended
138
Rupture of the Small Intestine .
coil of intestine, and through the canula as much flatus as possible
was emptied. Then a concentrated solution containing §i. of
mag. sulph. was injected. The puncture was closed by Lembert’s
suture ; there was nothing in the peritoneal cavity to wash away,
but as a stimulant some hot saline solution was poured into the
abdomen. The wound was then closed. The patient’s pulse was
very rapid and feeble during the operation. For some two or three
hours subsequently he seemed to improve, the vomiting having
ceased, but about 11 he began to vomit again. His pulse, which had
slowed down to 140, became faster and faster, his temperature rose
to 103°, and finally he died about 1 50. Just before death a gush
of vomiting came on.
THE INFLUENZAL CHANGE OF TYPE OF ACUTE PNEUMONIA.
In the second edition of their Manual of Bacteriology (Edinburgh
and London : Young J. Pentland) Drs. Muir and Ritchie observe:—
“ Up till 1889 acute catarrhal pneumonia was comparatively rare
except in children. In adults it was chiefly found as a secondary
complication to some condition such as diphtheria, typhoid fever, &c.
Since the first recent great epidemic of influenza in the year named,
however, it has been of much more frequent occurrence in adults,
has assumed a very fatal tendency, and has presented the formerly
quite unusual feature of being sometimes the precursor of gangrene
of the lung. Moreover, not only has the prevalent type of pneu¬
monia (the term being used in its widest sense) changed through
the occurrence of a greater proportion of catarrhal cases, but it
appears to be now more common to find cases which microscopically
present a mixed type — i.e., in which both an acute croupous condition
and an acute catarrh occur in the same lung.” The above state¬
ments are entirely confirmatory of the clinical description of the
pneumonia which so often presented itself as a complication of the
epidemic influenza of 1889-90 in Dublin. In a paper upon that
epidemic, published in the number of this Journal for April, 1890
(Yol. 89, page 315), Dr. J. W. Moore wrote as follows: — “The
pneumonia, while producing the ordinary physical signs of acute
croupous pneumonia, is often latent in its course, or accompanied
by a profuse muco-purulent expectoration, with scarcely any rusty
sputa. The ebbing of the strength in some of these cases in elderly
people is something awful — it is often absolutely beyond control.”
ROYAL ACADEMY OF MEDICINE IN IRELAND.
President — Edward H. Bennett, M.D., F.R.C.S.I.
General Secretary — John B. Story, M.B., F.R.C.S.I.
SECTION OF OBSTETRICS.
President — F. W. Kidd, M.D.
Sectional Secretary — John H. Glenn, M.D.
Friday, March 17, 1899.
Dr. W. J. Smyly in the Chair.
Exhibits.
Dr. Alfred Smith exhibited three myomatous uteri removed
by retro-peritoneal hysterectomy.
(1.) The first specimen was a large soft myoma which had been
removed five days previously. The patient had given birth to two
children, and after the birth of the younger child, who was now
three years old, the uterus in repose came down to the size of a
three months’ uterus. The tumour, which was considerably
oedematous, and blocked up the pelvis completely, extended well
into the broad ligament.
(2.) The second specimen was a very small fibroid, which he
removed on account of the constant trouble which it gave to the
patient during micturition. On cutting through the pedicle there
was no haemorrhage, and he found that there was only one uterine
artery developed to any extent, and that was on the left side. The
absence of a uterine artery on the right side was the chief point of
interest in this specimen.
(3.) The third specimen which he had removed a fortnight ago
was large, and appeared to him before operation as sub-peritoneal
and pedunculated. On operating, however, he found a second
pedicle intimately adherent to the promontory of the sacrum, and
this gave him considerable trouble until he found out the condition.
He then attempted to perform a myomectomy. He put a clamp
round the cervix in the ordinary way in order to suppress
haemorrhage from it, and then proceeded to amputate the large
tumour which he exhibited. On loosening the ligature, however,
140 Royal Academy of Medicine in Ireland.
there was hcemorrhage everywhere. He tied several arteries, but
notwithstanding this he could not arrest the haemorrhage, so that
he was obliged to perform hysterectomy. The patient did remark¬
ably well.
Dr. Purefoy said that Dr. Smith’s failure to find the uterine
artery on one side was another illustration of the variations in
size which one often observed in different cases in the uterine
vessels. It was very difficult to forecast what the behaviour of a
fibroid would be. There were some harder than others, and the
rate of growth in these cases was comparatively slow. The diffi¬
culty Dr. Smith had in controlling the haemorrhage in the case of
myomectomy showed that one ought to be prepared for an
emergency, even in the case of a tumour with a small pedicle. He
suggested that tying the ovarian arteries might have had some
effect in checking the haemorrhage in this case.
Dr. Smyly suggested that the small tumour might have been
better removed per vaginam.
Dr. Smith, replying, said there seemed to be a growing opinion
that operation should be the treatment in the case of fibromata.
He looked upon these cases as strong arguments in favour of
operative treatment. The uncertainty of the prognosis was another
point in favour of operation. As regards the shock of removal of
the uterus by the retro-peritoneal method, his experience was that
patients suffered more pain and distress after removal of the tubes
and ovaries only than when they removed the tumour and the
uterus down to the level of the cervix. With reference to Dr.
Smyly’s suggestion, the reason he removed the tumour from above
was on account of the long pedicle attached to it making this easy.
SECTION OF PATHOLOGY.
President — J. M. Purser, M.D.
Sectional Secretary — E. J. McWeeney, M.D.
Friday , %4th March, 1899.
Prof. E. H. Bennett, M.D., President of the Academy, in the
Chair.
Chronic ( circumscribed) Abscess in Tibia ( Brodids ).
Mr. Henry Gray Croly communicated several cases of Brodie’s
abscess, and exhibited portions of bone removed by a small trephine
and drawings of the cases; the bones were much thickened and
diseased.
Section of Pathology . 14 L
Case I. occurred in a young man, in the lower end of the tibia,
admitted into the City of Dublin Hospital. The patient suffered
from severe pain confined to a small spot about four inches above
the ankle-joint. All treatment, constitutional and local, failed to
give relief. ME Croly trephined the tibia at the most painful
part ; a small quantity of pus escaped. The patient got immediate
relief and made a rapid recovery.
Case II. — A young lady, residing in the South of Ireland, suffered
from pain at the junction of the middle and lower ^hird of the tibia
for about sixteen years. The pain at times was excruciating ; she
got relief occasionally. All treatment having failed, amputation
was proposed and refused. She came to Dublin. Mr. Croly
trephined the tibia. A small quantity of pus escaped. The bone
was very hard and thickened. The patient made a perfect recovery.
Case III. — A young man, at present in the City of Dublin
Hospital, suffered for ten years from very severe pain in the lower
third of the right tibia. An incision was made through the perios¬
teum some months previous to his coming under Mr. Croly’s care.
The symptoms were not relieved. There was thickening of the
bone above the ankle-joint. Mr. Croly trephined, and about two
drachms of healthy pus escaped as the portion of bone was being
removed. The wound healed rapidly, and the patient got im¬
mediate and permanent relief.
Case IV.— A young girl, at present in the City of Dublin Hospital,
suffered for over three years from severe and constant pain in the
upper third of the right tibia. She was operated on by a surgeon,
but got no relief. Mr. Croly trephined the tibia. The portion of
bone was diseased, and there was considerable thickening and
density of the tibia. There were two cedematous and pouting
granulations at the part affected. The patient got instant lelief
from pain.
Mr. E. H. Bennett said it was interesting to note that these
abscesses were not confined to the epiphyses, as desciibed by Biodie.
He believed that they had nothing to do with tubercular disease of
the bone, owing to their great clironicity, and the fact that they
are relieved by emptying.
Mr. T. Myles said that he had very recently operated on a boy
for Brodie’s abscess in the upper end of the tibia. He had operated
on him three years previously for Brodie s abscess, and the boy
went home well. He came back to him a few days ago with a
superficial abscess over the site of the original Brodie’s abscess,
and operation showed that there had been no attempt whatever at
the production of new bone in the cavity, and there was simply a
142 Royal Academy of Medicine in Ireland .
mass of granulation. Another case on which he operated was
remarkable in its recovery in that the skin dipped down into the
recess, and patient had now a pocket extending backwards an inch
in depth into the tibia. He presumed that the insufficiency of the
new bony growth was due to the non-vascularity of the extremely
dense tissue, and that there was not room for the blood vessels to
expand. He thought that the explanation of the alleged frequency
of this condition in the tibia was that the disease was not re¬
cognised when occurring in other situations. Probably many cases
of tubercular disease of the knee-joint began as a tubercular process
in the layer of bone immediately underlying the cartilage of the
tibia.
Dr. Knott had seen Mr. Croly’s case in hospital, and could bear
testimony to the prolonged and intermittent character of the pain.
In Brodie’s cases, there was no external appearance that could lead
to a suspicion of what the nature of the disease was.
Mr. T. E. Gordon had a case recently. Patient, forty-five years
of age, had a very marked swelling of the upper third or more of
the tibia, and a sinus led down to this part of the bone. History
was that patient had first noticed a swelling after an injury received
twenty or thirty years previous. About twelve years ago a sinus
had formed and closed, and a second formed and closed, but a third
sinus which formed persisted. A thick layer of dense bone was
chiselled through with difficulty, and a large abscess found in the
bone.
Mr. Croly, in reply to Mr. Myles, said that he had not meant
to convey that circumscribed abscess of bone was confined to
the tibia, but it was met much more frequently there. He could
not see any analogy between a cartilage erosion and sub-cartilage
trouble as described by Barnwell, who believed that the disease did
not begin in the cartilage or bone, but in the cartilage under the
bone. He had cut out the head of the humerus, but it bore
absolutely no analogy to circumscribed abscess of the tibia.
Tubercular disease of the knee-joint had nothing to say to the
condition.
Enteric Fever fatal through Embolic Hemiplegia.
Dr. J. W. Moore reported a case of this disease. [It will be
found in Yol. CVIL, page 350.]
Dr. E. J. McWeeney asked Dr. Moore how he accounted for
the coagulation of the blood in the left side of the heart by myo¬
cardial changes. Apart from some endocardial change, it was not
143
Section of Pathology.
clear how he accounted for the formation of the thrombus. Was a
microscopic examination of the spleen made with a view to dis¬
covering the typhoid bacillus? Was the sero-diagnostic test
applied during life ? Regarding cerebral implication in the course
of general infective diseases, a most remarkable case which had
come under his notice was that of a late distinguished Fellow of
that Academy, in whose case the pneumococcus of Fraenkel became
localised in the meninges after the morbid process to which it
gave rise had been successfully overcome in tjie lung. He had
seen a case of typhoid fever last winter, in which the symptoms
which prevailed during the entire course of the attack were indis¬
tinguishable from meningitis, and the real nature of the case was
only ascertained by Widal’s reaction.
Dr. R. Travers Smith asked Dr. Moore if a microscopic ex¬
amination of the myocardium had been made, and did it exhibit
parenchymatous or fatty degeneration? Was it from clinical or
post-mortem experience that he had made the statement that enteric
fever is one of the fevers which most profoundly affects the myo¬
cardium ?
Dr. J. W. Moore, in reply to Dr. McWeeney, said that the
endocardium was perfectly healthy, and in it there was nothing to
account for the ante-mortem clotting. He attributed the clotting to
the extremely feeble action of the heart which existed for the last ten
or twelve hours of life. The spleen was not examined for Eberth’s
bacillus. Widal’s reaction was positive. In reply to Dr. Smith,
he said that in speaking of profound changes of the heart he was
speaking generally and not with regard to the present case, in
which no minute examination of the heart muscle was made.
Cardiac failure not infrequently did lead to death in enteric fever.
He spoke solely from clinical experience on the subject.
Primary Carcinoma of Liver , ivith Enormous Enlargement of Spleen.
Dr. D. F. Rambaut exhibited specimens.
Gall-stones with Multiple Abscess of Liver and Carcinoma of the
Bladder.
The Secretary (Prof. McWeeney) showed this specimen, which
was the liver of a woman, aged nearly seventy, who suffered from
severe and persistent jaundice for several months before death, and
was thought to have cancer of the liver. Post mortem the organ was
not much enlarged (weighed 60 oz.), and was studded on the surface
and throughout with hundreds of small abscesses, varying in size
144 Royal Academy of Medicine in Ireland.
from a pin’s head to a hazelnut, and containing a greenish pus,
thick and inodorous. The larger bile ducts were greatly dilated
and contained an inspissated bile mingled with soft gritty concre¬
tions. The common bile duct was large enough to hold the little
finger, and contained several crumbling calculi, one of which quite
blocked the passage into the duodenum. Of gall bladder there was
no trace, its position being occupied by a solid white nodule about
the size of a walnut, to -which the duodenum was firmly adherent.
On microscopic examination this proved to have the structure of
adeno-carcinoma, and a gradual transition from normal bile duct
to carcinoma structure could be distinctly traced in the sections.
There was no trace of the wall of the gall bladder to be detected
with the microscope. The hepatic duct ran into this nodule, and
the common bile duct ran from it to the duodenum. The cystic
duct seemed to be represented by a solid cord about -J- in. in
diameter, consisting of cancerous tissue. The wall of the numerous
small abscesses was composed of flattened layers of hepatic cells,
which gradually became necrotic as the abscess was approached.
The abscesses were not demonstrably contained in the bile ducts,
or associated with the portal vein. They contained two varieties
of Bacillus coli , distinguished by their appearance on gelatine plates
and on potato. Both were highly virulent for animals (rabbits),
and produced abundance of indol. The autopsy was made a few
hours after death, so that post-mortem immigration need not be
assumed. Exhibitor was inclined to look upon the organisms as
the primary mtiological factor, then came the calculi and finally
the conversion of the gall bladder into a solid mass of neoplasm.
Dr. Eustace asked, with reference to Dr. Rambaut’s specimen,
if there was any evidence of collateral circulation in the spleen.
Dr. Littledale thought that there was no doubt about Dr.
Rambaut’s specimen being one of primary cancer, as the normal
liver tissues could be actually seen undergoing transformation into
cancerous tissue. He thought that liver abscesses, in Professor
McWeeney’s case, resembled kidney abscesses in that in the case
of the kidney it has been stated that when Bacterium coli is found
in the urine with symptoms of pain about the kidney, it was a pretty
certain sign of stone in the kidney, and it has been said that the
presence of the stone in the kidney allows the Bacterium coli to
get through the abraded membrane of the pelvis of the kidney.
Dr. J. W. Moore said that the enlargement of the spleen in
Dr. Rambaut’s case was most interesting and very unusual in
carcinoma of the liver. There must have been very considerable
145
Section of Pathology.
pressure on the portal vein to cause the condition. The bacterio¬
logical origin of gall-stones was very interesting. It has been
observed that patients recovering from typhoid fever have become
subject to gall-stones, and probably it is really a manifestation of
the localisation of Eberth’s bacillus producing a deposition of
. cholesterine and lime salts.
Dr. Knott asked if there was a large quantity of ascitic fluid
in Dr. Rambaut’s case.
Dr. Rambaut, in reply to Dr. Eustace, said that there was a
varicose condition of the gastric and oesophageal veins, and also the
veins behind the peritoneum. In asylum post-mortems , only about
one-twelfth of the cases of cancer of liver were primary. Perhaps
the cirrhosis of the liver would account for the portal obstruction
in this case. With reference to Dr. McWeeney’s case he said that
he had lately made a post-mortem examination on a woman who
died of consumption, and found four abscesses in the liver. From
the pus obtained he got almost a pure culture of Bacterium
coli.
Dr. McWeeney, in reply, said that he had lately seen a very
large kidney completely riddled with small abscesses containing a
creamy pus which contained one organism only — the Bacillus coli in
prodigious numbers, and they could be seen easily filling up the
urinary tubules. Without doubt the process had penetrated from the
pelvis through the papillae along the straight tubules, and had
excited suppuration from the interior of the urinary tubules out¬
wards. The same thing is constantly found in what are unjustly
called “ surgical ” kidneys. In cases of typhoid fever, it was his
experience to find Eberth’s bacillus invariably present in the gall
bladder. Cases are on record where, in cases of typhoid fever, the
typhoid bacillus was found twenty years afterwards in the gall
bladder. In fact, the bile seemed to be an ideal medium for the
long preservation of the life of various pathogenic species of
bacteria.
Peculiar Clot from a Case of Epistaxis.
Dr. Ninian Falkiner reported the following case — M. C.,
aged seventy-six years, suffered from a chronic cough ; was a
native of Birr, King’s County ; a dressmaker ; a widow ; had
eight children, one living. On Sunday, 27th March, 1898, when
coughing, blood commenced to flow from mouth and nose, and
continued intermittingly until 29th March, 1898, when with a
severe fit of coughing, accompanied by a feeling of suffocation, the
clot was coughed up. The bleeding ceased, but patient sank and
K
146 Royal Academy of Medicine in Ireland.
died April 11th, 1898. The clot, which he was unable to break
down with a spoon, is evidently a cast of the posterior nares, with
a process about 8 inches in length, which probably extended down
into the oesophagus ; it is composed entirely of blood-clot and
contains no organised tissue.
Dr. McWeeney regarded Dr. Falkiner’s explanation of the
cases of rhinoliths as, at any rate, extremely suggestive.
THE WILLIAM F. JENKS MEMORIAL PRIZE.
Dr. James V. Ingham, Secretary of the Trustees of the College
of Physicians of Philadelphia, informs us that the Fifth Triennial
William F. Jenks Memorial Prize of Five Hundred Dollars,
under the deed of trust of Mrs. William F. Jenks, will be
awarded to the author of the best essay on “The Various
Manifestations of Lithaemia in Infancy and Childhood, with the
Etiology and Treatment.” The conditions annexed by the founder
of this prize are, that the “ prize or award must always be for some
subject connected with Obstetrics, or the Diseases of Women, or
the Diseases of Children and that “ the trustees, under this deed
for the time being, can, in their discretion, publish the successful
essay, or any paper written upon any subject for which they may
offer a reward, provided the income in their hands may, in their
judgment, be sufficient for that purpose, and the essay or paper be
considered by them worthy of publication. If published, the dis¬
tribution of said essay shall be entirely under the control of said
trustees. In case they do not publish the said essay or paper, it
shall be the property of the College of Physicians of Philadelphia.”
The prize is open for competition to the whole world, but the essay
must be the production of a single person. The essay, which must
be written in the English language, or if in a foreign language,
accompanied by an English translation, must be sent to the College
of Physicians of Philadelphia, Pennsylvania, U.S.A., before
January 1, 1901, addressed to Richard C. Norris, M.D., Chairman
of the William F. Jenks Prize Committee. Each essay must be
typewritten, distinguished by a motto, and accompanied by a sealed
envelope bearing the same motto and containing the name and
address of the writer. No envelope will be opened except that
which accompanies the successful essay. The Committee will
return the unsuccessful essays if reclaimed by their respective
writers, or their agents, within one year. The Committee reserves
the right not to make an award if no essay submitted is considered
worthy of the prize.
SANITARY AND METEOROLOGICAL NOTES.
Compiled by J. W. Moore, B.A., M.D. Univ. Dubl. ;
P.R.C.P.I. ; F. R. Met. Soc. ;
Diplomate in State Medicine and ex-Sch. Trin. Coll. Dubl.
Vital Statistics
For four Weeks ending Saturday , June 17, 1899.
The deaths registered in each of the four weeks in the twenty-
three principal Town Districts of Ireland, alphabetically arranged,
corresponded to the following annual rates per 1,000 : —
Towns,
&c.
Week ending
Aver¬
age
Towns,
<fec.
Week ending
Aver¬
age
May
27
June
3
June
10
June
17
Rate
for 4
weeks
May
27
June
3
June
10
June
17
Rate
for 4
weeks
23 Town
23-1
224
21-5
211
22-0
Limerick
23-9
12-6
8*4
5-6
12*6
Districts
Armagh -
00
21-4
71
14-3
10-7
Lisburn
21-3
29-8
17-0
29'8
24-5
Ballymena
22-5
22-5
451
39-5
32-4
Londonderry
26-7
23-6
22-0
40-8
28-3
Belfast
21-8
231
20-6
20-6
21-5
Lurgan
271
271
18-2
18*2
22-8
Carrickfer-
5-8
17-5
o-o
23-4
11-7
N e wry
201
201
121
28-2
201
gus
Clonmel -
48*7
14-6
341
o-o
24-3
Newtown-
ards
17-0
11-3
34-0
17-0
19*8
Cork
21-5
26-3
18-0
20-8
21-7
Portadown -
18-6
18*6
12*4
12-4
15-5
Drogheda -
22-8
11*1
22-8
7-6
16-2
Queenstown
11-5
11*5
17-2
23'0
15*8
Dublin
25‘8
21-5
24-5
20'6
231
Sligo
30-5
20-3
51
15-2
17*8
(Reg. Area)
Dundalk -
12-6
4-2
377
16-8
17-8
Tralee
11-2
22-4
11-2
22-4
16-8
Galway
15-1
37-8
26-4
41-5
30'2
Waterford -
25-9
25-9
29-8
29-8
27-8
Kilkenny -
28-3
51-9
14-2
28-3
30*7
Wexford
13-5
31-6
271
22-6
237
In the week ending Saturday, June 17, 1899, the mortality
in thirty-three large English towns, including London (in which the
rate was 15T), was equal to an average annual death-rate of 16*5
per 1,000 persons living. The average rate for eight principal
towns of Scotland was 17*9 per 1,000. In Glasgow the rate was
17*6. In Edinburgh it was 17*0.
148 Sanitary and Meteorological Notes.
The average annual death-rate represented by the deaths regis¬
tered during the same week in the Dublin Registration Area and
in the twenty-two principal provincial Urban Districts of Ireland
was 21 T per 1,000 of their aggregate population, which, for the
purpose of this return, is estimated at 1,053,188.
The deaths from the principal zymotic diseases in the twenty-
three districts were equal to an annual rate of 2*3 per 1,000, the
rates varying from 0*0 in thirteen of the districts to 16’0 in
Ballymena — the 7 deaths from all causes registered in that district
comprising 2 from measles and one from whooping-cough ; the
Registrar remarks — u A severe epidemic of measles prevails in the
town and neighbourhood . several deaths. The
disease is so general and has spread so rapidly that I expect it will
soon exhaust itself.” Among the 138 deaths from all causes
registered in Belfast are 9 from measles, 4 from whooping-cough,
6 from enteric fever, and 5 from diarrhoea. The 26 deaths in
Londonderry comprise one from measles and 2 from diarrhoea.
In the Dublin Registration Area the births registered during the
week amounted to 217 — 105 boys and 112 girls; and the deaths
to 144 — 80 males and 64 females.
The deaths, which are 21 under the average number for the
corresponding week of the last ten years, represent an annual rate
of mortality of 21-5 in every 1,000 of the population. Omitting
the deaths (numbering 6) of persons admitted into public institutions
from localities outside the area, the rate was 20*6 per 1,000.
During the twenty-four weeks ending with Saturday, June 17, the
death-rate averaged 28*5, and was IT under the mean rate for the
corresponding portions of the ten years 1889-1898.
The number of deaths from zymotic diseases registered during
the week was 18, being equal to the average for the corresponding
week of the last ten years, but 2 under the number for the previous
week. The 18 deaths comprise one from measles, one from scarlet
fever (scarlatina), 5 from influenza and its complications, 4 from
whooping-cough, one from enteric fever, and 4 from diarrhcea.
The cases of measles admitted to hospital amounted to 28,
against 3 in the preceding week ; 3 measles patients were dis¬
charged, one died, and 30 remained under treatment on Saturday ?
being 24 over the number in hospital on Saturday, June 10.
The number of cases of scarlatina admitted to hospital was 7,
being 12 under the admissions in the preceding week, 10 patients
were discharged, and 75 remained under treatment on Saturday,
being 3 under the number in hospital on the previous Saturday.
There were, in addition, 11 convalescents from this disease under
Sanitary and Meteorological Notes. 149
treatment at Beneavin, Glasnevin, the Convalescent Home of Cork-
street Fever Hospital.
As in the preceding week, 17 cases of enteric fever were admitted
to hospital; 12 patients were discharged, one died, and 57 remained
under treatment on Saturday, being 4 over the number in hospital
at the close of the preceding week.
The hospital admissions for the week included, also, 4 cases of
diphtheria; 19 cases of this disease remained under treatment in
hospital on Saturday.
Twenty-five deaths from diseases of the respiratory system were
registered, being 2 over the average for the corresponding week of
the last ten years, and also 2 over the number for the previous week.
They consist of 10 from bronchitis, 13 from pneumonia, and 2
from pleurisy.
Vital Statistics
For four weeks ending Saturday , July 15, 1899.
The deaths registered in each of the four weeks in the twenty-
three principal Town Districts of Ireland, alphabetically arranged,
corresponded to the following annual rates per 1,000 —
Town?, &c.
Weeks ending
Aver¬
age
Rate
for 4
weeks
Towns, &c.
Weeks ending
Aver¬
age
Rate
for 4
weeks
June
24
July
l
July
S
July
15
June
24
July
1
July
8
July
15
23 Town
19-6
20-3
196
211
2
Limerick -
16-8
36-5
9-8
4-2
16-8
Districts
Armagh
28*5
o-o
28*5
21-4
19-6
Lisburn
25-7
21-3
12-8
12*8
18-2
Ballymena
16-9
16-9
28-2
22-5
211
Londonderry
23-6
31-4
17-3
7-9
201 !
Belfast
18-0
17-4
20-4
21*5
18-3
Lurgan
3L9
18-2
18-2
31-9
25-0 |
Carrickfer-
17'5
1T7
o-o
5-8
8’8
Newry
161
4-0
201
201
151 1
gus
1
Clonmel -
19-5
9*7
4-9
29-2
15-8
Newtown-
11*3
22-7
28-3
34-0
241
ards
Cork
23-5
17‘3
18*0
23-5
20-6
Portadown
247
6 2
18'6
18-6
17*0
Drogheda -
3*8
26‘6
2
2
2
Queenstown
11*5
17-2
5*7
11-5
H-5
Dublin -
20-7
22-2
22*4
251
22-6
Sligo
35-5
20-3
10-2
25*4
22-8
(Reg. Area)
Dundalk •
12-6
29'3
16-8
4-2
157
Tralee
22-4
33*6
28-0
o-o
21*0
Galway
11-3
151
22-7
151
161
Waterford
15’9
25*9
13-9
19-9
18-9
j Kilkenny -
!
42-5
23-6
14-2
9-4
22-4
Wexford -
13-5
9-0
9-0
22-6
13-5
150 Sanitary and Meteorological Notes.
In the week ending Saturday, July^, 1899, the mortality in
thirty-three large English towns, including Eondon (in which the
rate was 15*9), was equal to an average annual death-rate of 16 9
per 1,000 persons living. The average rate for eight principal
towns of Scotland was 16*7 per 1,000. In Glasgow the rate was
17*1. In Edinburgh it was 17*2.
The average annual death-rate represented by the deaths regis¬
tered during the same week in the Dublin Registration Area and
in the twenty-two principal provincial Urban Districts of Ireland
was 21*1 per 1,000 of their aggregate population, which, for the
purpose of this return, is estimated at 1,039,480. This number is
exclusive of the population of Drogheda, in one district of which,
owing to alterations in boundaries, registration was suspended
during the last fortnight.
The deaths from the principal zymotic diseases in the twenty-
three districts were equal to an annual rate of 2*2 per 1,000, the
rates varying from 0*0 in nineteen of the districts to 3*3 in
Belfast— the 144 deaths from all causes registered in that city
comprising 3 from measles, 1 from scarlatina, 3 from whooping-
cough, 1 from diphtheria, 8 from enteric fever, and 6 from
diarrhoea.
In the Dublin Registration Area the births registered during
the week amounted to 185 — 106 boys and 79 girls ; and the deaths
to 173 — 94 males and 79 females.
The deaths, which are 31 over the average number for the
corresponding week of the last ten years, represent an annual rate
of mortality of 25*8 in every 1,000 of the population. Omitting
the deaths (numbering 5) of persons admitted into public institu¬
tions from localities outside the area, the rate was 25*1 per 1,000.
During the twenty-eight weeks ending with Saturday, July 15, the
death-rate averaged 27*8, and was 0*7 under the mean rate for the
corresponding portions of the ten years 1889-1898.
Twenty-five deaths from zymotic diseases were registered
during the week, being 6 in excess of the average for the corre¬
sponding week of the last ten years, and 5 over the number for
the previous week. They comprise 7 from measles, 4 from
whooping-cough, 3 from diphtheria, 1 from enteric fever, 1 from
infantile cholera, 5 from diarrhoea, and 1 from erysipelas.
The number of cases of measles admitted to hospital was 39,
being 5 under the admissions in the preceding week, but 9 over the
number in the week ended July 1. Seventeen measles patients were
discharged, 2 died, and 105 remained under treatment on Saturday,
Sanitary and Meteorological Notes. 151
being 20 over the number in hospital at the close of the preceding
week.
As in the week preceding, 13 cases of scarlatina were admitted
to hospital; 17 patients were discharged, and 54 remained under
treatment on Saturday, being 4 under the number in hospital on
that day week. There were, in addition, 18 convalescents under
treatment at Beneavin, Glasnevin, the Convalescent Home of Cork-
street Fever Hospital.
Ten cases of enteric fever were admitted to hospital, against 8
in the preceding week. Six patients were discharged, 1 died,
and 53 remained under treatment on Saturday, being 3 over the
number in hospital on the previous Saturday.
The hospital admissions for the week included, also, 6 cases of
diphtheria (an excess of 2 as compared with the admissions in the
preceding week), and 1 case of typhus. Seven cases of the former
and 8 of the latter disease remained under treatment in hospital on
Saturday.
The number of deaths from diseases of the respiratory system
registered was 20, being 1 under the average for the corresponding
week of the last ten years, and 4 under the number for the previous
week. The 20 deaths consisted of 12 from bronchitis, 7 from
pneumonia, and 1 from croup.
Meteorology.
Abstract of Observations made in the City of Dublin , Lat. 53° 20
N., Long. 6° 15' W.yfor the Month of June , 1899.
Mean Height of Barometer, -
Maximal Height of Barometer (9th, at 9 a.m.),
Minimal Height of Barometer (20th, at 9 a.m.),
Mean Dry-bulb Temperature,
Mean Wet-bulb Temperature,
Mean Dew-point Temperature,
Mean Elastic Force (Tension) of Aquerous V apour,
30*071 inches.
30*466
29*392
60*5°.
56*4°.
52*9°.
402 inch.
Mean Humidity, ... - 77*0 per cent.
Highest Temperature in Shade (on 11th), - 74*4°.
Lowest Temperature in Shade (on 19th), - 45*9°.
Lowest Grass Temperature (Radiation) (on 19th), 40*9°.
Mean Amount of Cloud, -■ 43*7 per cent.
Rainfall (on 8 days), - 1*643 inches.
Greatest Daily Rainfall (on 20th), - - ’903 inch.
General Directions of Wind, - - N.E., N.W., W.
152
Sanitary and Meteorological Notes.
Remarks.
June, 1899, was a fine, warm, and sunny month. In and near
Dublin it was rainless until the 17th, when an absolute drought of
23 days’ duration was broken by a genial fall of rain. On the
20th a heavy downpour took place, the measurement exceeding l-ej
inches at the Co. Wicklow stations. A severe thunderstorm early
on the morning of the 28th brought 1*420 inches of rain to Grey-
stones, 1*087 inches to the Consumption Hospital at Newcastle, but
only *240 inch to Dublin. At the close of the month the weather
fell into a broken, rainy, chilly condition. In Dublin the mean
amount of cloud during the month was as low as 43*7 per cent.,
only one-third of the sky on the average being covered at 9 p.m.
In Dublin the arithmetical mean temperature (61*3°) was above
the average (57*8°) by 3*5° ; the mean dry-bulb readings at 9 a.m.
and 9 p.m. were 60*5°. In the thirty-four years ending with 1898,
June was coldest in 1882 (M. T. — 55*8°) and in 1879 (uthe
cold year”) (M. T. — 55*9°). It was warmest in 1887 (M. T.=
62*3°); in 1865 (M. T. = 61*0°); and in 1896 (M. T. = 61-4°).
The mean height of the barometer was 30*071 inches, or 0*154
inch above the corrected average value for June — namely, 29*917
inches. The mercury rose to 30*466 inches at 9 a.m. of the 9th,
and fell to 29*392 inches at 9 a.m. of the 20tli. The observed
range of atmospheric pressure was, therefore, 1*074 inches.
The mean temperature deduced from daily readings of the dry-bulb
thermometer at 9 a.m. and 9 p.m. was 60*5°, or 9*o above the
value for May, 1899. Using the formula, Mean Temp.= Min. +
(max.— min. X *465), the value was 60*8°, or 3*6° above the
average mean temperature for June, calculated in the same way,
in the twenty-five years, 1865-89, inclusive (57*2°). The arith¬
metical mean of the maximal and minimal readings was 61*3 ,
compared with a twenty-five years’ average of 57*8°. On the
11th the thermometer in the screen rose to 74*4°— wind, N.E. ;
on the 19th the temperature fell to 45*9° — wind, N.W. The
minimum on the grass was 40*9° on the 19th.
The rainfall amounted to 1*643 inches on only 8 days. The
average rainfall for June in the twenty-five years, 1865-89,
inclusive, was 1*817 inches, and the average number of rainy days
was 13*8. The rainfall, therefore, was slightly below, while the
rainy days were far below, the average. In 1878 the rainfall in
June was very large — 5*058 inches on 19 days; in 1879, also,
4*046 inches fell on 24 days. On the other hand, in 1889 only
*100 inch was measured on 6 days; in 1887 the rainfall was
Sanitary and Meteorological Notes. 153
only *252 inch, distributed over only 5 days. In 1898 1*547
inches fell on 14 days.
High winds were noted on only 3 days, and the force of a gale
was on no occasion attained. The atmosphere was foggy on the
22nd. Solar halos were seen on the 3rd and 13th. Temperature
reached or exceeded 70° in the screen on 14 days, compared with
17 days in 1887, only 1 day in 1888, and 4 days in 1898. A
thunderstorm occurred on the 28th, and lightning was seen on the
17th. Hail fell on the 28th.
The rainfall in Dublin during the six months ending June 30th
amounted to 1T295 inches on 95 days, compared with 12*115
inches on 98 days in 1898, 13*950 inches on 113 days in 1897,
7*854 inches on 84 days in 1896, 12*282 inches on 80 days in
1895, 14*361 inches on 109 days in 1894, 9*624 inches on 78 days
in 1893, 11*770 inches on 97 days in 1892, 8*748 inches on 77
days in 1891, only 6*741 inches on 67 days in 1887, and a twenty-
five years’ average of 12*313 inches on 95*4 days.
At Knockdolian, Greystones., Co. Wicklow, the rainfall was
4*035 inches distributed over 9 days. Of this quantity 1*520
inches fell on the 20th, and 1*420 inches on the 27th. The total
fall since January 1 has been 19*510 inches on 95 days compared
with 13*500 inches on 88 days in the first six months of 1898, 18*125
inches on 106 days in those of 1897, 7*356 inches on 61 days in
the same period of 1896, 14*270 inches on 67 days in 1895, 17*381
inches on 96 days in 1894, and 11*776 inches on 75 days in 1 893-
The rainfall at Cloneevin, Killiney, Co. Dublin, amounted to 2*47
inches on 10 days. The greatest fall in 24 hours was 1*30 inches
on the 20th. The average rainfall for June in the 14 years, 1885-
1898, was 1*700 inches on 12*5 days. In 1897, 3*59 inches fell on
20 days, in 1898 2*03 inches fell on 15 days. Since January,
1899, 13*62 inches of rain have fallen at this station on 89 days,
compared with 13*10 inches on 97 days in the corresponding six
months of 1898.
At the National Hospital for Consumption, Newcastle, Co.
Wicklow, the rainfall was 3*748 inches on 8 days, compared with
2*459 inches on 14 days in June, 1898, and 4*078 inches on 15
days in June, 1897. On the 20th, 1*682 inches were measured,
and on the 27th, 1*087 inches. The maximum temperature in the
shade was 70*3° on the 6th, the minimum temperature in the shade
was 42*0° on the 19th. At this station the rainfall for the six
months ending June 30 amounted to 18*639 inches on 91 days,
compared with 14*918 inches on 88 days in the same period of
1898, and 18*372 inches on 102 days in that of 1897.
PERISCOPE.
THE INJECTION OF SALINE SOLUTIONS IN COLLAPSE.
The use of intravenous injections at blood heat of sterilised
water, containing salts of sodium or potassium to prevent
coagulation, has placed a simple and powerful means at the
surgeon’s disposal for the treatment of collapse from haemor¬
rhage, &c. The older method of transfusion of blood was
limited by conditions which could not always be promptly
fulfilled, and its results were by no means reliable or dependable.
On the other hand, many remarkable results are recorded in
which saline injections have been employed, and the treatment
is admirably adapted for use in emergencies owing to its
simplicity and to the fact that no complicated apparatus is
required. The use of saline solutions is based upon the con¬
clusions of Dr. Wm. Hunter that the immediate source of
danger from sudden loss of blood is the rapid fall in blood
pressure; that the value of transfused blood is almost solely
physical and dependent on its volume ; and that all its advan¬
tages can be more readily and more safely obtained by the use
of simple saline solutions. The method of application varies
in the hands of different practitioners and with the circumstances
of the case. In some instances it will suffice to inject two or
three pints into the rectum, whilst in extreme conditions it is
necessary to open up a vein and inject the saline solution
directly therein. If the latter method is adopted, means must
be taken to prevent the injection of air into the venous system.
The following paragraph, extracted from the Lancet of Nov.
26th, 1898, describes the method adopted to W. Thelwall
Thomas, Esq., E.R.C.S., Eng., of the Royal Infirmary and
University College, Liverpool: — “ The apparatus generally
used by me consists of a glass syringe (capacity 4 oz,), 2 feet of
rubber tubing, and a curved metal canula to fit a vein of the
size of the median basilic vein. The piston is withdrawn and
the whole apparatus filled with salt solution before fitting the
canula into the vein, to prevent, of course, entrance of air into
the venous system. The canula is tied into the vein selected
and the syringe is elevated ; if the fluid does not run in quickly
enough the piston is inserted and the solution is forced in. A
finger-and-thumb clamp on the tubing at the nozzle of the
155
Periscope.
syringe enables the syringe to be withdrawn, filled again,
and reapplied, and so on until enough fluid has been forced in.
I have used a Higginson’s syringe as the motive power. The
writer proceeds to illustrate the value of the treatment by
quoting three cases in which it was successfully employed.
The first, a case in which the internal jugular vein was cut
clean through, the common carotid cut into, and the external and
anterior jugular veins were divided ; the second, one in which
there was collapse from secondary haemorrhage after amputation
of the leg and thigh ; and the third, that of a patient who was
in a critical condition from loss of blood consequent on a railway
accident, followed by amputation of the crushed leg and thigh.
In describing the effects of saline injections the same authority
says that normal saline solution promptly injected into the
venous system will wash up the stranded corpuscles and give
the heart something to contract upon — liquid within its
normal stimulus, and enable the circulation to be carried on
and the oxygenation of the red blood-cells to proceed. If the
patient be not too old, manufacture of new blood goes on
rapidly, and in a few hours the change produced is little short
of marvellous, and anyone for the first time seeing a patient
saved, even when .apparently at his last gasp, will be astonished
at the effect.
PHLEGMASIA DOLENS IN TYPHOID FEVER.
Phlegmasia dolens is rare in typhoid fever ; Murchison estimated
its incidence as 1 per cent. In an interesting lecture published
in the Boston Medical and Surgical J our mail of March 23id
Dr. Da Costa states that among 215 cases of typhoid fever in
soldiers admitted into Pennsylvania Hospital phlegmasia dolens
occurred in no less than 30, or 14 per cent. The general pi.o-
portion of cases with this complication in the hospital is not
more than 1 or 2 per cent. In 18 cases under the care of Di.
Da Costa the left leg was affected in three, the right in two, and
both legs in 13. He explains the frequency of the complication
in soldiers by predisposition from distension of the veins of the
legs in marching. But excepting some from, Porto1 Pico most
of the soldiers came from training camps where marching was
not excessive though more than men just come from civil life
were accustomed to. The gravity of the infection also was impor¬
tant, for nearly all the cases occurred in those in whom the
fever had been severe. This complication occurred mostly at
the end of the fever or during convalescence. The earliest
156
Periscope.
symptoms are increased temperature and pain in the limb.
Chills sometimes precede it. The pain is usually associated
with tenderness, which first shows itself in the calf. Swelling
is generally obvious, especially below the knee. The limb is
tense and hard, though there may be some pitting around the
ankles and calf. The skin is pale or white, but here and there
an erythematous blush or even a small ulcer is seen. The veins
may be prominent or not, tender or not. Those most usually
affected are the internal saphenous and femoral, especially at
their junction ; sometimes the affection extends to the iliac
veins and even to the vena cava. As to the pathology Dr. Da
Costa regards the complication as primarily thrombosis, which
afterwards may or may not be complicated by phlebitis or
periphlebitis. As a rule the thrombus gradually disappears
without serious symptoms, and the phlebitis, if present, slowly
yields, or an adhesive inflammation results, and a collateral venous
circulation is established. But cases have been recorded in
which pyaemia or fatal embolism occurred. In a case observed
by Dr. Da Costa death resulted from embolic pneumonia. Gan¬
grene is an occasional result. Recovery is slow, and the leg may
remain swollen for months, or readily become so after exercise.
The dilated superficial veins may show how much the circulation
has been interfered with, and adhesive inflammation may leave
the saphenous or femoral vein hard and cord-like. The treat¬
ment consists in elevating the leg to assist the circulation, and
in applying heat and bandaging to relieve the pain. A fomen¬
tation of equal parts of hot lead lotion and laudanum gives the
most relief. Constipation, if present, must be treated. If the
pain is persistent, belladonna plaster in strips, or belladonna
ointment, applied along the vein is often useful. When the
patient leaves his bed the limb should be well bandaged, which
must be continued, or an elastic stocking must be used for a
long time, until the veins recover their tone and until symptoms
of obstruction have disappeared. — Lancet , May 20, 1899.
TUBERCLE OF THE TESTICLE IN CHILDHOOD.
The Journal de Clinique et de Therapeutique Infantiles of
May 4th contains a report of M. Felizet’s observations on 58
cases of tubercle of the testicle in childhood. From these it
appears that the disease almost invariably attacks this organ
in children under seven years of age. As in adults, the epididy-
mus is by far its most usual place of origin, the cord is less often
invaded, the prostate, the vesiculce seminales, and the bladder
157
Periscope.
still less frequently. Hydrocele is rarely present, and the course
of the disease, as might be expected in tissues which are virtually
embryonic, is often rapid, infection proceeding not only by the
spermatic blood-vessels but by the inguino-iliac lymphatics also.
M. Felizet is not an uncompromising advocate for castration
as a remedy, but is disposed up to a, certain point to rely on
hygienic and medicinal measures. Even when there is adhesion
of the testicle to the scrotum and subsequent abscess formation
he is content to employ local conservative methods. When, how¬
ever, in addition to suppuration there are present the signs of
general impairment of health he advocates immediate removal
of the gland as the only means of preventing a very rapidly
fatal form of general tuberculosis. Unfortunately, we are not
informed of the results obtained by treatment in these 58 cases.
If they should hereafter be forthcoming they ought materially
to aid a decision as to the true indications for castration in the
infantile variety of this disease. M. Felizet contends that the
condition of rapid tissue development is not favourable to the
resistance of an infective process, and in that case the stage of
hygienic treatment and local conservative surgery must be
a period of watchful care and not be too prolonged. Many
authorities consider that in the adult excision of the testicle
offers the best hope of cure, and we are still in want of proof to
show that the case of children is materially different. — Lancet ,
May 20, 1899.
THE USELESSNESS OF GARGLES.
Singer {Munch, med. Woch., Feb. 21, p. 250) has experimented
with a view to settling the vexed question of the value of
gargling. If the tonsils be painted with methylene blue, and
pure water be used as a gargle, it returns in the great majority
of cases perfectly clear. If coloured at all, this is due to the
air expired during gargling, spraying some of the blue forwards
on to the tongue, and not to the water coming in contact
with the tonsils. In the same way if starch powder be in¬
sufflated on to the anterior surface of the soft palate, the root
of the tongue, and the tonsils, and immediately afterwards a
dilute solution of glycerine of iodine in water be used as a
gargle, that on the tongue and velum is coloured blue, while
that on the tonsils is unaffected. The writer admits that if
coloured fluids are used as gargles, the posterior pharyngeal
wall and the tonsils are frequently stained, but explains this as
being due not to actual contact of the gargle with the parts, but
158 New Preparations and Scientific Inventions.
to an infinitesimal fraction of it trickling downwards while the
head is retracted. Accordingly as the fluid employed never
penetrates behind the anterior pillars of the fauces, gargles are
useless in affections of the pharynx and tonsils. Another
reason for abandoning them is that they are commonly used in
acute affections, though the act of gargling calls into activity the
inflamed fauces and soft palate, though like all other inflamed
parts they require rest. He recommends as a substitute that
the parts should be painted, not in the usual way by rubbing
the fluid in with a camel’s hair brush, but by dabbing it on
with a pad of cotton wool fastened to a holder. He says
patients quickly learn to do this themselves. — Med. and Surg.
“ Iievievj of Reviews.”
LOCAL TREATMENT OF PSORIASIS.
Mr. Hutchinson’s favourite prescription ( Archives of Surg.,
vol. i., p. 72) is : — R. Acid, chrysophanic., gr. x. ; liq. carbonis
deterg. (Wright’s), rq- x- J hyd. amm- chlorid., gr. x. ; adip.
benzoat if ; M. Fiat unguent. The patient is to remove all
scales as far as possible by washing or a warm bath, and to
spend half an hour in rubbing the ointment into all patches.
It is better to leave the ointment on all night, but if this is too
disagreeable it may be wiped off (not washed). In the morning
a bath with soap is taken. In most cases he prescribes arsenic
also, but he relies chiefly on the ointment, and sometimes uses
it alone. The tar solution materially prevents staining. With
perseverance relapses become slighter and slighter and the
intervals longer. — Med. and Surg. “ Bevieiv of Beviews.”
NEW PREPARATIONS AND SCIENTIFIC INVENTIONS.
u Soloid ” Saline Solutions for Intravenous Injections.
In order to provide a convenient means of preparing normal
saline solutions for intravenous injections in cases of collapse
from haemorrhage and other conditions, “ Soloid” Saline Solu¬
tions have been issued by Messrs. Burroughs, Wellcome & Co.,
of Snow Hill Buildings, London, E.C. These preparations are
portable and require no weighing, the simple solution of two
in a pint of sterilised water at a temperature of 100° F. forming
an injection of the proper strength. Their suitability and great
convenience for use in a method of treatment which is essen-
159
New Preparations and Scientific Inventions.
tially an emergency one will therefore be fully appreciated : —
Sodium chloride, gr. 30 (1*944 gm.). Sodium chloride and sodium
sulphate : R — sodii chloridi, gr. 15 (0*972 gm.) ; sodii sulphatis,
gr. 15 (0*972 gm.). Sodium chloride compound: II — sodii chloridi,
gr. 25 (1-62 gm.) ; sodii sulphatis, gr. 1| (0*081 gm.) ; sodii
carbonatis, gr. 1J (0*081 gm.) ; sodii phosphatis, gr. 1 (0*065
gm.); potassii chloridi, gr. 1-J (0*097 gm.). These “ soloids”
are supplied, in tubes containing 6, at 5d. per tube,
l
New “ Soloids.”
Messes. Bueeoughs, Wellcome & Co. have introduced the
following — “ Soloid” Lead Subacetate, gr. 10 (0*648 gm.). By
the introduction of “ Soloid” lead subacetate the practitioner is
enabled to carry the material for the instant preparation of
Goulard water in a most convenient form. One dissolved in
five ounces of water yields a solution containing approximately
the same quantity of lead subacetate as the official liq. plumbi
subacetatis dilutus. It offers many conveniences for the pre¬
scription of an astringent and soothing application, replacing
the bulky and unsightly bottle of lotion, and enabling the patient
to adhere to the physician’s directions when travelling or when
pursuing his usual daily vocation, without being encumbered
with a fluid preparation.
“ Soloid ” Lead and Opium Lotion : — Plumbi acetatis, gr.
2 (0*13 gm.) ; tinct. opii, min. 20 (1*184 c.c.) This preparation
offers the same advantages and conveniences for the preparation
and regular use of a lead and opium lotion as “soloid” lead
subacetate does with regard to Goulard water. Owing to the
quality of its constituents and the accuracy of the dosage it is
possible to prepare a fresh and active lotion of reliable strength
with great ease.
Gucciacol Camphor ate.
This new drug— a result of original work in the Wellcome
Chemical Research Laboratories, and now prepared by Messrs.
Burroughs, Wellcome & Co. — is a combination of guaiacol with
camphoric acid.
It is well known that these bodies have been used separately
for some time in the treatment of consumption with most
iavourable results. Guaiacol has been found to exercise a
general action in controlling the disease, and camphoric acid
diminishes the characteristic night sweats. Inferentially,
160 New Preparations and Scientific Inventions.
therefore, it was considered likely that a combination of these
two therapeutic agents would be extremely valuable. Clinical
trials by a responsible authority appear to justify this view.
He reports as a result of his observation of a series of test
cases that he is well satisfied with the results obtained, especially
as this combination appears to be much better borne than other
preparations of guaiacol.
Guaiacol camphorate is supplied in powder, in bottles con¬
taining ioz., or as “ Tabloid” Guaiacol Camphorate, gr. 5, in
bottles containing 25 and 100.
Aspirin.
Messes. Fbiedbich Bayeb & Co., of Elberfeld, Prussia, have
introduced a substitute for salicylic acid under this name.
Aspirin is the acetic ester of salicylic acid, and forms a white
crystalline powder, with a melting point of 135°. It dissolves
sparingly in water, but readily in alcohol. The chief advantage
which aspirin has over salicylic acid and its salts is, that iu does
not irritate the mucous membrane of the stomach , furthermore,
that it passes through the stomach entirely unchanged, decom¬
posing only in the alkaline gastric juice. Owing to these
properties, digestive troubles are completely avoided and the
appetite is not diminished. A further recommendation is the
pleasant, slightly acid taste which aspirin has, as against the
disagreeably sweet taste of the salicylates. Aspirin, owing to
its very slow decomposition, -scarcely gives rise to singing in
the ears, which is so frequently noticed during the administra¬
tion of the salicylates. From the clinical 'observations already
recorded by Dr. Kurt Witthauer, Chief Physician of the House
of Diaconessesses, in Halle o/S (“ Heilkunde,” April, 1899),
and by Dr. Wohlgemuth, Physician of the First Clinic of Privy
Counsellor von Leyden in the Berlin University (“ Therapeu-
tische Monatshefte,” No. 5, 1899), it wTould appear that aspirin
is a perfect substitute for salicylic acid and its salts. The
following mixture is recommended as a pleasant form for ad¬
ministering the product : — Aspirin, 15 grains ; sugar, 50 to 60
grains ; water, half an ounce.
THE DUBLIN J0URNA1
OF
MEDICAL SCIENCE.
SEPTEMBER 1, 1890.
PART I.
ORIGINAL COMMUNICATIONS.
Art. VIII. — Clinical Reports of the Rotunda Hospitals, for
One Year , November 1st , 1897, to October 31s£, 1898.a By
R. D. Purefoy, F.R.C.S.I. (Master); and R. P. R.
Lyle and IT. C. Lloyd, Assistants.
During the twelve months comprised in this Report 1,840
women were admitted to the maternity department, 1,513
were confined, and 327 were discharged not in labour.
V
Table No. I. — Admissions to Maternity Department , 1897—98.
Nov.
Dec.
Jan.
Feb.
Mar.
Apr.
May
June
July
Aug.
Sept.
Oct.
Total
Total number of
Deliveries (child
viable)
105
129
128
113
122
131
111
121
125
110
124
115
1,434
Ditto (child non-
viable)
4
3
1
5
3
0
4
3
2
5
3
5
|
38 |
Abortions
1
4
5
6
2
2
6
4
1
2
4
4
i
41
Total cases treated
...
...
• • «
• • •
• • •
...
...
• • •
• • 9
...
• • •
• • •
1,513
Patients admitted,
but discharged
not in Labour -
30
21
38
21
24
29
31
28
22
31
30
22
327
Total admissions
140
157
172
145
151
162
152
156
150
148
161
146
1,840.
a Lead before the Section of Obstetrics, Royal Academy of Medicine in
Ireland, Friday, March 14, 1899.
VOL. CVIII. — NO. 333, THIRD SERIES.
L
162 Clinical Reports of the Rotunda Hospitals.
Table No. II. — Dispensary for Out-door Patients.
Number of
First Attendances
Number of
Repeated Attendances
4,223
4,990
Table No. III. — Showing Number and Nature of Cases Treated in
the Extern Maternity , 1897-98.
Total number of cases
Abortions -
Chorea
Deformed pelvis
Haemorrhage —
Accidental
Placenta praevia
Post-partum -
Haematoma vulvae
Hydramnios
Infantile conditions—
Anencephalus -
Hydrocephalus
and spina bi¬
fida -
Moles —
Vesicular
Carneous
12
8
29
Mortality, infantile (born
dead)-
Macerated
-
14
Non- viable
-
24
Premature
-
18
Putrid -
-
2
Recent
-
45
2,129
275
1
49
2
8
108
Mortality, maternal
Multiple pregnancies —
-
1
7
Twins —
Females
6
Males -
13
Male and Female
15
34
Triplets —
All males
-
2
Operations —
Curetting for
abortion
78
Forceps
Paracentesis
31
capitis
Placentae re-
1
moved manu-
ally -
27
Version
9
146
Presentations—
Breech -
65
Brow -
1
Face
5
Footling
13
Occipito-posterior
13
Shoulder
1
Transverse
6
104
Prolapse of funis
-
7
Rupture of uterus -
1
INTERESTING CASES IN EXTERN MATERNITY.
Case I. — M. Q., aged thirty-five, 1-para; delivered November 2,
1897. Concealed accidental haemorrhage. When seen patient was
collapsed, pulse 160, scarcely perceptible, and showed all the
symptoms of severe internal haemorrhage ; there was no external
haemorrhage. The uterus was greatly distended, and painful on
palpation ; the vertex was presenting, but the os did not admit the
Clinical Reports of the Rotunda Hospitals. 163
finger. Porro’s operation was performed, the patient being too
collapsed to move into the hospital ; a large quantity of blood was
found free in the uterus, with the placenta entirely detached. The
patient rallied somewhat after the operation. The following
morning she was transfused with saline solution, but died the next
day.
Case II, — M. K., aged thirty, 3-para; delivered November 1,
1897. Generally contracted pelvis. Labouy was induced in the
hospital by Krauze’s method. Labour pains supervened, and
expelled the bougies, after which the pains ceased. She left the
hospital against advice, and was delivered the following day in the
Extern Maternity. The child was alive.
Case III.— Mrs. F., aged twenty-nine, 9th pregnancy. Triplets.
Six months pregnant. The first two were born as breech presenta¬
tions, the third being a vertex ; all three were males. There were
two placentae. The infants lived for only a short time after birth.
There was a family history of multiple pregnancies, though this was
the first occasion on which the patient had had more than one at a
birth.
Case IV. — M. B., aged thirty-nine, 10th pregnancy. There
was nothing of interest in this case beyond the fact that the
placenta was retained for 2\ hours, and then readily expressed.
The patient had, however, given birth to twins on three occasions,
and once had three at a birth ; one of the triplets still lives and five of
the twin children.
Case V. — M. A. M;G-., aged twenty, 2nd pregnancy. Chorea.
Was seen by various students at frequent intervals during the
previous two months. She, on each occasion, refused to come into
the hospital. She had very pronounced chorea ; so violent were the
movements that she could scarcely get food to her mouth. She
delivered herself, at term, of a living child, and soon after delivery
the movements began to abate.
Case VI. — M. W., aged thirty- two, 5th pregnancy. Triplets.
First child born as breech presentation, its placenta following
it in 15 minutes ; the second, also a breech, and the third, a vertex.
These two had a common placenta ; they were all males, the first
being stillborn. The mother was seen five months later, when one
child was still alive and well.
Case VII. — M. W., aged thirty. Paracentesis capitis. Breech
presentation and hydrocephalus. In this case the child, a female,
164 Clinical Reports of the Rotunda Hospitals.
was delivered as far as the neck, when it was found that the uterus
contained an enormous head. This was punctured behind the eai,
and a very large quantity of fluid escaped, delivery then being easy.
The child had also a spina bifida.
EXTERN MATERNITY — ACCOUNT OF DEATHS.
Case I. — M. Q., aged thirty-five, 13-para. Concealed accidental
haemorrhage. Porro’s operation. Reported under “Interesting
Cases,” q.v.
Case II. — M. J., aged twenty-three, 4-para. Postpartum
haemorrhage. Patient was attended by a “ handy woman,” who
sent to the hospital for assistance two hours subsequent to delivery
of the child. During this time the patient had been bleeding freely,
and when seen was nearly exsanguine and pulseless. The placenta
was adherent and had to be removed manually, but the patient died
a few minutes later.
Case III. — M. M‘E., aged forty-six, 6-para. Probable rupture
of the uterus. — Sudden death undelivered ; no autopsy obtainable.
Patient had all the symptoms of rupture of the uterus, with severe
internal haemorrhage. She was at full time. There was a histoiy
of short but very violent labour, with pains suddenly ceasing and
slight external haemorrhage, followed by collapse.
Case IV— M. T., aged thirty-three, 8-para. Placenta praevia
lateralis. This patient died of severe haemorrhage caused by the
above condition on the arrival of the Extern Assistant.
Case V.— M. D., aged thirty-five; 11th pregnancy. Septic
pneumonia. Shortly after this patient was seen she discharged an
apoplectic ovum from the uterus. This was the size of a hen s
egg ; had exceedingly thick walls. At this time her temperature
was 105° F., and pulse 120. The temperature continued high not¬
withstanding daily douching and plugging with iodoform gauze.
On the sixth day she had pneumonic signs, with marked jaundice,
and on the eleventh she died. The spleen and liver were both
enlarged on palpation.
Case VI.— L. D., Hemiplegia. Had been treated for some time
before delivery by dispensary doctor for right hemiplegia and loss of
speech. She had incontinence of faeces. Delivery was normal, and
the child was born alive. There was no rise of temperature or
pulse during puerperium, but on sixth day she had several epilepti¬
form seizures, and died shortly afterwards.
Clinical Reports of the Rotunda Hospitals. 165
Case YII. — B. D., 10th pregnancy. Phthisis. This patient had
been confined to her bed for two months, and was in advanced
phthisis, both lungs being much affected ; she had been under
treatment by the dispensary doctor. She died on the third day
after confinement ; the child was alive.
Table No. IV. — Showing Number and Nature of Cases Treated in
the Intern Maternity , 1897-98.
1
Total number of cases
1,513
537
Mortality, maternal
6
Primiparte -
-
Multiple pregnancies —
Abortions
-
41
Twins —
Deformed pelvis
-
5
Females -
9
Eclampsia -
-
2
Males
7
Haem or rh age —
Male and female
13
Accidental
6
29
Placenta praevia
5
Post-partum
19
30
Myomata
Operations —
-
2
Hsematoma vulvas -
-
3
Artificial abortion
6
Hydramnios
-
11
Caesarean section
2
Hyperemesis
-
1
Forceps -
57
Infantile conditions —
Induction of pre-
Anencephalus -
5
mature labour
3
Hydrocephalus -
3
Paracentesis
Hydrenceplialocele
1
capitis
2
Ophthalmia
5
Craniotomy
3
Procidentia uteri
1
Placentas, manual
Spina bifida and
removal of
18
talipes
3
18
Version -
11
102
Insanity —
Mania -
8
Phlebitis
-
2
Melancholia
1
Presentations —
9
Breech -
62
Miscarriage -
-
38
Brow
3
Morbidity
-
158
Face
6
Mortality, infantile (born
Hand and head -
2
dead) —
Occipito-posterior
28
Macerated
29
Transverse and
Non-viable
26
oblique
7
Premature
13
108
Putrid -
2
Recent - . -
42
Prolapse of funis
-
17
—
112
Do., died in hospital
-
35
ABORTIONS.
There were 41 cases of abortion admitted during the year.
Some of these required no special treatment ; only those in
which the haemorrhage was severe, or in which any part of
the ovum was still retained, were interfered with. In all
166 Clinical Reports of the Rotunda Hospitals.
these cases the treatment adopted was the emptying of the
uterus _ if possible by expression of the contents. This
failing, and the os being sufficiently dilated, the ovum was
removed by the finger, or if the latter condition was not
fulfilled, by Kheinstadter s curette.
The percentage of abortion in the Intern Maternity is
extremely low compared to that in the Extern, owing to the
fact that patients suffering from haemorrhage in the early
months of pregnancy usually remain in their own homes,
and send to the hospital for assistance.
One patient was admitted with a temperature of 10T6° F.
A decomposing ovum was detached and expressed; shortly
afterwards she had a rigor lasting ten minutes, and three
hours subsequently the temperature was 102‘4°F. Next
morning it was 98*6° F., and remained normal throughout
the puerperium. Another had a myoma the size of a fist on
the left side of the fundus, and this probably was the cause
of the abortion.
In a third case, after the remains of a recent abortion had
been removed with a Rheinstadter’s curette, it was found
that the uterus was still abnormally large, while the curette
gave the sensation that the uterus wuis not empty. A sharp
curette was used, and a considerable quantity of organised
blood-clot and old decidual tissue were removed from the
posterior wall. There was another case similar to this.
MISCARRIAGE.
There were 38 cases of termination of pregnancy between
the third and sixth months, one of which was twins ; and in
six the gestation was terminated artificially. Two-thirds of
the total number were pelvic presentations. •
In six cases the child was born alive, but died a few
minutes afterwards ; in eight the child was macerated ; and
the remainder — a few of which were expelled with the mem¬
branes intact — were stillborn. In one case (M. B.) there
was placenta prsevia, in another (W. P.) accidental haemor¬
rhage ; they are recorded respectively under these headings.
One case of hydramnios will be described later.
Clinical Reports of the Rotunda Hospitals. 167
ECLAMPSIA.
There were two cases of eclampsia treated during the year.
Case I. — M. J. S., aged twenty-four, 1-para ; seven months
pregnant. Had general anasarca, and the urine, which was scanty,
turned almost solid on boiling. Prior to being seen she had had
seven eclamptic fits, she was then given half a grain of sulphate of
morphia hypodermically, and was removed to hospital. On her way
to hospital she had another fit. On her arrival she was given two
drops of croton oil. In the next six hours, during which she had
seven fits without regaining consciousness, another half grain of
morphia was administered. During the next three hours she had two
fits, and got a quarter of a grain of morphia, and two simple enemata,
both of which were retained. One hour after the last hypodermic
of morphia she had another fit ; the chest was dry-cupped behind
and the steam-pack employed. This caused her to perspire pro¬
fusely. Some hours later, labour supervened, and she was delivered
with the forceps of a dead child as soon as she came into the second
stage.
Next morning, after being unconscious for thirty hours, she
became semi-conscious, and passed gxvi. of urine. She was given
calomel and mist, -sennas co. Later on her bowels moved freely,
and she passed sxiv. of albuminous urine.
Two days later she developed puerperal mania, was very restless
and excitable, suffered from hallucinations, and refused to take any
food. It was found necessary to feed her with a soft oesophageal
tube. The mania lasted only three days ; it gradually disappeared ;
she became convalescent, and was discharged well on the 13th
day.
Her temperature and pulse, both of which were normal on
admission, rapidly rose during the fits, and are recorded as 104° F.
and 156 respectively one hour after the last eclamptic fit. They
both fell to normal on the morning of the third day, but rapidly
rose again with the mania, and reached 103° F. and 140 on the
morning of the fifth day. Next day they dropped to normal, and
remained so throughout the puerperium. She has since been seen
several times in perfect health.
Case II. — M.M.,aged twenty-eight, 1-para ; full time pregnancy.
Patient got an eclamptic seizure lasting three minutes while in the
second stage. The urine was highly albuminous. Forceps were
applied, and the child, weighing 8 lbs., delivered alive. Six hours
later she had another fit, followed in half an hour by a third.
188 Clinical Beports of the Botunda Hospitals.
Two drops of croton oil were then given. An hour later, as she
had another fit, half a grain of sulphate of morphia was given
hypodermically. As she had only one other fit shortly after the
hypodermic, the morphia was not continued. She made a good
recovery, and was discharged well on the eighth day.
Table No. V. — Accidental Haemorrhage.
Name
Variety
Treatment
Result to
Child
Remarks
c. w.
Concealed
No interference
D.
No symptoms; retro-
placental clots
B. K.
5 5
D.
55 55
B. N.
Apparent
Version
D.
Detailed under hydro¬
cephalus
M. H.
Concealed
Plug and binder
T).
Delivered herself
B. C.
55
No interference
D.
Betro-placental clots
W. P.
55
Plug and binder
D.
Delivered herself
Two of these were mild cases without symptoms, the
condition only being found on delivery, by the placenta, with
a quantity of coagulated blood, coming away immediately
after birth of the dead foetus. One had considerable disten¬
sion of the uterus, and a slight escape of blood ante-partum .
The two others are as follow : —
Case I. — M. II., aged twenty-two, 3-para ; admitted August 9th
from Extern Maternity ; 7 months pregnant, with history of sudden
and very severe abdominal pain, with vomiting and fainting.
There was very slight external haemorrhage. The uterus was nearly
up to the ensiform cartilage, was very tense, and palpation gave
patient great pain. The foetus could not be felt. On vaginal ex¬
amination the membranes were unruptured, os the size of a florin,
and vertex presenting. Patient was in a condition of collapse, and
the pulse scarcely preceptible at the wrist, and 135 per minute.
The vagina was carefully douched and tightly plugged with boiled
cotton wool pings, and an abdominal binder applied. Hot drinks
and whiskey were administered by the mouth, and one hour later
good pains came on, partly forcing the plugs from the vagina. On
removing them the patient expelled a dead foetus, which was im¬
mediately followed by the placenta, and about lj pints of dark-
Clinical Reports of the Rotunda Hospitals. 169
coloured blood, and a quantity of clots. The uterus contracted
well, and convalescence was uneventful.
Case II. — -W. P., aged thirty-four, 13-para ; admitted August
19th ; 6 months pregnant, with a history of severe abdominal pain,
vomiting and fainting, coming on while she was lying in bed.
There was very slight external haemorrhage on one occasion only.
The condition was almost similar to that of M. H., with pulse of
132. She became more collapsed after adyiission — had sighing
respirations, tossing her arms about, and became cold all over.
Similar treatment was pursued, and, as she improved considerably,
morphia £ gr. was given hypodermically 4 hours later. She then
slept for hours, waking occasionally to take nourishment. At
the end of this time good pains came on, and she expelled the plugs,
which were followed by the foetus and placenta, with two enormous
blood-clots lying behind it. Her temperature the same evening
was 103° F. Next day it was normal, and remained so throughout.
Table No. VI. — Placenta Prcevia.
Name
Variety
Result to
Child
Presentation
Period of
Pregnancy
Treatment and Remarks
M. B.
Marginalis
D.
Footling
6 months -
Ruptured the mem¬
branes and traction
on the foot
E. R.
Lateralis
A.
Vertex -
Full time -
Patient in labour; rup¬
tured the mem¬
branes
K. L.
Marginalis
A.
Occipito-
posterior
Full time -
5 5 55
M. K.
Lateralis
A.
Face
Full time -
Internal version and
foot brought down
L. M.
,
Lateralis
A.
Vertex -
Full time -
Bi-polar version and
foot brought down
In every case convalescence was normal.
POST-PARTUM HEMORRHAGE.
There were nineteen cases of post-partum haemorrhage,
ten of which were mild. Two of these were caused by
retained portions of membranes, the others by atony of
the uterus. They wTere treated by removing the cause, hot
douching, ergot, and massage. One only had a tempera¬
ture ; it did not exceed 101*2° F., was normal on the fourth
day, and remained so. In three forceps had been applied.
170 Clinical Reports of the Rotunda Hospitals.
One was a case of twins, another followed placenta prrnvia.
Four of the severe cases were due to adherent portions of
placenta, which were removed manually : the remainder were
due to atony of the uterus. In these the treatment was
hot uterine douching, massage, and ergot. There were two
cases of secondary haemorrhage — one occurring on the second
day after delivery, the other on the fifth day.
HJEMATOMATA.
Ca.se I. — M. M‘C., aged twenty-six, 2nd pregnancy ; admitted
to gynaecological department with history of discharge of dark-
coloured blood from vagina a week before. She had a mass
of knotted varicose veins protruding from the vulva occupying
the posterior vaginal wall. It had a base about 3 inches long ;
the surface was about to break down. From the rectum a depres¬
sion was felt at the back of the mass. It was dissected off, and a
quantity of blood-clot displaced from behind. The raw surface
was stitched with continuous catgut suture. Fourteen days
later labour came on, and in the birth of the child the wound
opened. It was stitched up after confinement and healed up
excellently. This was a case of polypoid hgematoma, as described
by Ahlfeld.
Case II. — R. B., aged twenty-three, 1st pregnancy; was delivered
in the Extern Maternity. Labour was normal. An hour afterwards
she began to feel some pain in the left labium. On examination this
was found to be distended by blood-clot to the size of a small cocoa-
nut, black and glossy in surface at its lower portion. The swelling
was opened in hospital under an anaesthetic, and a blood-clot as
large as a fist was removed and the surface stitched with inter¬
rupted silkworm-gut sutures. The result was excellent, and the
patient went out well on the 20tli day.
Case III. — E. W., aged twenty-one, 1st pregnancy ; after twelve
hours labour some haemorrhage was observed, and on examination it
was found that there was a tear in the posterior vaginal wall reaching
to, but not involving, the perineum, the foetal head being about lj>
inches from the outlet. There suddenly appeared a swelling extend¬
ing rapidly from near the right anterior margin of the anus into the
labium of the same side. Forceps were applied and delivery
effected, after which the lacerations and cavity from which the
blood was evacuated were stitched up with silkworm-gut sutures.
Puerperium was uneventful, and result good.
Clinical Reports of the Rotunda Hospitals. 171
HYHRAMNIOS.
In the eleven cases of hydramnios there were one brow
and two face presentations. In seven of the cases the
membranes had to be ruptured artificially. Of the children
four were anencephalic, one had spina bifida with talipes
varus, and another, although it lived three hours, was
macerated. Two of the mothers were admitted in a very
debilitated condition, and improved rapidly during their stay
in hospital. One had a pulse of 130, and temperature 102° F.
on the evening of admission, with venous thrombosis of
the right leg ; the foetus, besides being anencephalic, was
macerated. Her temperature ranged between 100° F. and
102*6° F. for the first six days in hospital, when it fell to
normal, and continued so until the 21st day, when she was
discharged well.
The other, six months pregnant, had a pulse of 134 on
admission, and was greatly emaciated. Her temperature,
however, was normal. The membranes were ruptured, and
fifteen measured pints of fluid escaped. The foetus, besides
being anencephalic, had cleft palate, hare-lip, spina bifida,
and apparently no cervical vertebras — it weighed 2 jibs. The
puerperium was uneventful, and she was discharged well on
the 8th day.
HYPEREMESIS.
Case.' — A. M., aged twenty-eight, 2nd pregnancy; admitted
March 26th. This was the only case of this condition occurring
in the practice of the hospital during the year, and we regret to
have to record it as a death. She was about eight months pregnant,
and was admitted in an extremely emaciated condition and mori¬
bund, with a history of continued vomiting for the previous two
months. She also stated that there had been no movement of the
bowels for four weeks. Her temperature was 97*6° F, and pulse
104, hardly perceptible. On examination the foetal heart was
heard on the left side, and the head was engaged in the pelvis.
Soon after, on the onset of labour pains, the foetal heart ceased,
and as soon as she came into the second stage forceps were
applied and delivery effected, the child being dead. She lingered
on until the next day, taking small quantities of fluid nourishment,
and then died. The lower bowel contained no faeces, and there
172 Clinical Reports of the Rotunda Hospitals .
was no result from the enema which she got on admission. She
was transfused with five pints of 1 per cent, saline solution intra¬
venously, and though this gave rise to some improvement in con¬
dition it was only very transient. The autopsy showed the stomach
much dilated, the intestines empty, and the kidneys large, soft, and
fatty.
TWINS.
There were 29 twin births. In one case the second child
was transverse, the hand, foot, and cord prolapsed ; delivery
was effected by traction on the foot, and pushing up the
head. In another case a hand of the second child was
prolapsed past its head ; it was left to nature. A third case
is reported under “ Forceps.” The presentations were —
Both vertex - - - 14
Vertex and breech - - 7
Breech and vertex - - 5
Both breeches - - 1
Vertex and transverse - 1
Vertex, vertex and hand - 1
ARTIFICIAL ABORTION.
There were six cases of artificial abortion during the year,
the patients being pregnant for periods varying from three
and a half to six months, and suffering from repeated
haemorrhages.
In every case laminaria tents were used, and the vagina
plugged with boiled cotton wool, the wool and tents being
removed when the patient came into labour, which usually
occurred within twelve hours.
In two cases the foetus was extracted piecemeal by
Schultze’s spoon forceps on account of insufficient dilatation
of the cervix. In four cases the placenta was adherent, and
had to be removed with the fingers. Three of these cases
were plugged with iodoform gauze on account of haemorrhage
subsequent to removal of the placenta.
In every case convalescence was normal.
{To be continued.)
Trade Callosities.
173
Art. IX. — Trade Callosities. By II. S. Purdon, M.D. ;
Consulting Physician, Belfast Hospital for Diseases of
the Skin, &c.
Persons employed in certain trades bear on various parts
of their bodies the marks of their calling. You can tell a
sweep or a flour-miller by looking at him when in working
clothes ; but the cases to which I refer arp due, in the first
instance, to an excess in the nutrition of the skin, causing
excessive growth, followed by a hard, thickened condition
of the skin, due to pressure and constant friction — in other
Avords, a callus or callosity. It is possible, in many
instances, to tell the occupation of a person from the nature
and situation of his callosities. Moreover, in a medico-legal
point of view the identification of a person might thus be
satisfactorily settled. These trade “marks” are due to
want of moisture in the cuticle, caused by the pressure of
the fools or other mechanical appliances used by the
worker at his occupation.
A I rench physician, Dr. Y ernois (De la Main des Ouvriers
et des Artisans, an point de vue de V Hygiene et de la Mede-
cine legale) has written on callosities produced in different
arts and occupations.
the trades I have noticed callosities to be caused by
are, first, those occurring on the Hight Hand , as in —
Trade
Laundress
Burnishers
Flax Hecklers
Shoemakers
Wood Carvers
Cabinet Makers
Compositors .
Carpenters and Joiners
Situation
The entire internal surface
of hand.
Fingers and internal surface
of hand.
Index finger of right hand.
Fingers of right hand and
palm of hand.
Radial border of index finger.
Internal surface of fingers of
hand.
Index finger and thumb.
Internal surface of hand and
fingers.
174
Imperforate Hymen.
Trade
Situation
Locksmiths
Left hand.
. Thumb and index finger and
Sailors
thenar eminence.
. Palms of both hands.
Forearms.
Washerwomen who
wash in tubs
Cubital surface of both fore-
Shoemakers
arms.
Thighs.
. Anterior surface of left thigh.
Knees.
Slaters
. Both knees.
Feet.
Tailors
. Over fifth metacarpal bone
externally.
Wheelwrights
Sternum.
. Over epigastric region.
The skin is thickened and in a callus condition in the
situations named.
Many other occupations have their characteristic callo¬
sities, as the tip of the fingers of the left hand in “ ’cello ”
players, three fingers of a drummer, the thighs of a harpist,
gilders of metal, lacemakers, horsemen (ischiatic region),
have special callosities.
I need scarcely remark that when the cause is removed,
as by the person ceasing or taking to another occupation,
the skin takes on in time a natural condition, and the
hypertrophied callus state disappears.
Abt. X. — Imperforate Hymen if). By B. J. Kinkead,
M.D. ; Professor of Obstetrics, Queen’s College, Galway ;
Physician and Gynaecologist to the Galway Hospital.
Case. — M. N., alleged to be aged thirteen and a half years, was
admitted to the Galway Hospital on 13th June, 1899.
She complained that for some time she had suffered from
pains in the abdomen— so severe that to obtain relief during
the paroxysms she had applied “a hot ‘griddle’ to her
stomach,” the skin of which was singed and discoloured ; she
had never menstruated, suffered from constipation, had not
vomited, and had never had any difficulty in passing water.
175
By Dr. K. J. Kinkead.
«/
In face and stature she appears to be older than the age stated,
her mother, however, is very positive that she is only thirteen
and a half ; the breasts are fairly developed, the growth of
hair on genitals is very scanty, especially on pubes, the vulva
appears to be that of a girl prior to puberty, the fissure, however,
is larger than usual, the nymphse large, project beyond the
labia majora, a tumour is seen at the vaginal orifice, shining,
greenish-blue in colour, long axis from above downwards, a well-
marked raphe, with horizontal striae passihg from it to mar¬
gins, in size that of half a hen’s egg, cut in long axis, adhering
closely to its circumference, especially at upper margin, its tissue
resembling that of a normal hymen.
On abdominal palpation a tumour the size of a turkey egg is
felt on a level with and to the left of the umbilicus, oval and
movable, from tumour to pubes was a semi-elastic mass, dull
on percussion.
On the 14th ether was administered, and a bimanual examina¬
tion made through the rectum.
The tumour at level of umbilicus proved to be the en¬
larged uterus ; the mass moving down from it to the distended
vagina, which occupied the middle of the pelvis and could
be traced up into the abdomen, was cylindrical, not as
figured in books, ballooned out, so as to fill the pelvis, room
for the'retained menstrual fluid being obtained by longitudinal
extension, not by lateral distension.
The vulva having been thoroughly washed and disinfected,
I excised a piece of the membrane, somewhat larger than a
shilling ; a large quantity of thick, viscid, reddish-brown fluid
flowed out with considerable force ; on its ceasing to flow the
vagina was irrigated with Gondy’s fluid and water, and an
aseptic gauze drain introduced.
On 15th about a wineglassful of fluid escaped on removal of
plug, vagina irrigated, and fresh drain introduced ; on 16th
drain removed, no discharge ; on 17th there was difficulty in
introducing glass tube of irrigator ; on 18th she was again put
under ether. The opening had contracted so much that there
was some difficulty in passing in tip of index finger, the mem¬
brane felt exactly like an indiarubber ring ; I incised the
membrane in four places, it wTas so tough and resisting that
I was obliged to transfix at vaginal margin and cut out to its
free edge ; a gauze plug was packed in and left in situ for
twenty-four flours.
Throughout there were no feverish symptoms — the pulse 72
and the temperature normal.
176
The Water Supply of Dublin.
Having in mind a case, which I brought before the Eoyal
Academy of Medicine in 1887, in a paper on “ The Signs
of Virginity,” in which I found, in a woman in labour,
who some years previously had been operated on for
imperforate hymen, an opening in the hymen not as big
as a crow-quill, and in which the hymen was an obstacle
to delivery, I endeavoured to avoid a similar result in
this case by excising a large piece of the membrane, yet
it would have occurred if I had not afterwards cut freely
the remnants of the elastic membrane, the rapid contrac¬
tion of which surprised me.
Unfortunately the excised piece was lost, so that sections
could not be made and its structure studied. Its appear¬
ance prior to operation, and the feel and appearance
of the parts after operation, point to the obstruction not
being merely a dense or thick hymen without an opening,
but rather that the occlusion was caused by a membranous
septum immediately behind the hymen, and to which the
latter was adherent.
Art. XI. — The Water Supply of Dublin. By John
William Moore, M.D., M.Ch., B.A., Univ. Dubl. ;
P.B.C.P.I. ; Ex-Scholar and Dipl. State Med., Trin.
Coll., Dubl. ; Physician to the Meath Hospital.
Dublin and its suburbs are fortunate, in possessing an
abundant supply of pure soft water, and the Dublin Cor¬
poration Water Works enjoy a reputation far and wide
for completeness and efficiency.
The following account of the Water Works is abridged
from the description written in 1875 by the Engineer, Mr.
Parke Neville, C.E., M.I.C.E., F.R.I.A., M.R.I.A., and pub¬
lished by Mr. John Falconer, 53 Upper Sackville-street,
Dublin. For the more recent information I am indebted to
Mr. Spencer Harty, C.E., the City Surveyor and Water¬
works Engineer, and Mr. Charles Power, Secretary to the
Waterworks Committee of the Corporation. Both gentle¬
men spared neither trouble nor time in answering certain
queries which I addressed to them with the view of
By Dr. J. W. Moore. 177
making this description as complete and accurate as
possible.
In August, 18 BO, Mr. (afterwards Sir John) Hawkshaw
visited Dublin as a Royal Commissioner to examine into
all the schemes at the time proposed for improving the
water supply of the Irish metropolis. In his Report,
dated October 20, 1860, Sir John Hawkshaw expressed
the opinion that the then existing supply of water to the
City of Dublin was bad, that there was urgent need of an
improved supply, and that the best source from which
such could be obtained was the River Yartry in the
County Wicklow. The Yartry scheme had been in the
first instance suggested by Mr. Richard Hassard, C.E.
After a severe Parliamentary contest the Dublin Cor¬
poration Water Bill, based on the Royal Commissioner’s
recommendations, obtained the Royal assent on July 21,
1861. The first stone of the WaterWorks was laid at the
Prince of Wales’ Reservoirs, Stillorgan, by the Earl of
Carlisle, Lord Lieutenant of Ireland, on November 10,
1862. The water of the River Yartry was turned from its
ancient course through a tunnel under the main embank¬
ment of the great storage reservoir near Roundwood, Co.
Wicklow, on June 30, 1863, when the Lord Lieutenant
(Lord Carlisle) conferred the honour of knighthood on Sir
John Gray, M.D., Chairman of the Dublin Corporation
Waterworks Committee. It was not, however, until 1868
that the Yartry water was supplied to Dublin and its
suburbs on the completion of the works.
The River Yartry rises on Calary moor, Co. Wicklow, at
the base of Djouce Mountain and of Great Sugar Loaf
Mountain, whence it flows in a southerly direction through
a thinly peopled district to the Devil’s Glen. Passing as
a mountain torrent through this beautifully wooded valley,
it flows by the village of Ashford, finally reaching the
Broad Lough, as the lagoon inside the Murrow of Wicklow
is called, and discharging into the sea at the town of
Wicklow. The length of the river from its rise to the
sea is 17J miles, and its catchment area is 34,890 acres.
The geological formation of this area is the lower Silurian
and Cambrian slate, except on the hill-tops towards the
M
178 The Water Supply of Dublin.
west, where the granite crops out in spots. The Vartiy
water is peculiarly soft and pure, quite colourless during
the greater part of the year. In a word it closely re¬
sembles Loch Katrine water, with which Glasgow is sup¬
plied. The catchment area draining into the river above
the waterworks is 14,080 acres.
Fortunately for the success of the scheme the rainfall in
the Vartry district was under-estimated. No rain-gauges
existed prior to 1860. It was calculated that, allowing
for loss by evaporation and absorption, 14' 8 inches would
remain for the supply of Dublin, and that this over the
catchment area of 14,080 acres would equal 12,000,000
gallons a day, or 25 gallons a head tor a population of
400,000, with 2,000,000 gallons for manufacturing pur¬
poses. Since 1860 several rain-gauges have been in action
in the district.
The following Tables have been compiled from the
Official Returns : —
Table I. — Showing the Yearly Rainfall at Vartry Lodge , Round wood,
Co. Wicklow, for each of the Thirty -eight It ears, 1861—1898.
Inches
Inches
Inches
Inches
1861
60-86
1871
51-65
1881
55-52
1891
49-04
1862
60-65
1872
69-34
1882
57-45
1892
44-63
1863
45-09
1873
40-08
1883
61-52
1893
33-74
1864
47-76
1874
42-50
1884
39-16
1894
67-13
1865
48-69
1875
61-75
1885
47-82 ;
1895
54-07
1866
53-43
1876
61-27
1886
49-91 j
1896
51-14
1867
46-05
1877
64-80 ;
18S7
31-91
; 1897
63-58
1868
56‘15
18.78
43-15
1888
6013
1898
52-51
1869
49-00
1879
53-07
1889
47-34
1870
43-68
1880
53-78
1890
|
47-02
.
Decennial
Means,
1861-1870
Inches
51-14
Decen¬
nial
Means,
1871-
1880
Inches
54-14
Decen¬
nial
Means,
1881-
1890
Inches
49-78
[Means,
1891-
1898
(Eight
years)
Inches
51-98
Table II. — Showing the Monthly and Yearly Rainfall at Vartry Lodge , Roundwood , Co Wicklow, for the following fifteen years.
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180 The Water Supply of Dublin.
The foregoing figures clearly show within what wide
limits the precipitation in the Vartry Catchment fLsin
varies from year to year. In 1872 the rainfall amounted
to 69-34 inches. In 1887 it reached 3T91 inches only.
The average rainfall for the fifteen years included
in the Table— 1884-1898— was 49‘28 inches. . For the
whole series of 38 years the average annual rainfall was
51-75 inches— a figure which may be regarded as final..
The great storage reservoir stands about 7^ miles
from the source of the Vartry River and 1^ miles S.E.
of the village of Roundwood. When filled to the level
of the bywash, the water in the reservoir covers 409 acres,
its greatest depth being 60 feet and its mean depth 22 feet.
Its surface is 692*45 feet above Ordnance datum (low
water of a 12-feet tide at the Poolbeg Lighthouse, Dublin
Bay). The storage capacity of the reservoir or Lough
Vartry is about 2,400,000,000 gallons, equal to 200 days’
supplv for the City of Dublin and its suburbs at the late
of 12,000,000 gallons a day.
The water leaves the reservoir through three 24-inch
valve inlets at different levels in a turreted water-tower
connected with a 33-inch pipe, which passes through a
tunnel some 300 feet in length under the great eastern
embankment. At the far side the water is carried into a
series of filtering beds, and thence into two pure water
tanks. From these last the water is conveyed to a tunnel
4,332 yards in length, through which the water is carried
from the valley of the Vartry under a range of hills,
averaging 1,000 feet in height, dividing it from the districts
towards the east. Great difficulties were met with in
driving this wonderful tunnel of over 3 miles in length. The
chief of these were the hardness of the rock, which was of
the lower Cambrian or Silurian system, the irregularities
of the stratification and the thinness of the layers, which
were frequently horizontal, and the quantity of water met
with in the borings. The tunnel was driven from 21 shafts,
each 200 yards apart. The first shaft was commenced on
January 4, 1863, and the last heading was opened out in
September, 1866, the total time taken to drive the tunnel
being thus 3 years and 8 months.
181
By Dr. J. W. Moore.
At the northern end of the tunnel, at Callow Hill, a cast-
iron gauge weir has been erected for registering the'
quantity of water passed down daily for the metropolitan
supply. The water is measured six times daily by a
floating meter. From a tank, 86 feet in diameter and 10
feet deep, the water is conveyed from a level of 602 feet
above Ordnance datum through a 33-inch main to the
service reservoirs at Stillorgan. The length of this main
is 30,942 yards, or 17 miles, 4 furlongs, and 142 yards, and
the falling hydraulic line is 20 feet per mile. Three
relieving tanks to diminish the pressure are constructed on
the line of main — at Kilmurray (473 feet), Kilcrony (414
feet), and Rathmichael (341 feet), the last distant 7,431
yards from the Stillorgan reservoirs.
The three distributing reservoirs at Stillorgan (of which
the two which were first constructed are called the Prince
of Wales’s Reservoirs) are 4 miles, 5 furlongs, and 150
yards from the City boundary at Eustace Bridge, Leeson-
street. The fine new reservoir, called the Gray Reservoir
in memory of Sir John Gray, is capable of holding
100,000,000 gallons. The top water level in the upper
of the two original reservoirs is 274 feet, and in the
lowest 271 feet above Ordnance datum, or 170 feet above
the highest part of the City. The lowest reservoir
contains 43,166,548 gallons, with an average depth of
22 feet of water; the middle reservoir contains 43,057,424
gallons, with an average depth of 20 feet of water. The
screen chamber is a handsome octagonal building, of
granite ashlar, situated at the south-eastern angle of the
lower reservoir. It is 46 feet wide at the bottom, and 49
feet at the level of the floor line, each side being about
20 feet long on the floor line. The screens, through
which the water is passed to the distributing mains, are of
copper-wire gauze, having 30 strands to the square inch.
The entire area of the screens is 1,500 superficial feet.
Two 27-inch mains, controlled by two 27-inch valves,
convey the water from the screen chamber to Dublin, and
a 15-inch main is laid out of it for the supply of Kingstown
and Dalkey.
The water is distributed to every part of the City
182
The Water Supply oj Dublin.
through lines of pipes varying from 27 to o inches in
diameter, which extend to 110 miles in length. Fountains
for the use of the poor have been erected in several parts
of the City. Since the Yartry water has been introduced
into the City, the necessity for using fire-engines has
practically ceased, although such are kept in readiness
for any emergency. Hydrants of the pattern known as
Bateman and Moore’s patent have been put down to the
number of 1,390. They are about 100 yards apart. In
case of fire a standpipe and hose is attached to these
hydrants, the water thrown from them being sufficient to
extinguish the largest fire.
The Dublin Corporation Water Works have been in full
working order since 1868. Only in 1893 were there any
apprehensions of a water famine. The total cost of the
works up to the present date, 1899, has been T720,000 — a
figure which (with a metropolitan population of 330,000)
is equal to about T2 3s. 8d. per head.
From 1868 to 1872 the consumption of water by the
city and townships varied from 13 to 16 million gallons
per day compared with an estimated consumption of
12 million gallons. From 1872 to 1893 the daily average
consumption was about 14 million gallons.
The lowest levels in feet below the sill of the by wash
reached in the following years were : — 1870, 20‘90; 1874,.
16-00; 1876,13-40; 1884,26-80; 1885,7-40; 1887,26-90;
1891, 3'70 ; 1893, 39’00. In the last-named year the rain¬
fall was only 33' 74 inches, and in the late autumn serious
apprehensions of a scarcity of water were entertained.
As statements impugning the purity of the Yartry water
were being made from time to time, the Water works Com¬
mittee, acting on the suggestion of Sir Charles A. Cameron,
early in 1896 requested Professor Percy F. Frankland,
Ph.D., B.Sc., F.R.S., Professor of Chemistry in Mason
University College, Birmingham, to examine the water,
particularly from a bacteriological standpoint.
Professor Frankland’s Report is embodied in the follow¬
ing letters to Sir Charles Cameron: —
183
By Dr. J. W. Moore.
Chemical Department,
Mason College,
Birmingham,
22 nd May , 1896.
Dear Sir Charles Cameron,
I have to report to you on the bacteriological examination
which I have made at your request of a number of samples
representative of the water supplied to' the City of Dublin.
All the samples, seven in number, were11 collected by myself,
personally, in specially sterilised bottles, on the afternoon of
Saturday, the 9th inst. ; and they were all submitted to gelatine-
plate cultivation in your laboratory on the same afternoon, whilst
the plate cultures thus prepared were taken by me to Birming¬
ham, and there! incubated in my laboratory.
The following results were obtained : —
Sample No. 1. — This was taken from the small open carrier
supplying the filter beds, and is, therefore, representative of the
unfiltered water coming direct from the reservoir. This yielded
535 colonies per 1 cubic centimetre of water.
Sample No. 2. — This was taken from what is known as Clear
Water Basin No. 2, and is representative of the filtered water
coming from one group of filters. This yielded 290 colonies per
1 cubic centimetre of water.
Sample No. 3. — This was similarly taken from what is known
as clear Water Basin No. 1, and is representative of the filtered
water coming from another group of filtered beds. This yielded
116 colonies per 1 cubic centimetre of water.
Sample No. 4. — This was taken from the main supplying
filtered Canal water to a brewery in the City of Dublin, and may,
as I understand, be taken as representative of this portion, of the
Dublin supply. This yielded 276 colonies per 1 (cubic centimetre
of water.
Sample No. 5. — This was taken at the same place, and
immediately after No. 4. It yielded 270 colonies per 1 cubic
centimetre of water.
Sample No. 6. — This was taken from a Stand Pipe affixed to
the main in the yard of the disused Barracks. This yielded 432
colonies per 1 cubic centimetre of water.
Sample No. 7. — This was taken from a tap attached to the
main in veur laboratory, in Castle-street. This yielded 299
colonies per 1 cubic centimetre of water.
These results show that the unfiltered Vartry water contains
for surface water only a very moderate amount of bacterial life.
184
The Water Supply of Dublin.
To appreciate, in fact, this relative freedom from bacteria, I may
remind you that in the Thames water, prior to its treatment by
the London Water Companies, I have generally found from 10
to 20 times as many, and sometimes 200 times as many, bacteria
as in this unfiltered Yartry water although the latter contains
more than I have found in the water of Scotch Loehsi, such as
Loch Katrine water as supplied to Glasgow, and the water of
Loch Lintrathen supplying Dundee.
The examination of the two filtered samples shows that in the
process of filtration about 62 per cent, of the bacteria present
in the unfiltered water were removed. Possibly a greater
efficiency might have been indicated by taking samples of the
water as it issues from each of the filter beds, as some multiplica¬
tion of the bacterial present may take place during the time that
the water remains in these Clear Water Basins. I (should men¬
tion, that the sand employed for filtration impressed me of being
of remarkably coarse grain, and I think it very probable that
superior results would be obtained if a finer sand were used.
Certainly, the number of bacteria in these filtered samples is
greater than should be present in efficiently filtered water, being-
in excess of that found in filtered water, which initially, i.e.,
prior to filtration, is much richer in bacterial life than the
Yartry.
The number of bacteria found in the samples taken at the
Barracks and at the laboratory shows that some multiplication
takes place between the filtration works and the City, but the
considerably larger number found in the Barrack’s tap is pro¬
bably due to local multiplication in the main, in consequence of
this tap being, asi I presume, not much drawn upon at present.
As regards the nature of the bacteria in the several samples of
the Yartry water, I made a special examination for the Bacillus
coli communis , by the method of phenol-broth cultivation of each
sample, but although this test was applied in duplicate through¬
out, not one of the Yartry samples, either unfiltered, filtered, or
as distributed in the City, responded to the test.
The two1 samples of Canal water which I examined, con¬
tained much the same number of bacteria as were present in the
filtered Yartry waters. On submitting these samples to the
phenol-broth test, I obtained evidence of the presence of a micro¬
organism resembling in some respects the B. coli communis , inas¬
much as it gave gas bubbles in the depth of the gelatine, but it
was easily distinguishable from the B. coli communis on further
examination, inasmuch as it neither caused milk to' curdle when
185
By Dr. J. W. Moore;.,
cultivated in the latter, nor did it yield the indol-reaetion on
cultivation in peptone-broth. In conclusion, I would state that
from what I saw of the Vartry watershed I am, of opinion that
it is a magnificent gathering ground, being, considering its
extended area, but very scantily populated, whilst the great size
of the Reservoir affords abundant opportunities for the purifica¬
tion of the water by sedimentation and oxygenation. I have,
however, always recommended that exclusive reliance should not
be placed in mere storage, and that surface waters; should also be
subjected to filtration. The works designed for this purpose just
below the Reservoir appear admirably adapted for their task,
being sufficiently large to permit, as I understand, of a slow rate
of filtration ; they are also constructed, I believe, so> that the head
of water can only be very slightly altered. The depth of fine
sand, again, I am informed, is considerably upwards of two feet ;
but, as already indicated, I am, of opinion that an improvement
might be effected in employing a finer grained sand. In fact,
unremitting efforts should be made to reduce the number of
bacteria in the filtered water to a minimum by the most careful
attention to the now well-known factors involved in obtaining
efficiency in filtration.
I am,
Yours faithfully,
PERCY F. FRANKLAND.
Sir Charles Cameron , Ph.D., F.E.C.S.I. , <fic.,
Medical Officer of Health ,
Dublin.
Chemical Department,
Mason College,
Birmingham,
24 th June , 1896.
Dear Sir Charles Cameron,
In response to the request of the Waterworks Committee
of the City of Dublin, conveyed in your letter of the 17th inst.,
I beg, herewith, to offer the following remarks; on the subject of
the Vartry Water Supply.
1. The Vartry water is derived from a gathering ground which,
considering its enormous area, supports a very scanty population.
As far as my inspection went, and from what I could ascertain by
enquiry, there is upon the whole area, only a single group of
habitations to which the name of Village can be applied, and in
che case of this, I understand that the sewage has been carefully
186
The Water Supply op Dublin.
diverted, thus avoiding1 all possibility of contamination from that
source. The remainder of the population is scattered over the
gathering ground in isolated houses.
O O O
2. That some contamination may arise from these isolated
dwelling-houses is unquestionably possible, but the absolute
amount of such contamination must be extremely small, and its
proportion to the volume of water very minute. It is almost
unnecessary to remark that with such a daily supply as is required
by the City of Dublin, it is hardly within the range of practical
politics to obtain anywhere a gathering ground of adequate size,
which would not be liable to the possibility of such fractional
contamination as that to which the Yartry is exposed.
3. Under these circumstances it is necessary to consider what-
barriers are interposed between such possible contamination and
the water consumer. The line of defence appears to me to be an
idle one.
In the first place, in the absence of systematically drained
dwellings, contaminating matters must, in general, take a very
circuitous route to the water, and in the percolation through soil
such contaminating matters, both organised and unorganised, are
for the most part either arrested or destroyed.
In the second place, assuming that a part of these contaminat¬
ing matters generated in the several homesteads do actually
gain access to the Yartry and its feeders, they will be carried
into the Reservoir, in which, in consequence of its enormous
capacity, their fuller progress would necessarily be arrested for
a long period of time.
Now in such a reservoir, as has been shown by myself and
others, there are the most important agencies at work tending to
remove bacteria in particular. Thus, during the storage of water
in reservoirs, the total number of bacteria present generally
becomes very generally diminished, doubtless in consequence of
the process of subsidence which goes on, whilst the vitality of
pathogenic forms like the typhoid bacillus is rapidly destroyed,
probably through the products elaborated by the common water
bacteria. Thus, I have shown that typhoid bacilli remain in a
living state for a longer period of time in Loch Katrine water
when the latter has been sterilised than when it is in its natural
condition and populated with the ordinary water bacteria.
From the results of my experiments in this connection I am of
opinion that when water is subjected to a prolonged storage of
weeks, or even months, in reservoirs or lakes, the chance of any
such bacilli being still alive is extremely remote.
187
By Dr. J. W. AIoore
But even should these bacilli escape this ordeal of the storage
reservoir they will still be met by the third line of defence
the sand filter. The capacity of removing bacteria of all kinds
possessed by this agent of purification is now so well established
and generally known, that it is unnecessary for me to dwell upon
it in detail, more especially as I have already in my previous
report referred to this matter. But inasmuch as by the exercise
of due precautions upwards of 99 per cent, of ^ the bacteria pre¬
sent in the water can be removed by this means, I would again
urge the desirability of rendering this third and last line of
defence as perfect as possible.
4. When the existence of these three lines of defence against
any possible contamination is borne in mind, it must be suffi¬
ciently obvious that, assuming any pathogenic bacteria to be at
any time present on the gathering ground, the chance of their
reaching the water consumer must be excessively remote.
5. Under these circumstances, I am of opinion that the Vartry
water complies with the most stringent demands of modern
sanitary science.
I am,
Faithfully yours,
PERCY F. FRANKLAND.
ENTEROLITHS FORMED BY DRUGS.
Dr. Puis y sans ( Criteria Catholico en las Ciencias Medicas ) pre¬
scribed salicylate of magnesium and benzo-naphthol to be taken
in a cachet of the smallest possible size. The patient took
the dose, and next day Dr. Puis received a whitish body, hard
as stone, resembling an enterolith, which had been found in the
motions. It consisted entirely of the drugs administered, con¬
solidated into a stony mass. Dr. Rovira (D. Juan) saw a
similar result after the administration of carbonate of magnesium
and salol in the same form, and Dr. Lloret had the same result
after salicylate of bismuth and benzo-naphthol had been given in
a cachet. These cases show that the physical and chemical
compatibility of drugs administered together should be known. —
Med. and Surg. “ Review of Reviews."
PART II.
REVIEWS AND BIBLIOGRAPHICAL NOTICES.
- - - - -
A Manual of Obstetrics. By A. F. A. King, A.M., M.D.,
Professor of Obstetrics and Diseases of Women and
Children in the Columbian University, Washington.
Seventh edition. Bevised and enlarged. 1898. Lon¬
don : Henry Kimpton & Co. Pp. 574.
As this manual has already passed through six editions
one would be inclined to think that that fact was sufficient
proof of its scientific value ; however, having read it care¬
fully through, we are inclined to think that the work falls
far short of the best scientific teaching of the present day.
The treatment of abortion recommended is antiquated
in the extreme. It is that which we find recommended
in text-books of thirty to fifty years ago, the results of
which treatment have been anything but satisfactory,
because the patient, in the majority of cases, either lost
her life or became a chronic invalid. Having dilated con¬
siderably on this form of treatment, the author says :
“If it doesn’t succeed in twenty-four hours” (which it
seldom does), “ to adopt the more radical measures of ex¬
traction by the finger and curette.” Now, why not adopt
these measures at once, when the abortion is inevitable
or incomplete, and save the patient twenty-four hours’
misery, the risk of becoming septic, the risk of endo¬
metritis, and all the other consequences of an incomplete
abortion.
There is no worse antiseptic solution used for douching
the uterus and vagina than the solution of bichloride of
mercury. In the first place, when used for this purpose
it is not an antiseptic, but rather a dangerous poison, as
the mercury unites with the albuminous secretions of
the parturient canal, forming an insoluble albuminate of
mercury, which remains inert there, and is absorbed into
189
King — Manual of Obstetrics.
the system later on. In the second place, it acts as an
astringent, hardening the tissues and preventing the
natural secretions from taking place.
With regard to creolin, the author appears to have had
no experience of its use, as he recommends it to be first
mixed with “ a little hot water,” just what it will not mix
with, and he recommends the strength of it to be from
1 to 2 per cent., a solution which would burn the average
patient, and would ruin the operator’s hands. One in 320
is the usual strength recommended.
Routine post-partum douching is a totally unnecessary,
and often a dangerous, proceeding. “Milk fever” is a
very good name to use to the patient or her relatives for
the milder forms of saprsemia or mastitis, but per se does
not exist. The establishment of the flow of milk is a
purely physiological function, unattended with any fever.
One thing in which the author differs from most
authorities is in placing flexion before descent in the
mechanism of head presentations. In this he is probably
right, as the contractions of the uterus commence in the
circular muscular fibres of the lower uterine segment ;
they then travel to the fundus, and are rapidly followed
by contractions of the longitudinal fibres. Consequently,
to be still more correct, we would recommend him to
put in his next edition — 1. Flexion ; 2. Descent and
flexion, &c.
His treatment of occipito-posterior positions comes
under the head of “ Meddlesome Midwdfery.” From 90
to 95 per cent, of these positions rotate naturally to the
front if left alone, and, in any case, do not terminate in
anything worse than an ordinary case of forceps.
In cases of delay in the after-coming head in breech
presentations, the author recommends — instead of the im¬
mediate delivery of the head — to pass up two fingers
between the face and the vaginal wall, or a large catheter
into the child’s mouth, so as to enable it to take an in¬
spiration. The result of this would be to fill its bronchi
and lungs with vaginal mucus, meconium, and liquor
amnii, which means certain death to the child. The
application of forceps to the breech is a useless and
190 Reviews and Bibliographical Notices.
dangerous proceeding. The author does not appear to
have ever heard of Neville’s axis-traction forceps.
In several of the illustrations — e.g., figs. 136, 137 and
156 — the author will probably soil his cuffs during the
operation.
Carbolised vaseline being a mechanical mixture, the
vaseline protects the micro-organisms from the action of
the carbolic acid, and is consequently a dangerous lubri¬
cant.
The extremely grave prognosis which the author gives
in cases of placenta prsevia is undoubtedly due to the
treatment he recommends. Accouchement forc'e and
mechanical dilatation, or rather tearing of the cervix, are
the immediate cause of the lamentable maternal mortality
he mentions.
On page 413 is a collection of highly septic old Gamp
measures which you are recommended to perform while
you stand by and watch the patient dying. The para¬
graph is as follows : —
“A perfectly clean aseptic sponge, or preferably a
similarly clean bit of rag or small pocket-handkerchief,
saturated with spirits of turpentine or whiskey, passed
into the womb, and squeezed, so that the spirit comes in
contact with the uterine walls, are efficient stimuli to
uterine contraction. A cloth containing pure chloroform
passed into the uterus, and allowed to remain there for a
time, has also been used successfully. * The old, but well-
tested remedies of a rolled gashed lemon and a sponge
filled with vinegar being introduced, and squeezed while
in the uterine cavity, have of late been objected to as
being aseptically unclean. They are, however, powerful
excitants of uterine contraction. The vinegar can be
sterilised by boiling, and in cases of emergency it is
usually obtainable in every household. A lemon can be
rendered aseptic on its exterior by immersion in a bichlo¬
ride solution, and that septic germs inhabit its interior
structure is at least improbable, and certainly not demon¬
strated.”
The author’s treatment of prolapse of the funis is similar
to that of a medical student at an examination who has
191
Atlas of Urinary Sediments.
never seen a case. He lays great stress on the reposition
of the cord, an operation not often practicable, and usually
a failure. The author says, “ when the membranes rupture
artificial reposition of the cord must be attempted,” irre¬
spective of whether the child is dead, whether the head is
fixed, or whether the patient is in the second stage.
The author’s treatment of eclampsia is almost as anti¬
quated, and even more dangerous than jais treatment of
placenta prsevia and abortion. He recommends the two
most dangerous drugs which give the highest possible
maternal mortality — i.e., pilocarpin and chloroform, while
he scarcely mentions morphin, a drug which is extensively
used over the Continent and at the Eotunda Hospital, where
its success has been undoubted, reducing the maternal
mortality from 40 or 60 per cent, to 4 or 8 per cent.
The maternal mortality in cases of accidental haemor¬
rhage is given at 50 per cent, due to the treatment re¬
commended— fie., rupture of the membranes. By this
means you convert a simple case of accidental haemorrhage
into what might be called malignant accidental haemor¬
rhage. The extremely successful method of treating this
formidable complication of labour by efficient plugging of
the vagina the author does not mention in his text-book.
Atlas of Urinary Sediments; with special reference to
their Clinical Significance. By Hr. Hermann Rieder,
of the University of Munich. Translated by Frederick
Craven Moore, M.Sc., M.D. (Viet.) ; Assistant Lec¬
turer and Demonstrator of Pathology, Owens College.
Edited and annotated by A. Sheridan Delepine, M.B.,
C.M. (Edin.), B.Sc. ; Professor of Pathology in Owens
College and Victoria University, Manchester. London :
Charles Griffin & Co. 1899. Large quarto. Pp. 111.
Not since 1853, when Dr. Otto Funke, “ Privatdocent
der Physiologie an der Universitat Leipzig,” published his
most artistic Atlas of Physiological Chemistry, has so
valuable a contribution to the subject been made as the
work which now lies before us.
The Atlas proper consists of thirty-six beautifully
192 Reviews and Bibliographical Notices.
executed plates, comprising 167 figures, many of which
are printed in colours. In addition, several explanatory
figures are inserted in the text which follows the Atlas
and runs to 111 pages of large quarto size.
The work deals almost exclusively with the micro¬
scopical character of the sediments formed by the deposi¬
tion of certain of the constituents of the urine when it is
allowed to stand. This deposition takes place very rapidly
sometimes, at other times slowly. Dr. Delepine points
out that it is often desirable to examine the urine
immediately after it has been voided and before any
sediment has been formed in the usual manner.
It may be well to mention that the German original of
this important work was published at Munich in Novem¬
ber, 1897. On its appearance, Messrs. Griffin, who had
long contemplated the publication of an Atlas of Urinary
Sediments, and had placed themselves in communication
with Dr. Delepine on the subject several years ago, ex¬
pressed the desire that Dr. Delepine should edit for them
an English edition of Dr. Eieder’s work. After securing
the able co-operation of Dr. F. C. Moore, who undertook
the work of translation, Dr. Delepine agreed to edit the
English version.
Dr. Hermann Eieder possessed the great advantage of
being Assistant in the Medical Clinic of Geheimrath von
Ziemssen, who, with his usual courtesy, placed the
material of the clinic at his disposal. ' The illustrations
throughout were carefully prepared by the University
draughtsman from original specimens, and the Munich
publishers spared neither trouble nor expense to obtain
faithful reproductions of these drawings. The lithographs
have been executed by the lithographic firm of Julius
Klinkhardt, of Leipzig, and reflect much credit on the ar¬
tistic skill of that establishment. The sediments have been
drawn as seen with a moderately high power of a Zeiss
microscope — namely, a D. objective and No. 2 ocular.
As far as possible the same magnification has been
employed, so as to admit of comparison of one specimen
with another.
But it would not be accurate to suppose that this Eng-
193
Pocket Case-book for Nurses.
lish edition is a mere translation. On the contrary, while
none of Dr. Rieder’s statements have been materially
altered, Dr. Delepine has not hesitated to modify the
original in the way of abbreviation so as to avoid needless
repetitions, while numerous additions have been made to
the translation of the German text in the shape of annota¬
tions for which Dr. Delepine is responsible. These are
distinguished from the original text bf being enclosed
within square brackets. Most of these notes, as well as
sixteen out of twenty figures which have been added to
the text, are derived from records of over 4,000 urinary
analyses and microscopic examinations made by Dr.
Delepine himself in the course of some eight years.
In the text reference is made to the characters, the
mode of occurrence, and the pathological significance of
urinary sediments. With regard to the inorganic or crys¬
talline sediments, some of the micro-chemical reactions
have been given, since the crystalline form alone cannot
in many cases be relied upon for diagnosis.
As we write we have the advantage of having before us
Dr. 0. Funke’s Atlas, in which the lithographs are of
extraordinary finish and delicacy. Dr. Rieder’s Atlas
bears the ordeal of comparison well. The “fields” are
large, which is of course a gain. Their diameter is 63mm.
compared with 50mm. in Funke’s. Taken together, the
two atlases give a faithful and invaluable representation
of urinary deposits, and reflect credit on the German
school of microscopical research in clinical medicine.
The price of Dr. Rieder’s and Dr. Delepine’s Atlas is
eighteen shillings. It is well worth the money.
The Pocket Case-Book for District and Private Nurses.
London : The Scientific Press, Ltd. 1899. Demy 16mo.
Pp. 50.
This is a very useful little book, enabling the nurse to
give every detail of her patient’s condition for the doctor’s
inspection, or for the verbal report required from the district
nurse on her return home, and forming a complete history
of her case for future study and reference. We, however,
N
194
Previews and Bibliographical Notices.
venture to suggest that the price — a shilling for the re¬
cord of fifty cases will not tend to make it popular. We
have just seen a district nurse’s sheet of fifty cases attended
in the month of June alone.
On the Relation of the Nervous System to Disease and Disorder
in the Viscera. Being the Morison Lectures * delivered
before the Royal College of Physicians in Edinburgh in
1897 and 1898. By Alexander Morison, M.D. Edin¬
burgh and London: Young J. Pentland, 1899. Pp.
132.
These lectures have been already published in the Edin¬
burgh Medical Journal. The subject is a very large one,
and exceedingly indefinite. It is treated by the author
under the headings, Anatomy, Physiology, Pathology,
Disorders of Visceral Sensibility, and Disorders of Visceral
Motion, with a concluding chapter on Body and Mind — a
pretty wide subject. There are in each lecture many
interesting observations, particularly those dealing with
the minute anatomy of the nerves and ganglia; but the
greater part of the work is of a highly speculative char¬
acter, and hardly admits of a summary.
A very important discovery is that of the existence of
vaso-motor nerves supplying the cerebral vessels, which
Dr. Morison has made by means of a modified hmmatoxylin
method. Another interesting discovery is that of the spiral
course of the nerves in the uterus, heart, and probably in
other organs whose size is apt to vary within wide limits.
When the organ is contracted the nerve-fibres fall into a
close spiral, which becomes stretched out as the organ
enlarges.
From his researches Dr. Morison doubts the truth of the
commonly-received view that the rhythmic contractions
of the heart have their origin in the muscular tissue
itself — “The conclusion seems warrantable, until indubit¬
able proof to the contrary has been adduced, that at least
in the fully-developed organs of more complex animals,
persistent rhythmicality has its proximate and always sub¬
ordinate centres in the efferent stream of innervation.”
Scientia.
195
For the many other points of interest in these lectures
we must refer our readers to the work itself, which will
be found readable and suggestive in every page. The
text is illustrated by 39 figures, which are mostly repro¬
ductions of micro-photographs of the author’s preparations.
With few exceptions they are very indistinct, and
show either very imperfectly or not at all the points they
are said to illustrate. Indeed, they servte only to confirm
our opinion of the inferiority of photographs to good
drawings for the reproduction of microscopic appearances.
Scientia. Expose} et Developpement cles Questions scientifiques
a V Ordre du Jour.
It is with much pleasure that we call the attention of our
readers to this serial publication, which consists of short
monographs, each of about 100 pages, dealing with the
most important scientific questions which are of present
interest. The works are divided into two series — one
treating of physico-mathematical subjects, the other dealing
with biological questions. Among the names of the editors
we find those of d’Arsonval, Lippmann, Moissan, Poincare,
Balbiani, Marey, and Milne Edwards. The subjects are
treated not dogmatically, but while an orderly account is
given of the development and literature of each subject,
every stage in this development is submitted to a rigorous
criticism and a constant control by experiments. Each
subject is dealt with by a writer of acknowledged authority,
and if we may judge from the volumes we have seen, we
believe that the work will prove one of the highest
value.
The following are some of the volumes which have
already appeared or are in preparation : — In the physico-
mathematical series the Zeemann phenomenon, by Cotton ;
Stereo-chemistry, by Freundler; Determination of the
Ohm, by Lippmann ; Maxwell’s Theory and Hertzian
oscillations, by Poincare ; the new Gases, by Raveau ;
the Cathode Rays, by Villard. While in the biological
series we find the Coagulation of the Blood, by Arthus ;
Molecular Actions in the Organism, by Bordier ; Irrita-
196 Reviews and Bibliographical Notices.
bility in the Animal Series, by Conrtade; Fecundation m
Animals, by Delage and Labbe; Fecundation in Vegetables,
by Poirault ; the Nerve-Cell and the Neuron Theory, by
Van Gehuchten; and many others of no less interest.
We have received three volumes of the biological series.
No. I. is entitled La specificite cellulaire, ses consequences en
Biologie gmSrale, par L . Bard.— In this essay the question
is discussed whether the different kinds of cells can change
one into the other, or whether each kind of cell owes its
properties not to accidental conditions, but to pre-existent
properties transmitted by heredity, so that each cellular
species is fixed and unalterable. The author holds the
latter view in the strongest manner, and develops his
position and the bearings it has on pathology and biology
with the greatest clearness and attractiveness
No. IV. Les Actions moleculaires dans V Organisme, par H.
Bordier.— This volume deals with some of the most inte¬
resting problems which are at present agitating the
minds of physiologists. Whether absorption, secretion, the
separation of the lymph, the exchange of gases in the
lungs, can be explained by known physical laws, or
whether they require the intervention of so-called vital or
protoplasmic forces, which are at present unknown, is a
problem of the utmost importance, and one on which different
physiologists hold very different views. In Professor
Bordier’s able monograph such subjects are dealt with as
elasticity, adhesion, surface tension, osmosis and osmotic
pressure, capillary phenomena, gaseous adhesion, solution
of gases, diffusion and osmosis of gases. These subjects
are treated of in their relation to physiology, muscular
contraction and the electrical changes which accompany
it, secretion of urine, absorption from the stomach and
intestines, &c.
No. V. La coagulation du Sang , par M. A r thus, there
are few subjects which are more difficult to understand
than the present condition of the coagulation question.
There are nearly as many conflicting theories as there are
writers, and a student turned adrift among these is greatly
puzzled in finding his way through them. Of the numerous
workers on the question there are few of greater eminence
Hill — Manual of Human Physiology. 197
than Professor Arthus, and no one who is more capable of
giving a good account of the present state of the subject.
In his essay he gives a brief sketch of what was done
up to 1890, and starting from this date he discusses in
successive chapters the import of lime salts, of fibrin
ferment, the incoagulability of the blood caused by intra¬
vascular injection of proteoses, the seat of formation and the
nature of the anticoagulating substance produced by this
injection, the natural or acquired immunity against intra¬
venous injection- of proteoses, the anticoagulating power of
the serum of eels’ blood, of leech extract and of tissue
extracts, and finally, the substances which can produce
intravascular coagulation, nucleo-albumins, snake-poison,
artificial colloids.
We do not know any other work in which the whole
subject is so clearly treated, and the critical remarks of
the author are always marked by judgment and fairness.
The work will be a real boon to everyone engaged in
making up this most difficult but important subject.
Manual of Human Physiology. By LEONARD HlLL, M.B.
London : Arnold. 1899. Pp. 484.
The design of this book and the class of readers for whose
use it is intended, are best given in the words of the
author. He says — “ The author has tried to design this
book so as to give the general reader, and one who has not
received a scientific education, some insight into the
wonderful complexity of structure and function which,
taken together, compose a living man. He has therefore
endeavoured to avoid as far as possible the use of technical
terms, and has sought to lead the student to train himself
by observation, dissection, and the performance of simple
experiments.”
“ As a text-book this volume may be found suitable for
students training to qualify as teachers ; for nurses under¬
going hospital training ; for the higher classes of schools
and polytechnics. The medical student may find it of
some value as an introduction to the more advanced study
of physiology. A student who has mastered this book
198
Reviews and Bibliogrophical Notices.
should be able to pass the examinations at South Kensing¬
ton, both elementary and advanced, and the University
Local Examinations.”
The earlier chapters deal with a number of preliminary
considerations— as matter, weight, density, energy, gases,
liquids and solids, elements and compounds, electricity,
atmospheric pressure, life, protoplasm, sun-energy, cell
physiology, and differentiation of structure and function.
There are then several chapters on anatomy, in which
the skeleton, the joints, the connective tissues and the
muscles are described. We then have the physiology of
qiuscle and the mechanics of walking and some other
special movements, and then the different physiological
functions are described in the usual order, beginning with
the blood and terminating with the special senses, and
speech. A number of easy, practical exercises are given,
and the text is illustrated with 173 illustrations.
It is unnecessary to say that a work ot this kind, written
by a physiologist of Dr. Hill’s eminence, is well done, that
the information is exact, well up to the present level of
science, and strikingly put to the reader. There is nothing
in its pages which the student in advancing to larger works
will have to unlearn, but he will find that by mastering
this manual he has laid a solid and secure foundation
for further study. We would cordially recommend the
book to all those who are commencing their physiological
work.
Materia Medica, Pharmacy, Pharmacology , and Thera¬
peutics. By W. Hale-White, M.D., F.R.C.P. Third
edition. London: J. & A. Churchill. 1898.
Dr. Hale-White has made a reputation for his excellent
text-book not only by his promptness in publication shortly
after the issue of the “ Pharmacopoeia,” but also by his excel¬
lent arrangement of the subject and the working out of
the details.
The principal difference between his book and those of
other well-known authors is the arrangement of the
organic materia into therapeutic groups.
199
B ikch — Prccc ticct l Physiology .
His pages on Pharmacology and Therapeutics are lucid
and written in such a way as to be of real help to the
student .
There are 613 pages in the book, and Appendix I. gives
a list of the vegetable materia medica arranged according
to the natural orders.
t
The Students' Practical Materia Medica. By Grace
Haxton Giffen. Second edition. Edinburgh: E. &
S. Livingstone. 1899.
This book, written by a lady, consists of ninety-six pages,
seven chapters, and three blank pages for notes. The
author states it is intended for a pocket manual, “ and
should be read with the specimens before the student, and
will be found useful as a supplement to a text-book on
materia medica when studying the Pharmacopoeia.” It
gives definitions of the preparations, and classifies them,
giving their doses. These definitions might, perhaps, be
revised — for instance, such a definition as “ spiritus, a
liquid preparation made by maceration and distillation,”
can hardly be called correct.
In Chapter YI. the classification of the salts under their
acid radicles will be found useful to the student. In
Chapter VII. the tests for alkaloids and organic acids
require revision — e.g ., test for strychnin “ purple carbolic
acid with tinctura ferri perchloridi gives a blue colour.
Class Pooh of ( Elementary ) Practical Physiology , including
Histology , Chemical and Experimental Physiology. By De
Burgh Birch, M.D., C.M.,F.B.S.E. London: Churchill.
1899. Pp. 273.
This book contains an enormous amount of information
packed into very small compass. It is a complete elemen¬
tary handbook for the physiological laboratory, wanting
only those parts of the experimental work in which vivi-
sectional methods are necessary.
The sections on histology and on physiological chemistry
are exceedingly good, and comprise everything that a
i
200 Reviews and Bibliographical Notices.
student can require. But the greatest interest of the work
is found in the part on experimental physiology, for here
the authors ingenious and original apparatus is described.
This apparatus was designed by Professor Birch so as to
combine simplicity, efficiency, strength and cheapness. It
is very ingenious, and well worthy of the attention of all
those who have to teach practical physiology to’ classes of
students. We would particularly call attention to the
arrangement for distributing to the different tables the
time tracing given by a central clock or tuning fork,
described and figured at page 208.
There are a few inaccuracies in the text, as, for instance,
where on page 17 we are directed to raise the sternum of
the frog by dividing the ribs on each side.
On page 185 the voltage of a Daniell cell is given as 1*9.
On page 196 coccygeo-iliacus is spelt coccigeo-iliacus.
In the experiment on page 212 to show that the exten¬
sibility of muscle increases during contraction does not seem
quite conclusive. What is demonstrated is that the exten¬
sion is greater after than before contraction, and this may
be due merely to the fall of the weight with which the
preparation is loaded.
On page 248 the student is directed to bathe the auriculo-
ventricular junction of the frog’s heart with tincture of
atropin. The alcohol would exert a destructive action
on the vitality of the organ.
Such instances, however, detract but little from the
general excellence of the work. The book will be found
invaluable by students and teachers of practical physiology,
and even to practitioners it will prove very useful, as it
gives all necessary directions for the examination of the
urine, blood, digestive products, for the use of the sphyg-
mograph, and for many other operations daily required
in clinical medical work.
PART III.
SPECIAL REPORTS.
REPORT ON PRACTICE OF MEDICINE.
By Henry T. Bewley, M.D. Univ. Dubl. ; F.R.C.P.I. ;
Physician to the Adelaide Hospital; and Lecturer on
Forensic Medicine and Hygiene, Trinity College, Dublin.
I. ON litten’s diaphragm phenomenon.
II. BACTERIOLOGY AND CLINICAL MEDICINE.
III. DIAGNOSTIC POINTS CONNECTED WITH THE PUPIL.
IY. ON THE USE OF MAGNESIUM SULPHATE IN DYSEN¬
TERY.
Y. THE LOCAL APPLICATION OF GUAIACOL.
VI. HYDROCHLORIC ACID IN DIGESTIVE DISORDERS.
VII. THE BACTERIOLOGY OF DISEASE OF THE URINARY
TRACT.
VIII. THE USE OF POTASSIUM CHLORATE.
IX. THE TREATMENT OF CORYZA.
I. ON LITTEN’S DIAPHRAGM PHENOMENON.
Dr. R. Cabot gives his experiences of this phenomenon,
his paper being based on 220 cases : —
If a person lies with the feet pointing straight towards a
window (cross-lights being excluded), and the chest be exposed,
the following phenomenon can be observed during forced
respiration; along both axillae a sort of shadow is seen to
descend during deep inspiration from about the seventh to
about the ninth rib, passing up again during expiration. It
is best seen in spare, muscular young persons of either sex.
The phenomenon can be seen in all healthy persons except
those who are very fat, and those who cannot or will not
breathe deeply. The phenomenon is nearly or entirely absent
in the following conditions: — (1) Fluid or air in the pleural
cavity ; (2) Obliteration of the pleural cavity by adhesions ;
(3) Advanced emphysema of the lungs ; (4) Pneumonia of
202 Report on Practice of Medicine.
the lower lobe; (5) Intrathoracic tumours low clown in the
chest. Subdiaphragmatic tumours or fluid accumulations do
not impair the phenomenon unless they are of very great bulk.
Paralysis of the phrenic neiwe is also mentioned as a possible
cause for absence of the diaphragm shadow. The phenomenon
is briefly explained thus : At the end of expiration the
diaphragm lies flat against the inside of the thorax ; during
inspiration it “ peels off,” and allows the lower edge of the
lung to come down into the chink between the diaphragm
and thorax. This peeling off corresponds with the entrance
of the complementary air during forced inspiration. In quiet
breathing it is rarely to be seen. Litten observes no differ¬
ence in the distinction of the shadow on the two sides of
the chest. The importance of the phenomenon in clinical
medicine is due to the following facts : — It gives us an easy
and accurate measure of the volume or vital capacity of the
lungs, enabling us to dispense with the use of the spirometer
and of measurements of chest expansion. If the shadow
moves less than 2\ inches Litten considers the condition
abnormal. Such abnormality may be due to general debility,
emphysema, upward pressure of the pregnant uterus. Observa¬
tions conducted recently at Massachusetts resulted as follows: —
In 102 normal persons the excursion was practically the
same, and averaged about six centimetres. In eleven cases of
pleuritic effusion the shadow was entirely absent on the affected
side. In five cases of old pleurisy with adhesions, and in
three of acute dry pleurisy the shadow was absent on the
affected side. Six cases of bronchitis with emphysema were
examined; two of these showed no shadow on either side,
two showed a slight shadow on the right side only, and the
remaining two showed a slight shadow on both sides. Thirty
cases of pulmonary tuberculosis were examined ; in only one
case were the movements of the diaphragm normal. Even in
very early cases in which a few rales at one apex were the
only physical signs there was distinct limitation in the move¬
ments of the diaphragm. In a case of cirrhosis of the liver
in which the organ was palpable over a space a hand’s
breadth in width below the ribs and to the fifth rib above, the
shadow could still be seen to move with respiration. Similar
appearances were noted with respect to the spleen in a case
203
Report on Practice of Medicine.
of leukaemia. On the other hand, a very large collection of
ascitic fluid in a case of uncompensated valvular disease made
it impossible to detect any diaphragm shadow. It is pointed
out that the diaphragm shadow seems to render unnecessary
the use of the X-rays in the investigation of diaphiagm
movements. — A led. News, April 15, 1899, and Med. Chi on.,
June, 1899.
II. BACTERIOLOGY AND CLINICAL MEDICINE.
Dr. Cave (Bath) writes an interesting paper on this subject.
He calls special attention to the information to be derived
from making an examination of the blood. Information may
be gained as to the presence of typhoid fever by Widal s
method, and also living organisms may be cultivated from
the blood. For the latter purpose he does not approve the
commonly employed method of obtaining a little blood viz.,,
by pricking the finger with a needle or small lancet, but much
prefers the following procedure : — 44 Have ready,'’ he writes,
44 an ordinary serum or hypodermic syringe of 10 c.c. capacity,
with an asbestos piston, which has been thoroughly cleaned,
sterilised by boiling, and wrapped in sterilised filter papei.
Also three or more tubes of ordinary meat peptone agar.
Most carefully sterilise the skin of the patient s elbow at the
bend, select a vein made prominent by compression higher
up the arm, and plunge the needle of the syringe through
the skin and then into the vein, the needle pointing either
upwards or downwards, as is most convenient. On gently
withdrawing the piston it is quite easy to draw off ( or 8 c.c.
of blood without risk of extraneous contamination. This is
immediately distributed over the surface of the tubes, which
are then incubated at 37° C. If preferred, the medium in
the tubes can be first liquefied and cooled to 40°, the blood
added to the liquid agar, and the shaken mixture poured flat
in a Petri’s dish. By this means, which involves no danger
to the patient, and is as painless as an ordinary hypodermic
injection, it is possible to demonstrate the presence of bacteria
in the blood in quite a number of infections. It is of service
in cases of septic infection, such as ordinary traumatic surgical
or puerperal septicaemia or osteomyelitis, and it often gives
positive results in the later stages of pneumonia. But it is
204 Report on Practice of Medicine .
of pre-eminent value in the more obscure septic conditions
which come under the notice of the physician, in cases, that
is, of kryptic infection and in malignant endocarditis. In
both these conditions I have been enabled to settle the
diagnosis with absolute certainty in cases otherwise obscure.
All physicians are familiar with cases of septicaemia in which
even the post-mortem examination may fail to determine the
point of inoculation ; and if the lesions have not gone on to
pyaemia, if none of the more conspicuous embolic phenomena
nor endocarditis, nor other localised septic inflammations,
have produced visible effects, the whole case may be an enigma.
But in these virulent cases the bacteriological examination
of the blood by the method described above will certainly
elucidate the mystery.”
He has also derived much information from Quincke s
lumbar puncture, which he carries out as follows : —
“ I generally use an ordinary serum syringe, the same as
for the abstraction of blood from a vein, and I prefer this to
the bottle aspirator. The needle should be not less than
6 c.c. long, and 1 to 2 mm. in diameter. The object is to
tap the spinal canal below the termination of the spinal
cord, in the region of the cauda equina. The nerve-roots
floating in the cerebro-spinal fluid will be pushed aside by
the point of the needle and run no risk of puncture. The
syringe and patient’s skin being carefully sterilised, as before,
the patient lies on his side with the spine flexed and the
knees drawn up on the abdomen. The needle is inserted
either in the third or fourth lumbar interspace, or in the
lumbo-sacral junction, as recommended by Chipault, and now
more usually practised. It is inserted close beneath the
spinous process, and in the adult a little to one side of the
middle line, to avoid the dense interspinous ligament, and
pushed slightly upwards and forwards along the under surface
of the spine of the vertebra, for a depth in the adult of
5 or 6 cms. Gentle suction with the syringe will, as a rule,
easily withdraw a few c.c. of fluid for examination. The
fluid can be sown on agar, inoculated, or examined direct
after centrifugalising. It is in cases of meningitis that this
method is of most avail, but it has also given positive results
in acute anterior poliomyelitis. In acute purulent menin-
205
Report on Practice of Medicine .
gitis, whether the so-called idiopathic form from pneumo¬
coccal infection, or the epidemic variety, or in cases secondary
to disease of the petrous bone, it affords most valuable
information.
“ A negative result must be allowed no weight whatever,
and no inference as to the absence of disease can be deduced
therefrom. For example, in purulent meningitis from ear
disease, the free communication of fluicTfrom skull cavity to
spinal canal may be prevented, and a clear, sterile fluid
withdrawn, but this is very exceptional. Lichtheim has laid
down a rule, that no patient should be trephined for the
cerebral complications of ear disease unless the probable
absence of meningitis has been established by this method.
“ A positive result, demonstrating the presence of pyogenic
organisms in the fluid, is conclusive of meningitis, though
the inflammation may be of slight extent and to the naked
eye entirely confined to the cerebral meninges.”
He has not found the lumbar puncture of any use for
purposes of treatment. On the other hand, he regards it as
perfectly innocuous. — Ed. Med. Jour., Aug., 1899.
III. DIAGNOSTIC POINTS CONNECTED WITH THE PUPIL.
Contracted Pupil.
1. Miosis from irritation. This condition is normal when
the eye is exposed to light, and when it accommodates ; it is
pathological in —
(ci) Diffuse inflammatory conditions of the brain and its
membranes, which cause a direct stimulation of the
8rd nerve.
(5) Tumours in the neighbourhood of the centre which
presides over contraction (anterior corpora quadri-
gemina), or in the neighbourhood of the centre of
the 3rd nerve, or in its fibres.
( c ) In the first stage of apoplexy, of epileptic, and of
hysterical attacks.
(d) In cases of haemorrhage in the pons.
( e ) After long-continued accommodation (fixing the
eyes upon some work or close to them) caused by
spasm of the muscle of accommodation and of the
sphincter pupillag.
206
Report on Practice of Medicine.
(f) Inflammatory conditions of the anterior portion of
the eye (keratitis, iritis, cyclitis, &c.).
(g) The use of eserin, pilocarpin, muscarin, nicotin,
opium.
2. Paralytic contraction (dependent on the sympathetic
nerve) occurs in —
(a) Injuries, apoplexy, tumours, inflammations of the
cervical cord.
(b) Mediastinal tumours, carcinoma of the oesophagus.
(c) Paralysis of the sympathetic.
Dilatation of the Pupil.
1. Paralytic dilatation (dependent on the 3rd nerve) occurs
in — -
(u) Haemorrhage or tumour in the floor of the aqueduct
of Sylvius.
(h) In diseases which, affect the fibres of the 3rd nerve
anywhere m their course — sinus-thrombosis,
glaucoma, &c.
(c) The use of atropin, duhoisin, daturin, liyoscyamin,
hyoscin, homatropim
(d) Crushing of the eyeball.
2. Spastic dilatation (dependent on the sympathetic) in—
(a) Fright.
(b) Accumulation of C02 in the blood.
(c) In the fully-developed epileptic and eclamptic
attack.
(d) Tumours and inflammations of the spinal cord
(e.g., in the early stage of tabes).
(e) Keflex action from the presence of worms in the
intestine, in lead, and biliary colic.
(y ) In tumours of the neck.
(g) Melancholia and mania.
(h) The use of cocain.
Points about the Papillary Reaction.
1. In miosis due to irritation, light, accommodation,
convergence and eserin cause still greater contraction;
atropin causes dilatation.
207
Report on Practice of Medicine.
2. In miosis from paralysis, light, accommodation, con¬
vergence and eserin cause contraction ; atropin has but
little effect.
3. In paralytic mydriasis there is no reaction with light,
accommodation or convergence ; eserin acts but very
feebly.
4. In spastic mydriasis, light, accommodation, conver¬
gence and eserin cause contraction.
Abnormal Varieties of Pupillary Reaction.
1. Argyll-Robertson pupil occurs in tabes and in general
paralysis ; it occurs, though rarely, in senile dementia,
paranoia, multiple sclerosis, syphilis of the central nervous
system, and epilepsy.
2. Hemianopic pupil-reaction (the pupil contracts when
one half of the retina is illuminated, but not when the light
falls on the other half) points to a lesion between the nucleus
of origin and the chiasma.
3. Cortical reflex of the pupil (Haab) ; the dilated pupil
(the patient being in a dark room) contracts when the mind
thinks of a strong light. — I)r. J. Pfister, Corresponclenzbl. f.
schweitzer Aerzte, 15th Jan., 1899; and Deutsche med.
Zeitung , April 13th, 1899.
IV. ON THE USE OF MAGNESIUM SULPHATE IN DYSENTERY.
Dr. Buchanan (Indian Medical Service) writes an in¬
teresting paper based on 102 cases of dysentery which have
come under his care.
In acute sthenic cases he finds ipecacuanha act like a
charm ; in chronic cases he does not find it useful. On the
other hand, he finds magnesium sulphate of the greatest
value in all kinds of attacks of dysentery. He believes it
acts by washing out the large intestine and thus removing
the causes of inflammation and the inflammatory products.
He uses the following mixture : —
Magnesium sulphate
-
-
§ii
Dilute sulphuric acid
-
—
3ni
Tincture of ginger -
—
—
5iii
Water to
-
-
oviii
And gives 5i-ii of this every one or two hours. It is
208
Report on Practice of Medicine.
necessary to secure free, gentle purgation. As long as the
stools remain yellow and loose or soft, the drug should be
continued for one or two days after the mucus and blood
have entirely disappeared. The quantity may then be re¬
duced. If the stools become thin and watery, the mixture
should be stopped at once.
He believes that if care be taken to keep every case in
hospital till every trace of mucus has for some days com¬
pletely disappeared from the stools, chronic relapsing cases
will be much more rare than they are.
As to diet, he allows boiled milk 1 pint, sago 8oz., and
soup. This low diet is rigorously enforced till the stools
have become solid, and on the first sign of a relapse (a re¬
currence of blood or mucus in the stools) a return is made
at once to sago and milk.
More or less full notes of his 102 cases are given ; in
them the treatment acted admirably, and there was only
one death. — Indian Medical Gazette , No. 12, 1898.
V. LOCAL APPLICATION OF GUAIACOL.
Popow (RussJci Med. Vestnik, Teb., 1899) reports a
number of observations of the action of guaiacol, applied
locally.- In 40 cases of typhoid fever, an average of 7 to 10
drops of guaiacol, either pure or mixed with equal parts of
oil, were rubbed in on the shoulder. This was invariably
followed within an hour by a fall of temperature lasting
from two to three hours, accompanied by excessive1 perspira¬
tion, which weakened the patient to a very great extent.
The pulse also became rapid and weak. In a few cases,
where larger doses were used, the perspiration was followed
by?* quite severe chills. In children, even very small doses
had the same bad effect. In severe cases the temperature
could not be lowered by guaiacol, although perspiration
and chills were produced by even small doses. The same
unfavourable results followed the use of guaiacol in re¬
lapses. In cases of typhoid fever, complicated by catarrhal
and croupous pneumonia, the application of guaiacol was
found to exert an evil influence. In croupous pneumonia
the same pernicious effect was noticed. In erysipelas the
Report on Practice of Medicine. 209
application was made in 23 cases. Here tlie results proved
to be very beneficial. The large doses found necessary by
the author were very well tolerated by the patients, exces¬
sive perspiration and chills being absent. The duration of
the disease was limited to four or five days. In chronic
pulmonary tuberculosis the effect was prejudicial. In acute
rheumatism the only effect noticed wa^ an amelioration of
the pain. The author concludes with the following state¬
ments: 1. Guaiacol, applied locally in fevers, is a powerful
antipyretic. 2. In typhoid fever, croupous pneumonia and
pulmonary tuberculosis, the lowering of the temperature is
followed by perspiration and chills, which weaken the
patient and reduce the heart’s action. Besides, it does not
shorten the duration of the disease. 3. In erysipelas the
application of guaiacol had a favourable influence on the
course of the disease. 4. In acute rheumatism it is a good
local analgesic — Internat. Med. Magazine, , Ap., 1899.
VI. HYDROCHLORIC ACID IN DIGESTIVE DISORDERS.
Hr. Tournier finds hydrochloric acid very useful in cases
of henteric diarrhoea accompanied by diminished acidity of
the stomach contents. These patients had very slightly
accentuated gastric disorders. One observes neither palpi¬
tation nor swelling, neither pain nor flatulence. Gastric move¬
ments are preserved and even exaggerated, and the chemical
analysis alone shows that the fault lies in a lack of acid
m the contents of the stomach. But there is always a lien-
teric diarrhoea occurring generally after each meal' and this
disappears in four or five days under the influence of the
acid fi eatment, although it had resisted all other remedies.
A second gioup of cases, where the use of large doses of
hydrochloric acid produces good results, is constituted by
certain gastric conditions with functional hypochloridia,
which may be obsei\ed in neurasthenic patients, and shows
itself especially in alimentary vomitings with no burning
sensations nor accompanied by soreness. The use of hydro*-
chloric acid in these cases does not fail to control these
vomitings. Lastly, this drug is especially useful in cases of
gastric catarrh with hypochloridia of alcoholic origin, when
the troubles consist more especially of alimentary vomitings,
distensions, sensations of weight after meals, insomnia and
o
210
Report on Practice of Medicine.
loss of appetite. The conditions which might constitute a
formal contraindication to the use of hydrochloric acid are
those in which the gastric troubles are accompanied by a
pronounced hyperesthesia of the mucous membrane of the
stomach for all acids. It is easy to understand the favourable
influence exercised by hydrochloric acid in cases of gastric
catarrh in conjunction with hypoacidity ; indeed, physiology
teaches us that this acid favours the secretion of the gastric
juice, the emptying of the stomach and the disappearance
of mucus ; further, that it acts as an antiseptic, and lastly
that it is an excitant of the pancreatic secretion. It is,
above all, this last property which Tournier invokes in
order to explain the curative action of hydrochloric acid in
cases of lienteric diarrhoea — Internal. Med. Magazine,
Dec., 1898.
VII. REPORT OF THE BACTERIOLOGICAL EXAMINATION OF 52
CASES OF DISEASE OF THE URINARY TRACT.
Dr. Max Melchior from extensive observations arrives at
the following conclusions : —
1. Bacterium coli is the most common cause oi
bacteruria with acid urine.
2. Bacteruria may also be caused by bacteria which de¬
compose urea,
3. Bacteruria may be of renal or of vesical origin.
In the latter case the source of the infection is often the
prostate.
4. The Bacterium coli is the organism which is most
frequently found in cystitis, pyelitis and pyelonephritis.
5. In many cases the cystitis is associated with acid
urine.
6. Even organisms which decompose urea may cause
cystitis with acid urine.
T. In women cystitis not unfrequently arises from infec¬
tion of the bladder with the B. coli per urethram.
8. The B. coli may be overpowered and destroyed by
other urea-decomposing organisms.
9. It appears that the B. coli can be conveyed bv the
blood from the intestinal canal to the urinary tract, and
may then set up cystitis and pyelitis.
10. Urea-decomposing organisms occasionally cause
Report on Practice of Medicine. 211
pyelonephritis, unaccompanied by cystitis, and with acid
urine. — Deutsche med. Zeitung, December 22, 1898.
VIII. ON THE TTSE OF POTASSIUM CHLORATE.
Dr. Henry Ashby (Ed. Med. Jour., January, 1899) calls
attention to the diminished doses of this salt now generally
ordered as compared with those formerly recommended. He
has tried it in scarlatina, diphtheria, tonsillitis, and various
forms of stomatitis, hut cannot say that he has found it of
much, if any, use in any disease except in ulcerative stoma¬
titis ; in this affection its effects are most striking.
Concerning the pathology of this disease, and how far we
can admit its claims to be considered a “ self-standing dis¬
ease, there is not much to be said. It does not occur in
infants prior to the eruption of the teeth : that children who
are attacked are mostly in a low state of health ; and that
this disease appears to be infectious, or, at least, occurs in
small epidemics. \ arious searchers have from time to time
proclaimed the discovery of a specific organism in the dis¬
charges from the gums, the most recent being Bernheim,
u ho, in thirty cases, found a motile bacillus and a spiro-
chsete. It is possible that more than one disease may be
included under the name of “ulcerative stomatitis.”
The attack is ushered in with fever ; there is tenderness
of the gums and teeth, with excessive salivation ; the lesions
are confined to the gums and cheek, and possibly the tongue.
The gums are swollen, often very markedly so; they readily
bleed , a foetid purulent discharge issues from their edges
where they come in contact with the teeth. There is usually,
also,, a sharply cut ulcer, perhaps half an inch to an inch
in diameter, with a yellowish base, opposite the lower molar
of one side ; the ulceration may involve the fissure between
the gums and the cheek, and also the tongue on the corre¬
sponding side. In those cases where there is this form of
stomatitis present in young children who have only cut
their incisor teeth, the only part ;of the gums affected is
that around the teeth, and there may be a yellowish infiltra¬
tion of the surface of the mucous membrane of the lip which
comes m contact. The position of the deep ulcer found
opposite the lower molars is no doubt determined by the
action of the buccinator muscle in chewing. This muscle
212
Report on Practice oj Medicine.
presses the bolus of food between the molars, and the fric¬
tion of the molars against the mucous membrane gives rise
to the ulcer. This friction is the exciting cause, in a
healthy condition of the mucous membrane it does not
occur. The disease occurs equally m children with healthy
as with carious teeth. . . _ ,
In such cases, chlorate of potassium given m o to 5 gr. doses
(child 3 to 7 years) every four or six hours, so that the dai y
dose is 20 to 30 grs., acts like a charm, and in a day or two
a marked improvement is manifest. The ulcer becomes
cleaner, the gums less swollen, the fcetor of the breath dis¬
appears, there is less tendency to bleed, and in a week or so
the child is practically well. The salt appears to be secreted
in the saliva very soon after being taken. It acts better
given internally than applied locally.
,IX. THE TREATMENT OF CORYZA.
Dr. Aassauer (Munich)’ finds that in permanganate
of potassium he possesses an admirable remedy for this
troublesome and common complaint. A little of the pei-
manganate is dissolved in warm water, just enough being-
used to give the solution a faint pink colour. After the
nose has been cleansed fby vigorous blowing the dilute
solution is used as a nose-wash, the solution being
allowed to flow or else injected first into one, then
into the other nostril; it flows out through the rnputh
or through the other nostril. Then the nose is cleansed as
far as possible with cotton-wool dipped in the same solution.
In this way, as far as the cotton-wool can reach, all mucus
and infectious material is removed. Then some dry cotton¬
wool is inserted into each nostril, and while the head is
held backwards the permanganate solution is poured into
the nostrils so as to soak the wool. The plugs are allowed
to remain in the nose for about an hour, and cause no incon¬
venience. They then are easily removed by blowing the
nose. — Klin, therop. Wochenschr ., January, 1899.
PART IV.
MEDICAL MISCELLANY.
- +- -
Reports, Transactions , and Scientific Intelligence.
- — . +. -
Rotes on Four Cases of Syringo-myelia .a By Lewis More
O’Ferrall, L.R.C.P.I. ; L.R.C.S.I.
I purpose bringing forward the notes of four cases of syringo¬
myelia. Three of the cases I have seen myself, the other case was
the first case of the kind ever recorded in Ireland, and was
exhibited by Lrs. Coleman and O’Carroll at the Royal Academy
of Medicine in 1893.
Before, however, going into the notes of the cases in detail it
may be well to briefly describe the commoner clinical features of
the disease, and to say a few words about its pathology, as I am
sure many of us here have never had a chance of seeing a case of
this rare but interesting affection.
The term syringo-myelia was first used over fifty years ago
to designate a condition attended by the formation of cavities
distended with fluid situated in the spinal cord, and the view
was put forward by Virchow and Leyden that these cavities were
always due to a dilatation of the central canal of the cord.
Assuming this hypothesis to be correct, the term hydro-myelia was
suggested as more suitably describing the pathological condition
present. It was soon found, however, that the view held by
Virchow and Leyden was erroneous, and it was moreover dis¬
covered that not only did the cavities form quite independently of
any dilatation of the central canal, but that in some cases the
central canal was itself quite occluded.
These cavities existing in the spinal cord independently of any
dilatation of its central canal constitute the disease which we now
term syringo-myelia, and the cavities may be formed in two
ways — first, by the formation and subsequent breaking down of a
gliomatosis ; and secondly, by a morphological defect in the develop¬
ment of the cord.
The posterior columns of the cord are, I believe, the last to be
aRead before the Medical and Scientific Society of the Medical School,
Cecilia-street, on June 5th, 1899.
214
Four Cases of Sy ring o-my elia.
developed, and in some cases an imperfect development occurs
at this part, which results in the formation of a cavity. In
such cases other developmental defects usually co-exist, such as
an encephalocele or an absence of the cerebellum.
Cases due to primary mal-development are of course congenital,
but cases due to a gliomatosis may not appear until adult life is
reached, or even until a much later period. Traumatism seems also
in some cases to play an important part as a determining factor in
the production of the disease.
So much for the aetiology and pathology of the subject. We
will now turn to its clinical aspect.
The symptoms of this disease are perhaps more diffuse and more
heterogeneous than those of any other known affection which
human flesh is heir to. But for the sake of brevity and intelligi¬
bility I think I may classify them under the following four
headings : —
1. Trophic Changes.— Which include, first, the strange arthro¬
pathies which occur, and which have been compared by some to
the u Charcot joint” which is so characteristic of locomotor ataxy;
and secondly, the formation of “ Mor van’s painless whitlows ,” which
may entirely destroy the phalanges of the fingers and cause them
to drop off without pain.
2. Sensory Disturbances. — Under this heading we get a sign
almost pathognomonic of syringo-myelia and known by the term
sensory dissociation .” It is that while the patient retains a perfect
sense of ordinary tactile sensation, yet over certain areas he entirely
loses his sense of pain , and his sense of distinguishing the temperature
of bodies. If pricked with a pin he will feel the pin as a touch, but
will experience no pain while the pin is being driven through his
flesh, and he may also be badly burnt over the areas where this
phenomenon of sensory dissociation exists without feeling the
least pain or being in any way conscious that he is being burnt.
3. Muscular Atrophies.— Under this heading we get an example
of the heterogeneous nature of the disease, for we find various
groups of muscles atrophying which have no known nerve supply
in common, and which apparently have no direct connection with
one another, probably due to direct pressure upon the anterior
cornua or to an interference with the blood supply to the cells in
the anterior cornua.
I may mention that these signs of muscular atrophy, as also the
other phenomena of the disease, are chiefly confined to the upper
limbs, for the simple reason that the cavities in the cord are for
the most part in its cervical region, and hence the lower limbs are
215
Four Cases of Syringo-myelia.
not implicated. If, however, cavities do form low down in the cord,
then the lower limbs become affected in an exactly similar manner
to the upper ones, and the sphincters may be engaged. Of course
when cavities form in the cervical region their pressure when
distended with fluid upon the lateral columns of the cord may
cause a descending sclerosis, and in such a case we should get
spastic symptoms in the lower limbs. This may be only unilateral,
or we may get complete “spastic paraplegia.” A gliomatosis
spreading up may also produce a form of vulvar paralysis.
4. Spinal Deformity. — Under the fourth heading is scoliosis , or
lateral curvature of the spine. This phenomenon is present in only
50 per cent, of the cases, and where present is almost invariably to
the right side in the dorsal part of the cord. It in all respects
corresponds to the ordinary form of scoliosis so often met with in
young and debilitated females, from 15 to 18 years of age.
With regard to differential diagnosis — The onset of the disease is
more gradual and its course more chronic than would be that of
a tumour or of haemorrhage, and it is too painless for a pachy¬
meningitis. In countries where leprosy exists this may sometimes
resemble clinically a case of syringo-myelia.
The prognosis is bad. It may be extremely chronic, but is
slowly progressive to a fatal termination. Treatment is of no
avail. The disease is commoner in males than females.
Having now given a short description of the clinical features of
the disease and mentioned its probable patholog}r, I will briefly run
over the notes of the four cases which have come under my notice.
Case I., I had not myself an opportunity of seeing, but as it is
the first case of the kind which was ever recorded in Ireland, I
thought it might be of some interest to you to hear the history of
it. The case was brought before the Royal Academy of Medicine
in Ireland in December, 1892, by Drs. Coleman and O’Carroll, and
an account of it was published in the Transactions of the Academy
for the following year.
The case was that of a man thirty-six years old, with good personal
and family history, who in 1880 got a bad fall and said he felt
something give way at the time. He also momentarily lost his
sight, and experienced some pain along the intercostal nerves.
In 1888 his right hand got swollen and he lost fine feeling in it.
He was a clerk at this time, and, as he described it, he had to watch
his pen while writing or it would slip from his fingers.
When exhibited at the Academy he presented the following
features : —
216
Four Cases of Syringo-myelia.
Right Leg. — Somewhat spastic; knee jerks increased; ankle
clonus slightly present.
Left Leg. — Not spastic ; slightly increased reflexes.
Sensation was perfect in both legs.
Clonus could be elicited in his fingers, and he experienced great
loss of power in his arms and hands. The upper part of his right
trapezius muscle was completely atrophied, probably, I should say,
from the implication of the spinal part of the spinal accessory nerve
by the spinal lesion. Electrical reaction to the faradic current
lessened, but no reaction of degeneration. There were definite
areas of anaesthesia and analgesia, and athermia (or loss of
temperature sense). His muscular sense, telling him the position
of his limbs, was also impaired in his right arm. His pupils were
normal and his sight good.
Case II. — This was the case also of a man. He was under the care
of Dr. M‘Hugh in St. Vincent’s Hospital a few years ago, and I
think I cannot do better than describe the case in Dr. M4Hugh’s
own words : —
“ The patient, R. B., is a native of the County Mayo, by occu¬
pation a farmer, and twenty-five years of age. His family history
presents no noteworthy feature, and up to his twentieth year his
health seems to have been good, his only illness having been an
attack of measles, which was followed by a delicacy of the respira¬
tory organs. Between four and five years ago, however, he met
with a serious accident, which consisted in a bad fall from a horse.
His foot caught in the stirrup, and he was dragged for a consider¬
able distance along the ground. When picked up by his friends
he was unconscious. He quickly recovered, however, from the
more immediate effects of his fall, but soon afterwards noticed that
his back was getting weak, and that he was not able to lift weights
or to carry sacks on his shoulder as well as before. This weak¬
ness gradually increased, and about a year after the accident he
began to experience pains, sometimes very acute, in his bones and
joints. These were particularly noticeable in his hip-joints, and
he attributes his difficulty of gait to stiffness of these joints. As
time passed these pains disappeared, and the peculiar changes in
his fingers (painless whitlows) became noticeable. The patient
attributed them to injuries received while at work, but he observed
that they showed no tendency to heal, and he therefore consulted a
doctor about them. They caused him little or no pain, and he also
found at this time that he could bear pain much better than other
people.
217
Four Cases of Syringo-myelia.
“The patient’s hands exhibit trophic lesions of a symmetrical
character, the terminal phalanx of the middle finger, with the soft
parts, having been completely lost on the right side and very nearly
so on the left, whilst many of the fingers present scars not unlike
those seen in Raynaud’s disease. The nails were not partially or
completely destroyed, present transverse grooving, and the skin
of the palmar surface of the fingers is marked by deep fissures
principally at the junction with the palm. Many of the phalanges
present remarkable thickening, suggestive at first sight of acro¬
megaly, and this is especially noticeable in the proximal phalanges
of the middle finger of both hands. The interossei muscles show
also considerable wasting. The mutilation of the digital extremities,
combined with the hypertrophy of the phalanges and the wasting
of the interosseous muscles, gives to the hands a most peculiar and
characteristic appearance.
“ The muscular wasting is not confined to the hands, but is also
marked in the deltoids and other scapular muscles and in the lower
portions of the trapezii, especially on the left side. The muscles,
however, respond to faradic stimuli, though not as readily as in
health. The vertebral column presents marked lateral curvature in
the dorsi-lumbar region, the convexity being directed towards the
right, and there is a compensatory curve in the cervical region. On
examining the lower extremities the knee jerks are found to be
greatly exaggerated, whilst ankle clonus and rectus clonus can
be readily evoked on both sides. Muscular rigidity is not demon¬
strable, and the gait is not very characteristic. The patient has
difficulty in walking, but can cover a mile, he says, in half an
hour.
“ The cutaneous sensibility presents very remarkable alterations,
showing typical sensory dissociation. In the hands, as elsewhere,
tactile sensation is unimpaired, but when needles are driven
through the skin, or when it is blistered with hot wires, no pain is
experienced by the patient, who has, in fact, frequently burned
himself from having unconsciously touched hot objects. I may
here mention that the whitlows which produced the loss of his
finger tips were almost altogether painless. This analgesia, though
best marked in the upper extremities, has been found to extend
over a considerable area of the body, and is accompanied with loss
of heat and cold sensations — at all events within certain limits.
Owing to the inexact means at our disposal I have had some diffi¬
culty in the exact delimitation of the areas of combined analgesia
and thermo-anessthesia. Both are, however, widely and symmetri¬
cally distributed, extending from the occipital region downwards to
218
Four Cases of Syringo-myelia.
the knee-joints. All forms of sensibility are present only in the
skin of the face and in that below the knees. Touch sensibility is
universally present, and there is no hyperaesthesia discoverable
anywhere.
“ The patient’s vision and speech are unaffected. His eyes have
been carefully examined by Mr. Odevaine, who has failed to
discover any deviation from the normal in them. There is also a
complete absence of ataxic symptoms, of vaso- motor disturbances
and of visceral lesions.”
Case III. — This was the case of a woman who had noticed the
disease first in very early life, and who exemplified all the ordinary
clinical features of the disease, except the one of u sensory dissocia¬
tion,” which, in her case, could not be satisfactorily demonstrated.
Case IV. — The fourth and last case was a boy, C. S., aged seven¬
teen, who was exhibited the other day at the Royal Academy of
Medicine by Dr. Coleman. This disease was congenital. He was
a typical example of the disease showing the following points : —
Nervous and painless whitlows ; sensory dissociation ; symmetrical
arthropathies, especially of elbow joints ; spastic gait ; muscular
atrophy and weakness ; sepliosis, with dorsal curve to right side.
In connection with this case it may be interesting to note that it
was first diagnosticated in London in its earlier stages as a case of
“ progressive muscular atrophy,” and certainly the deformities
produced in his hands would have led one easily into making this
mistake. Later on the boy went to America, and there the case
was diagnosticated as a case of amyotrophic lateral sclerosis, which,
I believe, is held by Cowers to be only a form of progressive
muscular atrophy, while other authorities, such as Charcot and
Talar, hold that it is a distinct and separate disease.
In conclusion, for the benefit of those who may be interested in
this subject, I will just mention a few works of reference, where
all further information about this strange affection may be
obtained —
BIBLIOGRAPHY.
Westphal. Brain. 1883.
Roth. Archiv de Neurologic. 1889.
Starr. American Journal of Med. Science. 1889.
Van Gieson. Journal of Nervous and Mental Disease. 1889.
I. C. Shaw. New York Med. Journal. 1890.
Blocq. Brain. 1890.
J. Hendric Lloyd. Univ. Med. Magazine. March, 1893.
Transactions of the Royal Academy of Medicine in Ireland. Yol. XI.
1893.
ROYAL ACADEMY OF MEDICINE IN IRELAND.
President — Edward II. Bennett, M.D., F.R.C.S.I.
General Secretary — John B. Story, M.B., F.R.C.S.I.
SECTION OF MEDICINE.
President — John W. Moore, M.D., President of the Royal
College of Physicians of Ireland.
Sectional Secretary — R. Travers Smith, M.D.
Friday , April 14, 1899.
The President in the Chair.
Diseases of the Suprarenal Capsules.
Dr. J. B. Coleman made a communication on the subject of
diseases of the suprarenal capsules, and exhibited the viscera and
microscopic sections of two cases, of which he narrated the clinical
history. One case presented the classical symptoms of Addison’s
disease, and it occurred in a girl aged twenty-six years, the duration
of the disease being three years. Both suprarenal capsules were more
than double the normal size, and were a mass of fibrocaseous material,
containing giant cells and tubercles ; sections of the skin showed
brownish-yellow pigment in the cells of the rete mucosum ; the
heart weighed only five ounces ; in the duodenum close to the
pylorus there were pin-head-sized greyish nodules, due to hyper¬
plasia of lymphoid tissue around the gland tubules. The other
case was one of primary sarcoma of the suprarenal bodies, the
patient being a man aged twenty-three years, who presented none
of the symptoms of Addison’s disease. For three months before his
death he suffered from epileptiform fits and from weakness of his
limbs ; on admission to hospital he presented the signs of ataxic
paraplegia ; after a debauch he rapidly passed from a drowsy con¬
dition into collapse and coma ; the necropsy showed both adrenals
uniformly enlarged to the size of a man s fist, the growths consist¬
ing of round-celled sarcoma ; there was a secondary growth about
the size of a cherry in the wall of the right auricle 5 no tumours in
the brain or cord ; the cord showed degeneration in the motor tracts
and in the posterior columns. Dr. Coleman suggested that the
220 Royal Academy of Medicine in Ireland .
epileptiform fits and the degeneration in the spinal cord were the
result of a toxaemia, the latter being due to the diseased condition
of the adrenals ; under the depressing influences of the debauch the
terminal symptoms were set up — drowsiness, collapse, and coma.
Dr. R. Travers Smith spoke.
Dr. Finny pointed out that great destruction of the suprarenals
could take place without any of the symptoms of Addison’s disease
supervening. There was also a group of cases which presented all
the evidence of suprarenal melasma, while a necropsy showed that
the suprarenals were perfectly healthy. He himself had an example
of the latter group under his care. The patient was suffering from
tubercular disease, but the suprarenals were unaffected. He there¬
fore thought it probable that the disease was due to some affection
of the large nerve elements in the neighbourhood rather than to
structural changes in the gland itself.
The President said that, as had been shown, there were three
groups of cases — namely, disease of the suprarenals and pigmenta¬
tion, disease without pigmentation, and pigmentation without
disease.
Dr. Coleman, in reply, said he thought Byrom BramwelFs
theory the safest, in which he combined the suprarenal inadequacy
and the nervous theory.
Cases of Pyloric Obstruction.
Dr. Parsons read a paper on the above subject.
The President, Surgeon Croly, Mr. G. J. Johnston, and
Dr. Langford Symes discussed the paper.
Chronic Pharyngitis.
Mr. Robert Woods read a paper on chronic pharyngitis and
its relation to nasal obstruction, in which he expressed his belief
that mouth-breathing was the essential cause of chronic simple
inflammations of the throat. He reviewed the chief functions of
the nose, and pointed out how in mouth-breathers the disuse of
the special apparatus for modifying the air, by warming, moisten¬
ing, and filtering from dust, must affect the throat injuriously,
since the throat was compelled to take on the function of the nose.
In support of this contention he quoted an observation he had
repeatedly made, that in these cases of chronic pharyngitis, if the
velum palati be lifted, the pharynx wall under cover of it will be
found normal. In addition to the more familiar forms of nasal
obstruction, he drew attention to a common condition of the nose
where the passage, though free enough in the daytime, became
221
Section of Surgery.
stopped at night. This results apparently from the difference in
level of the head between the upright and horizontal positions,
there being less drainage, and, therefore, greater tendency for the
congested soft tissues to encroach on the air-space in the horizontal
than in the upright. The paper concluded with a short account of
the operative nasal treatment necessary for the cure of the con¬
dition.
The Section then adjourned.
SECTION OF SURGERY.
President — R. L. Swan, President of the Royal College of Surgeons
in Ireland.
Sectional Secretary — John Lentaigne, F.R.C.S.I.
Friday , April 7 , 1899.
The President in the Chair.
lief s Internal Derangement of the Knee-joint.
Dr. Knott read a communication on this subject, in which he
made emphatic objections to the generally received view that this
lesion was a displacement of one of the semilunar fibro-cartilages
of the articulation. He described the signs and symptoms of the
condition as it had frequently occurred in his own person, and
compared them with the original description of Hey, and the sub¬
sequent accounts of other recognised authorities on the same
subject. Dr. Knott’s own view was that a subluxation of the
corresponding condyle of the femur took place, the joint then
becoming “ locked,” with the articular surface of the condyle
“ over-riding ” the prominent margin of the inter-articular fibro-
cartilage.
Mr. Lentaigne discussed the communication, and alluded to the
apparatus recommended by Mr. Shafter.
Mr. T, Myles thought that the most striking feature of the
descriptions in the text-books of this injury was the apparent total
ignorance of the ordinary elementary anatomy of the knee-joint.
He had seen a considerable number of cases. In two cases he opened
the joint expecting to find a loose cartilage, but found a peduncu¬
lated cartilage in the knee-joint. One case had a history pointing
to displacement of the internal semilunar cartilage, but he found
a small pedunculated cartilaginous body, growing from the front of
the joint, projecting between the condyle and tibia. On two other
222
Royal Academy of Medicine in Ireland.
occasions he found the anterior attachments of the internal semi¬
lunar cartilage completely torn away. In every case in which he re¬
moved a piece of the cartilage the patient always complained of
permanent weakness in the joint. Skiagrams of the affection he
considered to be most misleading and absolutely futile, and the
length of the ligamentum patellae would be compensated for by the
increased contraction of the quadriceps extensor.
Mr. R. C. B. Maunsell had removed a semilunar cartilage a
year ago from a girl’s knee. She had complained for several years
of recurrent attacks of the dislocation. Recovery was rapid, and
patient now perfectly strong.
Mr. Croly said that he had seen some important cases of this
condition. One case, a gentleman, came to him with one knee
slightly hexed and hopping on the good leg ; his knee-joint was
“ locked.” Extension, followed by sudden flexion, gave instant relief,
and the patient insisted on walking home. The interesting thing was
the slight violence causing the affectiou, but that applied to all dis¬
locations. The joint was locked in all the cases he had seen. The
reason why the external cartilage was not displaced was that the
popliteus tendon tied it so tightly in its groove. He thought there
was a difference in symptoms of loose cartilage and this affection.
The former caused a sickening sensation within the knee itself,
whereas the latter caused intense pain over the line of the internal
semilunar cartilage. He thought that Mr. Maunsell was very
fortunate in the case where he had removed the cartilage, but he
did not approve of the proceeding.
Dr. Knott, in reply, said that he believed the apparatus men¬
tioned by Mr. Lentaigne to be very good for converting the knee
into a hinge joint. He agreed with Mr. Myles regarding the
misleading character of the skiagrams. It was a remarkable fact
that direct cutting of ligamentous structures is attended with com¬
paratively slight pain, whereas stretching a ligament is most painful.
Regarding Mr. Maunsell’s case, it was beyond his comprehension
how a perfectly sound knee was left.
Advancement of the Recti Muscles of the Eyeball.
Mr. Story described the method of advancing the recti muscles
in the treatment of strabismus, which he had devised more than
three years ago, and had considered to be his own peculiar property
till a publication in the “ Annales d’Oculistique ” had informed
him that the essential point in his operation had been anticipated,
so far as publication is concerned, by Valude. The essential point
is splitting the tendon longitudinally, and suturing each half of it
223
Section of Surgery .
separately to the conjunctiva or sclerotic. Each half is engaged in
a loop of suture lying at right angles to the direction of the fibres
of the tendon, and the knots are tied over glass beads to prevent
the sutures cutting too rapidly through the conjunctiva. The
modification of splitting the tendon has also been described by
Praun in September, 1898, as a novelty. Valude’s description
appeared in August, 1896.
Mr. Benson had seen Mr. Story perforqi the operation and was
impressed by the satisfactory results. lie himself had employed
a modification of Schweigger’s operation, and frequently shortened
the tendon rather than advance it to the edge of the cornea, and
had been well satisfied with the results. In his modification of
Schweigger’s operation it was necessary, in order to avoid strain
on the sutures, to put in an anchor suture. The pulley operation
was a most abominably complicated thing to do. He thought it
probable that for the majority of cases the operation described by
Mr. Story would answer the purpose better than any other single
operation.
Mr. Maxwell said that Mr. Story’s seemed a good operation.
In Mr. Swanzy’s operation, the tying of the knot round the tendon
and the subsequent burying of that knot was a very grave draw¬
back, as the suture was removed afterwards with great difficulty.
However, in Mr. Swanzy’s operation the tendon was really split.
Shortening operations and advancement operations had practically
the same ultimate results. When a tendon is advanced it is not the
cut end alone which unites to the eyeball, but the conjunctiva
having been raised up from the globe, a raw surface is left below
and above, and the tendon becomes adherent to that raw surface at
the level of its division. to the eye. The great objection, he thought,
in almost all operations, is that the tendon is divided, and if any
slipping should occur, the patient’s condition is worse than formerly.
Another objection is that the suture is inserted into the tendon at
one side, which is firm enough provided the thread is carried across
the tendon, but the other end is inserted into the conjunctiva,
which is soft and delicate and easily torn. He described a method
of his own to obviate slipping, in which tendon was stitched to
tendon and the muscle was not divided at all, and even if slipping
should occur, the original condition would remain.
Mr. Croly also remarked on the communication.
Mr. Story, in reply, said he was sure that Mr. Maxwell’s was
a very good operation. There was not the same chance of one of
the sutures giving way in his operation as in many of the other
operations, because the only pull in his operation was directly along
224 Royal Academy of Medicine in Ireland.
the tendon to the conjunctiva. The same pull occurred on the
opposite side of that tendon, but in other operations where the
tendon was not divided into two, and where there is a pull from
one side of the tendon, the lower suture actually pulled on the upper
one, and there is a much greater chance for the sutures to cut
through. Dr. Valude’s reason for introducing the practice of
splitting the tendon was because he found it was only those of the
older operations were successful in which the tendon split accident¬
ally. He himself had never noticed the tendon split during the
operation.
The Section then adjourned.
SECTION OF OBSTETRICS.
President — F. W. Kidd, M.D,
Sectional Secretary — John H. Glenn, M.D.
Friday , April 21, 1899.
The President in the Chair.
Exhibits.
Dr. John Campbell (Belfast) — (a) Carcinomatous uterus removed
by vaginal hysterectomy ; ( b ) a dermoid cyst of the ovary removed
by abdominal section ; ( c ) an ovarian cyst removed by abdominal
section.
Dr. Purefoy — A case of pyosalpinx.
Dr. Glenn exhibited a pathological specimen of carcinoma of
the body of the uterus, with microscopical sections of secondary
nodules from the lungs, prepared by Dr. Earl.
Two Years Work at the Samaritan Hospital for Women , Belfast.
Dr. John Campbell read a paper on above.
History. — The Samaritan Hospital for Women, Belfast, was
founded in 1872 by the late Dr. W. K. M‘Mordie. The present
building was erected in 1874, through the munificence of the late
Mr. Edward Benn. In 1898 Mr. Forster Green generously added
two cancer wards.
Accommodation. — The hospital contains 30 beds, as well as nurses’
apartments. Of these, 8 are in the isolation wing and are devoted
to the treatment of cancer and septic cases.
Admission of Patients. — All comers are examined without question.
Each patient is then handed an appropriate form filled up, and is
Section of Obstetrics. 225
requested to submit it to her doctor, in order that he may either
himself carry out the treatment suggested, or sign the annexed
recommendation and send her back to hospital for treatment. This
system works well and throws the responsibility of conniving at
hospital abuse on the members of the local medical profession.
Preparation for Operations. — Patients are well scrubbed with soap
and water, and wear boric compresses over the seat of operation
for three or four days beforehand. The day before operation
the field is well washed with soap and water, rubbed with turpen¬
tine, again washed with soap and water, and finally washed
with 1 in 1,000 sublimate solution, and covered by a compress
wrung out of the same. This preparation is repeated on the
morning of the operation day. Septic cases are, as far as possible,
excluded from the operation room. Sterilisation by boiling is
carried out in regard to everything to which it can be applied. The
hands are cleansed by thorough washing, followed by washing in
turpentine, and. again in soap and water. They are then put
through the permanganate and sublimate processes in succession.
India-rubber gloves are used if a septic case has been recently
handled. The gloves are boiled.
Ancesthesia. — Chloroform is given by Junker’s inhaler. Sickness
in a patient is regarded as indicative of returning consciousness and
< >f incompetence on the part of the anaesthetist. -By the sponge and
towel methods the patient is alternately half -poisoned and half-
conscious.
Flushing the abdomen is done in tubercular peritonitis and cases
in which glairy fluid has escaped into the abdomen.
Drainage is used after flushing, in cases where much peritoneal
fluid has been present, and in cases in which pus has escaped. The
current of opinion has now set in too strongly against drainage. A
glass tube with a gauze wick is to be preferred, and the bed-head
should be raised. Small gauze drains float on the intestines.
Large ones prevent the bowels from resuming their natural position.
A rigid tube keeps the gauze in the pelvis.
Dressings. — Sterilised gauze is used for most cases. Iodoform is
used for wounds which are drained.
Post- operative Treatment.— Morphia is, if possible, avoided. One
half grain hypodermic may be given if pain is severe. The amount
of fluid allowed depends on the amount of vomiting present.
Duiing 189 /-98 forty-four intraperitoneal operations were per¬
formed in the Samaritan Hospital by Dr. John Campbell, namely;—
I. Iwenty ovarian tumours, including 16 ordinary cysts, three
dermoids, and one solid tumour. The patients’ ages varied
P
'226 Royal Academy of Medicine in Ireland.
from 21 to 65. In three cases both ovaries were removed ; in
four one ovary was removed and the other resected. In one
case a fcecal fistula was present for a fortnight, and in one
phlebitis occurred in the left leg after puncture of small
cysts in the corresponding ovary. All the patients re¬
covered.
II. Diseases of the tubes were operated on in three cases. In one
the tubes were catheterised; in another a four months’ foetus
was removed from the right broad ligament ; and in one a
tumour of myomatous appearance was removed from the
inner end of a tube, the outer end of which was dilated and
contained fluid like menstrual blood.
III. A fibro-cystic tumour independent of the tube and ovary,
and not obviously connected with the uterus, was removed
from the right broad ligament. It weighed 20 lbs.
IV. Fibro-myomata of the uterus were operated on nine times.
Four were abdominal operations, done by the intraperitoneal
method ; two were vaginal hysterectomies ; one was
amputation of a large subperitoneal fibroid ; one was an
enucleation after abdominal section ; and one was an ex¬
ploratory incision, in which the appendages could not be got
out, and the patient could not stand panhysterectomy. The
enucleation case died of shock ; the others all recovered.
V. One case of cancer of the corpus and one of cancer of the
cervix uteri were successfully removed by vaginal
hysterectomy.
VI. A case of prolapse and one of retroversion were treated by
vagino-fixation, with good result in both cases.
VII. Tubercular peritonitis was incised and drained twice. The
case in which there was much fluid appears to be cured ;
the other was not benefited.
VIII. A hydronephrotic kidney and a tubercular kidney contain¬
ing abscesses were removed with success.
IX. Gastrostomy for cancer of the oesophagus was done once
with excellent result. The vermiform appendix was once
removed. A cancerous caecum was exposed with the view
of making a faecal fistula and excising the growth when the
patient had recovered from the effects of the intestinal
obstruction caused by the growth, but she died exhausted
after the preliminary operation.
The mortality of these 44 cases was 4^ per cent., as good an
average as can be expected, if operations on so many different
abdominal organs are taken together.
22 7
Section of Obstetrics.
I he following form is signed by patients needing dangerous
operations. On it the operator writes his opinion as to the nature
)f the disease, as to the amount of danger the operation entails,
and as to the possible effect of it on menstruation and pregnancy.
The patient and a near relative must sign it : —
“ We> the undersigned, do hereby request Dr. John Campbell to
k< undertake the treatment of
and to pei form whatever operation he may think necessary.
u Name,
“ Address,
“ Name,
“ Address,
“ Date, „
I he minor operations require no special mention ; none of them
was followed by death.
I he President expressed his approval of the printed forms
which patients were asked to sign before undergoing an operation.
He thought that gloves should be used in operations only when they
suspected that they could not render their hands completely aseptic.
He did not agree with Dr. Campbell’s opinion that all the dangers
of chloroform were due to maladministration. When chloroform
was administered guttatim he had seen no ill effects. Dr.
Campbell’s mortality of 4*5 per cent, was very satisfactory.
Dr. Smith said he had practically given up drainage. He be¬
lieved that after a few hours no drainage took place, since a layer
of protective lymph was thrown out round the tube which acted as
a foreign body. Moreover, a solid drainage tube pressing against
the rectum was capable of causing a fistula. The operation he
preferred was retro-peritoneal hysterectomy, which gave excellent
results.
Mr. M^Ardle, referring to pelvic pain remaining after removal
of the tubes and ovaries, said that nearly all the abdominal viscera
reflected pain to the pelvis after laparotomy. It was not uncommon
m gouty affections of the kidneys to have the pain referred to the
pelvic region, and in many instances of spinal lesions the chief pains
were pelvic. He strongly advocated the intraperitoneal method of
opeiating, and considered drainage of the peritoneal cavity unneces¬
sary, except where there was some intestinal lesion or some infec¬
tion of the peritoneal cavity. He did not believe there was any
need of the printed form to be signed by patients about to undergo
operation.
Dr. Maca* agreed with Surgeon M‘Ardle’s last remark about
the printed form which Dr. Campbell had shown them.
228 Royal Academy of Medicine in Ireland.
Dr. Purefoy said lie was one of those who practised diainagc,
but he had never used a rigid tube. The gauze drain, in the foim
of a Mikulicz’ bag, or otherwise, he was satisfied was of the utmost
use.
Dr. Campbell, replying, said he believed that sudden death
during the administration of chloroform was generally due to the
use of a too concentrated solution. With regard to drainage, it
was quite true that it was useless after a few hours, but it was
during those few hours that it was especially required. He con¬
sidered the vaginal method of operating on fibroids the best, when
it could be done. The printed form he had shown them was
designed to show the patient that operation was indeed the lesser
evil.
On Uterine Cancer and its Treatment.
Dr. More Madden read a paper on this subject. [It was
published in the number of this Journal for June, 1899, Yol. C VII.,
page 401.]
The President said there were many conditions which re¬
sembled the initial stage of uterine carcinoma. A microscopic
examination was, therefore, always desirable. He had performed
vaginal hysterectomy on 7 patients for malignant disease. Four of
them, at least, he knew to be still alive.
Surgeon M4Ardle said with reference to removal of the glands
with the uterus and appendages, he had never yet seen thorough
removal of the retro-peritoneal glands. In operations for tubercular
disease of the vermiform appendix it was his custom to rip up the
peritoneum and remove the glands involved. *
Dr. Alfred Smith said sufficient stress was not laid upon rectal
examination for the purpose of determining infiltration of the
surrounding tissues, tie thought that the best chance for the patient
was offered by the abdominal method of operating, if there was any
doubt about the case.
Dr. Purefoy said that when he recognised malignant disease in
the uterus his inclination was to remove the whole organ.
Dr. More Madden replied.
The Section then adjourned.
!
SANITARY AND METEOROLOGICAL NOTES.
Compiled by J. W. Moore, B.A., M.D. Univ. Dubl. ;
P.R.C.P.I.; F. R. Met. Soc. ;
Diplomate in State Medicine and ex-Sch. Trin. Coll. Dubl.
Vital Statistics
For four Weeks ending Saturday , August 12, 1S99.
The deaths registered in each of the four weeks in the twenty-
three principal Town Districts of Ireland, alphabetically arranged,
corresponded to the following annual rates per 1,000 : —
Towns,
Ac.
Week ending
Aver¬
age
Towns,
&c.
Week ending
Aver¬
age
July
22
July
29
Aug.
5
Aug.
12
Rate
for 4
weeks
July
22
July
29
Aug.
5
Aug.
12
Rate
for 4
weeks
23 Town
20-3
220
24*7
24-9
230
Limerick
11-2
16-8
26-7
14-0
17*2
Districts
Armagh -
71
28-5
21-4
42*8
24-9
Lisburn
o-o
12-8
8-5
17-0
9-6
Ballymena
16-9
16-9
22-5
11-3
16-9
Londonderry
9*4
22-0
17-3
14T
15-7
Belfast
22-2
20-6
23-2
24-6
22-6
Lurgan
18-2
4-6
22-8
22-8
17T
Carrickfer-
23-4
23-4
o-o
17-5
16-1
Newry
28-2
81
12-1
12 J
1ST
gus
Clonmel -
9-7
9-7
14-6
19-5
13-4
Newtown-
ards
227
11-3
17-0
11-3
15-0
Cork
201
21-5
24-9
23'5
22*5
Portadown -
12-4
24-7
18-6
o-o
13*9
Drogheda -
38*0a
11-4
22-8
19-0
22-8
Queenstown
17-2
17-2
57
28*7
17-2
Dublin -
21-5
26-7
32-2
31-5
28-0
Sligo
10-2
40-6
o-o
10-2
153
(Reg. Area)
Dundalk -
25-1
12-6
8-4
16*8
15-7
Tralee
16-8
16-8
11*2
28'0
18-2
Galway
7-6
26-4
11-3
18-9
161
Waterford -
23*9
13-9
27-9
19-9
21*4
I^ilkenny -
l
18-9
37-8
9-4
33-0
24-8
W exford
27T
18T
18-1
9-0
18T
In the week ending Saturday, August 12, 1899, the mortality
in thirty-three large English towns, including London (in which the
rate was 23#7), was equal to an average annual death-rate of 24*3
per 1,000 persons living. The average rate for eight principal
towns of Scotland was 17’9 per 1,000. In Glasgow the rate was
10*7. In Edinburgh it was 18T.
a Owing to alterations in boundaries, registration was suspended in one of
the Drogheda districts during the weeks ended 8th and 15th July respectively.
230 Sanitary and Meteorological Notes.
The average annual death-rate represented by the deaths regis¬
tered during the same week in the Dublin Registration Area and
in the twenty-two principal provincial Urban Districts of Ireland
was 24*9 per 1,000 of their aggregate population, which, for the
purpose of this return, is estimated at 1,053,188.
The deaths from the principal zymotic diseases in the twenty-
three districts were equal to an annual rate of 5*3 per 1,000, the
rates varying from 0*0 in fourteen of the districts to 14*3 in
Armagh — -the 6 deaths from all causes in that district comprising
2 from diarrhoea. Among the 165 deaths from all causes registered
in Belfast are 3 from measles, 5 from whooping-cough, 1 from
diphtheria, 1 from simple continued fever, 6 from enteric fever,
and 15 from diarrhoea. The 34 deaths in Cork comprise 2 from
measles and 3 from diarrhoea. Two of the 24 deaths in London¬
derry were caused by diarrhoea, as were also 2 of the 10 deaths in
Waterford and both of the 2 deaths registered in Ballymena.
In the Dublin Registration Area the births registered during
the week amounted to 205 — 87 boys and 118 girls ; and the deaths
to 214 — 114 males and 100 females.
The deaths, which are 59 over the average number for the
corresponding week of the last ten years, represent an annual rate
of mortality of 31*9 in every 1,000 of the population. Omitting
the deaths (numbering 3) of persons admitted into public institu¬
tions from localities outside the area, the rate was 31*5 per 1,000.
During the thirty-two weeks ending with Saturday, August 12,
the death-rate averaged 27*9, and was 0T over the mean rate for
the corresponding portions of the ten years 1889-1898.
The number of deaths from zymotic diseases registered during
the week was 70, being 1 under the number for the preceding
week, but 37 in excess of the average for the 32nd week of the
last 10 years. The 70 deaths comprise 9 from measles, 1 from
typhus, 3 from whooping-cough, 2 from diphtheria, 4 from enteric
fever, 6 from simple cholera and choleraic diarrhcea, 43 from
diarrhoea (being 24 in excess of the average number of deaths from
that cause in the corresponding week of the last ten years, and 4 over
the number for the previous week), and 1 from erysipelas. Sixty
of the 70 deaths from zymotic diseases — including all of those from
measles and whooping-cough, and 46 of the deaths from diarrhoeal
diseases — occurred among children under 5 years of age, those from
diarrhoeal diseases comprising 34 of infants under 1 year old.
The cases of measles admitted to hospital during the week were
44, being 14 over the admissions in the preceding week, but 31
under the admissions in the week ended July 29. Fifty-three
Sanitary and Meteorological Notes. 231
measles patients were discharged, 5 died, and 120 remained under
treatment on Saturday, August 12, being 14 under the number in
hospital at the close of the preceding week.
Eleven cases of scarlatina were admitted to hospital against 10
admissions in each of the two weeks preceding : 12 patients were
discharged, and 49 remained under treatment on Saturday, being 1
under the number in hospital on Saturday, August 5. This number
is exclusive of 24 convalescents under^treatment at Beneavin,
Glasnevin, the Convalescent Home of Cork-street Fever Hospital.
The weekly number of cases of enteric fever admitted to hospital,
which, after having fallen from 11 in the week ended July 22, to
6 in the following week, rose to 12 in the week ended August 5,
further rose to 29. Eleven patients were discharged, 1 died, and
70 remained under treatment on Saturday, being 17 over the
number in hospital at the close of the preceding week.
The hospital admissions for the week included, also, 3 cases of
diphtheria : 8 cases of this disease remained under treatment in
hospital on Saturday.
Nineteen deaths from diseases of the respiratory system were
registered, being 5 over the average for the corresponding week of
the last ten years, and 1 over the number for the preceding week.
They consist of 12 from bronchitis and 7 from pneumonia.
Meteorology.
Abstract of Observations made in the City of Dublin , Lat. 53° 20;
A-., Dong. 6° 15' W.^for the Month of July ? 1899.
Mean. Height of Barometer, - 30*086 inches.
Maximal Height of Barometer (on 31st, at 9 a.m.), 30*471 ,,
Minimal Height of Barometer (on 1st, at 9 a.m.), 29*439 ,,
Mean Dry-bulb Temperature, - - 6T1°.
Mean Wet-bulb Temperature, - - 58*1°.
Mean Dew-point Temperature, - - 55*5°.
Mean Elastic Force (Tension)of Aqueous Vapour, *440 inch.
Mean Humidity, - 82*6 per cent.
Highest Temperature in Shade (on 5th), - 74*9°.
Lowest Temperature in Shade (on loth), - 49*1°.
Lowest Temperature on Grass (Radiation) (on
13th), -
Mean Amount of Cloud,
Rainfall (on 12 days),
Greatest Daily Rainfall (on 11th),
General Directions of Wind,
- 44*2°.
- 72*0 per cent.
3*121 inches.
1*402 inches.
- N.W., W.,
W.S.W.
232
Sanitary and Meteorological Notes.
Remarks.
A warm but changeable month, with very clouded skies (72 per
cent, of cloud), and occasional heavy rains. Both atmospheric pressure
and temperature ruled high. Winds from westerly points (from N.W.
through W. to S.W.) largely predominated. Periods of excessive
heat were felt in the S. and S.E. of England, and coincidently
torrential rains occurred in Ireland and Wales ; on the 11th 1*402
inches fell in Dublin ; on the 20th and 21st 3*36 inches fell at
Holyhead. A remarkable feature was the occurrence of afternoon
u evaporation ” showers, with a high and steady barometer, from
the 15th to the 18th inclusive. In one such shower on the 17th
the measurement at Fassaroe, near Bray, was 1*280 inches. In
London, on the night of the 22nd, thunder rains occurred, varying
from only *15 inch to 1*70 inches.
In Dublin the arithmetical mean temperature (62*2°) was above
the average (60*6°) ; the mean dry-bulb readings at 9 a.m. and 9
p.m. were 61*1°. In the thirty-four years ending with 1898, July
was coldest in 1879 (“ the cold year ”) (M. T. — 57*2°). It was
warmest in 1887 (M. T.=63*7°), and in 1868 (“the warm year )
(M. T. = 63*5°). In 1898 the M. T. was 60*6°.
The mean height of the barometer was 30*086 inches, or 0*171
inch above the corrected average value for July — namely, 29*915
inches. The mercury marked 30*471 inches at 9 a.m. of the 31st,
and fell to 29*439 inches at 9 a.m. of the 1st. The observed
range of atmospheric pressure was, therefore, 1*032 inches.
The mean temperature deduced from daily readings of the dry-bulb
thermometer at 9 a.m. and 9 p.m. was 61*1°, or 0*6° above the
value for June, 1899. Using the formula, Mean Temp.= Min. +
( max . — min. X *465), the value was 61*8°, or 1*6° above the
average mean temperature for July, calculated in the same way,
in the twenty-five years, 1865-89, inclusive (60*2°). The arith¬
metical moan of the maximal and minimal readings was 62*2 ,
compared with a twenty-five years’ average of 60*6°. On the
5th the thermometer in the screen rose to 74*9° — wind, W.S.W. ;
on the 13th the temperature fell to 49*1°- — wind, S.W. The
minimum on the grass was 44*2° on the 13th.
The rainfall was 3*121 inches distributed over 12 days. The
average rainfall for July in the twenty-five years, 1865-89,
inclusive, was 2*420 inches, and the average number of rainy days
was 17*2. The rainfall, therefore, was above, whereas the rainy
days were much below the average. In 1880 the rainfall in July
was very large — 6*087 inches on 24 days; in 1896, also, 5*474
233
Sanitary and Meteorological Notes.
inches fell on 18 days. On the other hand, in 1870 only *539
inch was measured on 8 days; in 1869, the fall was only *739
inch on 9 days; and in 1868 ’741 inch fell on but 5 days. In
1898, *945 inch fell on only 8 days.
High winds were noted on 5 days, but attained the force of a
moderate gale on only one occasion — the 26th. Temperature
reached or exceeded 70° in the screen on 11 days. In July, 1887,
temperature reached or exceeded 70° in the screen on no fewer
than 17 days. In 1888, the maximum for July was only 68*7°.
There was a thunderstorm on the 6th. Thunder occurred on
the 17th. A solar halo was seen on the 8th. The atmosphere
was rather foggy on the 19th, 20th, 21st, 22nd and 31st.
The rainfall in Dublin during the seven months ending July 31st
amounted to 14*416 inches on 107 days, compared with 13*060
inches on 106 days in 1898, 15*600 inches on 125 days in 1897,
13*328 inches on 102 days in 1896, 16*785 inches on 96 days in
1895, 18*133 inches on 130 days in 1894, 7*935 inches on 80 days
in 1887, and a twenty-five years’ average of 14*733 inches on
112*6 days.
At Knockdolian, Greystones, Co. Wicklow, the rainfall in J uly
was 3*480 inches on 14 days, compared with 1*145 inches on 6 days
in 1898, 1*625 inches on 10 days in 1897, 5*726 inches on 16 days
in 1896, 3*680 inches on 16 days in 1895, 3*805 inches on 19 days
in 1894, and 1*290 inches on 15 days in 1893. Of the total rain¬
fall 1*150 inches fell on the 11th, and *725 inch on the 20th.
The total fall since January 1 has been 22*990 inches on 109 days,
compared with 14*645 inches on 94 days in 1898, 19*750 inches on
116 days in 1897, 13*082 inches on 77 days in 1896, 17*950 inches
on 83 days in 1895, 21*186 inches on 115 days in 1894, and 13*066
inches on 90 days in 1893.
At Cloneevin, Killiney, Co. Dublin, the rainfall in July was 3*48
inches on 17 days, compared with a fourteen years’ average of
2*340 inches on 15*2 days. On the 11th the rainfall was 1*25
inches. In July, 1898, *840 inch fell on 7 days; in 1897, 1*28
inches fell on 10 days ; in 1896, 6*72 inches on 20 days ; in 1895,
3*58 inches on 17 days; in 1894, 4*08 inches on 23 days ; in 1885,
only *70 inch on 9 days. Since January 1, 1899, 17*10 inches of
rain have fallen on 106 days at this station.
At the National Hospital for Consumption, Newcastle, Co.
Wicklow, the rainfall was 3*232 inches on 13 days, compared with
1*380 inches on 6 days in July, 1898, and 1*425 inches on 11 days
in July, 1897, 1*068 inches being measured on the 11th, and *940
inch on the 20th. At this Second Order Station 21*871 inches
234
Sanitary and Meteorological Notes.
f rain have fallen on 104 days since January 1, 1899. The
maximal temperature in the shade in July was 75’0 on the 29th,
the minimum was 46*2° on the 13th.
CHOREA.
FornACA ( Journal of the American Medical Association ) reports
seven cases of chorea all rapidly cured with the oil of wintergreen
(methyl salicylate). It equals in efficiency, and can be used
instead of sodium salicylate. No more agreeable or effective
mode of administration could be suggested than that afforded by
the globules of colchicine with methyl salicylate, prepared by
Parke, Davis & Co., each containing l-250th grain of the alkaloid
and three minims of methyl salicylate.
STARCH DIGESTION IN THE STOMACH.
It has been usually supposed that the diastasic digestion of
starchy food in the stomach is interfered with by the hydrochloiic
acid of gastric juice within a short time after each meal.
Professor° A. E, Austin, A.M., M.D., Boston, Massachusetts,
has undertaken ( Boston Medical and Surgical Joui not ,
Yok 140, No. 14) to make a systematic research into this
important physiological function. For the purpose of study¬
ing the relative functions of starch and diastase, takardiastase
(Parke, Davis & Co.) was used, for its amylolytic powei is
remarkably strong as well as' stable. From the results of the
experiments the following facts seem to be -well established.
Taka-diastase digests starch with remarkable rapidity in a
neutral or slightly acid medium, in which it is capable of digest¬
ing 300 times its own weight of starch in one hour. The diges¬
tion of starch by taka-diastase is accelerated by the presence of
a small quantity of free HC1. The digestion of starch by taka-
diastase is not interfered with by organic acid ; on the contrary,
the presence of a small quantity of organic acid favours the
diastasic digestion of starch. Albuminous foods combine with
or neutralise HC1 of gastric juice. The combined acid lias
no inhibitory action on diastasic digestion by starch. In the
human stomach the albuminous matter of the food combines with
the HC1 of the gastric juice as fast as it is formed, and such
combined HC1 has no> hindering action on starch digestion. Xhe
diastasic digestion of starchy food is practically completed within
one hour.
PERISCOPE.
LAS VEGAS HOT SPRINGS, NEW MEXICO, U.S.A.
Las V egas Hot Springs, New Mexico, U.S.A., are situated
among the foothills of the Rocky Mountains in what is known as
the “dry belt, and are easily reached by the Santa Fe Route
from any portion of the country. These springs are a health
lesoit, and are especially suitable for those who desire a change of
environment, or for those who seek a climate which has an excess
of sunshine, a dry atmosphere, and a medium altitude, with no
extremes of heat or cold. Las Vegas Hot Springs are situated in
lat. 35° 30' N., long. 105° 12' W., at an altitude of 6,767 feet, the
mean atmospheric pressure being 23-5 inches. The following
climatological information is derived from the Report of the
Government Weather Bureau Station at Las Vegas, the observer
being Dr. William Curtiss Bailey, A.M., M.D., Medical Director
of the springs : Relative Humidity — Mean relative humidity for
the year, 40*82 per cent. ; lowest for any one month— May, 21*55 ;
highest foi any one month — Aug., 73*45 ; lowest recorded humidity
entire year, at 8 a.m., May 4th, 3*0 ; number of days humidity
recorded 20 or less, 90 ; number of days humidity recorded 10
or less, 30. Precipitation — Total precipitation, including melted
snow, for the entire year, 15*87 in. ; of this the amount that fell
in June and July, the rainy season, was 9*0 in. ; precipitation in
January, 0*0 in. ; number of days during the year in which 0*01 in. or
more precipitation fell, 63 ; number of days in which 1 in. fell, 0 ;
amount of snowfall, unmelted, for entire year, 28*35 in. Tern -
perature Mean temperature for the year, 49*11°; mean tempera¬
ture, May to October, inclusive, 61*31°; mean temperature, Novem¬
ber to April, inclusive, 3o*09 ; mean temperature for three summer
months, 66*64°; mean temperature for three winter months, 29*99° ;
mean average night temperature for summer months, indicating
lowest at night, 52*25°; number of days temperature reached
above 90 during entire year, 8 (all these occurred in June and
July, 1898); at no time did the thermometer reach 100°; five
times during the year the thermometer fell below zero (each of
these occurred during the night). Character of Shy— What is called
a “clear day” is when the sky is three-tenths or less overcast; a
“partly cloudy” day is indicated when the sky is four-tenths to seven-
tenths overcast ; a “ cloudy day ” is indicated when the sky is more
236 Periscope.
than seven-tenths overcast ; number of clear days during entire year,
261 ; number of partly cloudy days, 83 ; number of cloudy days,
21 ; the actual number of days in which the sun did not shine, 4 ;
average number of days, per month, of continuous sunshine during
last nine months of fiscal year, 25. Prevailing Winds — Prevailing
winds for entire year were from the southwest, or from a portion
of the country which is dryest, and partly desert.
EGG ALBUMEN IN ILLNESS.
“ Sister Elizabeth ” contributes to The Hospital , August 5, 1899,
an instructive article on the free use of raw white of egg in the
diets of youngish women suffering from anaemia, gastric ulcer,
and dyspeptic Troubles of a more or less severe character. The
usual proportion is two whites of eggs to one pint of cold water,
but if a more concentrated form of nourishment is desired double
that number may be used without inconvenience. Beat the whites
of the eggs well first, then stir them thoroughly into the water,
and strain the mixture through a fine sieve before administration.
The mixture is tasteless, and if given alone may be flavoured with
vanilla, cinnamon, &c., but when given in milk and whey it is better
unflavoured. From personal observation of the administration of
egg-water to patients suffering from dyspepsia, gastritis, and gastric
ulcer, Sister E. has learnt that the results have been a quicker
oessation of pain and uneasiness after food, and a steadier march
towards convalescence than in those cases where it was not given.
After a course of nutrient enemata a teaspoonful or two of albu¬
minous water — egg-water — every hour is a safe and nutritious
way of beginning mouth feeding again. In three cases who were
having large enemata of ten ounces of peptonised milk every six
hours, the addition of the raw white of an egg was made with
good results : there was an entire absence of diarrhoea and discom-
fort — a great gain, as all these cases were fed only by enemata for
ten days or a fortnight. In a fourth case the addition of white
of egg made no special difference, and the enemata were only
moderately retained, but it should be added that the patient was
taking two teaspoonfuls of Carlsbad salts every morning, so a loose¬
ness of the bowels was to be expected. In cases of obstinate
vomiting egg-water is very useful, and will often be retained when
nothing else is. Combined with whey, in bad cases of enteric
fever where milk is not tolerated and is speedily vomited in a
curdled, undigested condition, it forms a good food for some days,
till milk can be resumed. Taken in its concentrated form (four
whites of eggs to the pint) it proved of the greatest service
237
Periscope .
to a young woman suffering from a severe attack of enteric
fever in the above-mentioned ward, all sickness stopping after its
administration, and the strength being well maintained. Children
with diarrhoea and vomiting have benefited by taking it alone and
in conjunction with whey, when it has been advisable to stop milk
for a time. Stimulants may very well be diluted with albumen-
water instead of plain water in cases where it is desirable to in¬
crease the nutrition. Egg-water should "hot be added to boiling,
or even to very hot liquids, as the rapid coagulation of the albumen
under heat will at once render it indigestible, and negative the
hoped-for good results. It is well known in France as “Eau
albumineuse,” and one is inclined to surmise it to be a “ «-0od
remedy out of fashion,” though none the less valuable on that
account. The experiences of others who may have used egg-water
as an article of diet for the sick would be of great interest to the
nursing world, and especially to the writer.
SOME POINTS OF SPECIAL INTEREST IN THE STUDY OF THE DEEP
REFLEXES OF THE LOWER EXTREMITIES.
Professor C. K. Mills records an interesting case of valvular
disease of the heart, in which there was partial paraplegia, anal¬
gesia on the right side in 'the region supplied by the anterior
crural, external saphenous, and musculo-cutaneous nerves. The
knee-jerks were lost on both sides, but ankle clonus was present
on the left side. After death no changes in the brain or cord were
found, but some degeneration in the anterior crural nerve and in
the muscles of the lower extremities. From a careful study of the
cases in which ankle clonus persisted with loss of knee-jerk, the
author arrives at the following conclusions as to the conditions
which may induce their syndrome: — 1. It may be due to compres¬
sion or destroying lesion, such as caries with pachymeningitis, or
transverse myelitis, involving the cord in the region of the patellar
reflex arc — namely, somewhere between the second and fifth
lumbar segments, and most probably about the second or third
lumbar segments. 2. It may be due to disseminated sclerosis, foci
of sclerosis being present, both in the reflex arc for the patella and
in the lateral column. 3. It may be due to focal lesions, like
haemorrhage, softening, or cavity formation, attacking points in the
reflex arc and also the lateral columns. 4. It may be due to
peculiar forms of developmental arrest of the spinal cord— as, for
instance, the defect in the grey matter of the lumbar segments and
in the lateral columns. 5. It may be due to a combination of
muscular and neural disease, as in the author’s case, and as was
238
Periscope .
probably also the case in the man suffering from typhoid fever, as
recorded by Fleury. It is known that hyaline degeneration of
muscular fibres occurs especially in typhoid fever. Fleury’s case
was probably, in its pathology, not unlike that here recorded.
6. On theoretical grounds it seems probable that the syndrome
miodit be due to a focal lesion in the cerebral cortex, or in the
cortical spinal (pyramidal) tract, or to arrested development of the
tract, associated with disease (inflammation or degeneration),
limited to the crural nerves and their muscles. — Journal of Mental
and Nervous Diseases , March, 1899.
TREATMENT OF NOCTURNAL INCONTINENCE OF URINE.
Leslie Phillips, M.D. {Brit. Med. Jour., May 27, p. 1,274).
Antipyrin soon gives good results often in contrast to bella¬
donna, piehi, and rhus aromatica. The writer gives one nightly
dose of 8 or 10 grains to a boy of seven, and gradually increases
it. He has continued this for four months without toxic sym¬
ptoms. As the habit appears to be broken or modified a course
of arsenic may be added, pushing it if well borne. — Med. and
Surg. “ Review of Reviews .”
GONORRHOEA.
Dr. Orville Horwitz highly recommends the following formula,
which -Messrs. Parke, Davis, k Co. have added to their list as
soluble elastic capsule No. 162, methylene blue compound (Dr.
Orville Horwitz): — Methylene blue, 1 grain; pure santal oil, 1|
minims ; copaiba, 1|- minims ; oil of cinnamon, J minim. Dose :
Two capsules three times daily.
PRECAUTIONS AGAINST SUMMER DIARRHOEA.
The following excellent leaflet, drawn up by Dr. Niven, Medical
Officer of Health, is extensively circulated in Manchester
by the Sanitary Authorities : — 1. Infants fed by hand suffer
in a far greater degree from diarrhoea than infants fed at
the breast. This is chiefly due to errors in feeding. 2. All
milk should be boiled before use, either separately or after addi¬
tion to other food. The sooner ordinary milk is boiled after
milking the better, provided it is afterwards kept strictly clean
in a clean dish. 3. Children’s food should be freshly prepared.
When it is necessary to keep milk in the warm, season it should
be boiled and stood in a clean jug or dish, covered over with a
clean cloth, 4. Infants are very apt to suck their clothing,
which should therefore be kept scrupulously clean ; care should
be exercised to> prevent any dirty material getting into their
mouths. 5. All food should be kept in a clean, dry, and well-
239
Periscope.
aired place. 6. Meat and fish should be carefully examined on
purchase, and no tainted food should be bought. Food which has
become tainted after cooking should be rejected. Fruit should
be carefully selected and cleaned. 7. Overcrowding is a cause
of diarrhoea. During the warm season bedroom windows should
be left open day and night, and the fireplace should be kept open.
Bedroom walls and ceilings should be lime-washed early in sum¬
mer. If the room is papered, the paper should be cleaned.
Overcrowding should be avoided. 8. All dirt should be removed
from the house. The floors should be frequently scrubbed with
soap and soda. Dirty paper should be removed. If the walls
undei the paper are dirty or broken, the paper should be removed
and the walls made good and cleansed. 9. Damp foundations
or dirt under a house are conducive to diarrhoea. 10. Any
accumulation of an offensive character near a house, whether
arising from loose flags, from defective drainage, from collections
of manuie impioperly kept, or from defective cleansing of privies,
should be reported to the Sanitary Office or to the Medical Officer
of Health at the Town Hall. Other deposits near a house will
require to be removed at once by the householder. 11. The
yards should be kept clean, and the drains flushed with a few
buckets of water daily. 12. The ashtubs should not be allowed
to overflow, nor should vegetable refuse be put into them. Tea
leaves, cabbage, leaves, fish, potato peelings, Ac., should be
burned in the kitchen fire. No liquid should ever be placed in
the ashtub. 13. Where any offensive smell is perceived in or
near a house, the cause of which cannot be ascertained and
lemoved, complaint should be made to the Sanitary Office, Town
Hall. If. Diarrhoea mixture may be obtained, free of charge,
by P00r people, at the several police and fire stations of Man¬
chester, between the hours of 9 p.m. and 9 a.m.
THE INTERNATIONAL TUBERCULOSIS CONGRESS.
The International Tuberculosis Congress was held in Berlin from
Ma^ 2 4th to May 27th. It was opened by the Empress Augusta
Victoria, under whose patronage the congress was assembled.
There were 2,000 members present. Count Posadoinsky Wehner,
Minister of the Imperial Treasury, opened the session with an
address of welcome to the delegates, in which he declared that
this gathering and the peace conference at The Hague would
be the most glorious events in the history of the present time.
Empeior William, in answer to a message of respect, sent a
telegram expressing his good wishes. Surgeon J. C. Boyd, who
represented the Medical Corps of the United States Navy, was
240 New Preparations and Scientific Inventions.
made chairman of the United States delegates:, and Dr. von
Schweinitz, the American delegate, was chosen honorary presi¬
dent of the second section of the congress. It was stated that
medical science has already gained sufficient skill in combating
tuberculosis tO' effect cures in 20 per cent, of the cases. Professor
Virchow made an important address on the cause of infection.
Professor Brieget, in a lecture on Dr. Koch’s tuberculin, stated
that it undoubtedly has a strong healing power if the treatment
is persisted in, even in cases which have advanced to secondary
infection. In any event, by its means tuberculosis can be recog¬
nised in good time and in doubtful cases. The chief benefit of
the congress will consist in the renewed public interest aroused
in the subject of tuberculosis. — Medical News , June 3, 1899.
TINNITUS AURIUM.
Dr. Mendel, in the Journal des Praticiens, says that in patients
for whom fifteen to twenty drops of fluid extract of cimicifuga
racemosa had been prescribed for tinnitus aurium there was
benefit in a fair proportion of the cases. When effective, it is
rapid in its action, arresting the tinnitus for the time being for at
least two or three days. In the treatment of headache arising
from eye strain, cimicifuga racemosa is said to be very useful.
THE SMELL OF THE EARTH.
Nutt all has determined that, the smell of freshly turned earth
is due to the growth of a bacterium, the Cladothnx odorifera ,
which multiplies in decomposing, vegetable matter, and more
rapidly in the presence of heat and moisture. Hence the odour
is especially marked after a, shower, or when moist earth is dis¬
turbed. In dry soil the development of the bacterium is arrested,
but it is immediately resumed with vigour, as soon as moisture is
restored. — Medical News , June 3, 1899.
NEW PREPARATIONS AND SCIENTIFIC INVENTIONS.
Sanitary Feeding Bottles.
Messrs. Kennedy & Company, 159 Kingsland-road, London,
have devised an important improvement in the fittings of a feeding
bottle. The use of a rubber tube is dispensed with, and the
improved fittings can be taken to pieces and thoroughly cleansed.
It is obvious that, by adopting such improved fittings, the risk of
the occurrence of summer diarrhoea is lessened in the case of
infants who are bottle-fed. Samples of the new fittings may be
obtained free on application of a member of the Medical Profession.
THE DUBLIN JOURNAL
OF
MEDICAL SCIENCE.
'OCTOBER 2, 1899.
PART I.
ORIGINAL COMMUNICATIONS.
- ♦ -
Art. XII. — Dislocations and Fractures of the Astragalus d
By Henry Gray Croly, F.R.C.S.I. ; Ex-President,
Royal College of Surgeons; Senior Surgeon, City of
Dublin Hospital.
In the list of surgical accidents none are more serious in
character and consequences than the cases I have now the
honour of bringing under the notice of the Surgical Section
of the Royal Academy of Medicine in Ireland. In 1891, when
I occupied the chair as President of the College, I read a paper
on Compound Luxations of the Ankle-joint, illustrated by
cases, with special reference to the preservative surgery of
the foot, and in that communication I ventured to introduce
the subject with a few practical remarks on the surgical
anatomy of the joint. I see no reason to deviate from that
course in this communication.
The astragalus, also called os balistse and talus, is situated
between the tibia and os calcis and navicular bone in front, in
size ranks second among the tarsal bones, and is divided into
three parts — body, neck, and head. Five surfaces are observed
on the body. The superior surface, of an oblong, quadrilateral
shape, forms an articular trochlea, convex from before back¬
wards and slightly concave transversely (the reverse to the
form of the end of the tibia) ; it articulates with the inferior
a Read before the Section of Surgery of the Royal Academy of Medicine in
Ireland, on Friday, January 20, 1899.
VOL. CVIII. — NO. 334, THIRD SERIES.
Q
242 Dislocations and Fractures of the Astragalus .
extremity of tlie tibia, measures inches antero-posteriorly
and about transversely — the latter measurement is greater
in front than behind — a beautiful provision against luxations
backwards of the foot. The posterior surface is occupied by
a well-marked groove which passes obliquely downwards and
inwards, and lodges the tendon of the flexor pollicis longus,
which acts as a ligament, and prevents luxation backwards of
the astragalus. The external surface is occupied by a tri¬
angular facet which articulates with the fibula. The internal
surface is articular, for adaptation of the inner malleolus.
The inferior, or under surface, is occupied by a concave
articular facet, oval, with its long axis directed from within
outwards and forwards. This facet articulates with a corre¬
sponding one on the os calcis ; immediately in front of it there
is a deep and narrow depression, trumpet-shaped, which
separates it from an oval planiform facet for articulation with
the sustentaculum of the os calcis. The head is smooth and
oval, and is adapted to the concavity of the navicular bone.
The aspect of the head is forwards, inwards, and slightly
downwards. On the inferior part of the head there is
another facet, planiform and continuous with the surface
described. By means of this facet the astragalus moves on
the upper and anterior part of the os calcis. The neck is
rough and perforated by blood vessels.
The astragalus is firmly secured in position by ligaments.
The mortise cavity formed by the lower end of the tibia is
completed by the fibula. The powerful ligamentous connec¬
tion between the tibia and fibula makes the mortise very
strong. The tibia and fibula form together a cavity which
receives the pulley-like surface of the astragalus, and thus
presents one of the purest hinge-joints in the body. The
external malleolus projecting lower and more posteriorly than
the internal, gives considerable strength by “ wedging ” the
astragalus.
In flexion of the foot the astragalus rolls from before
backwards in the tibio-tarsal mortise, the anterior tibio-tarsal
and fibulo-tarsal ligaments are relaxed, the posterior and
middle fibulo-tarsal are rendered tense, the internal tibio-tarsal
ligament has its posterior fibres stretched, and its anterior
ones loosened.
243
By Mr. Henry Gray Croly.
During extension the astragalus rotates forwards in the
tibio-fibular mortise, the posterior ligaments are relaxed
and the anterior are put upon the stretch. In the upright
position the fibula plays no part in the function performed by
the joint. The tibia alone receives the weight of the body,
and transmits it to the astragalus. The astragalus has been
compared to the key-stone of an arch, the arch being
represented by the foot. The true design of the vaulted
form of the foot, however, is to permit its accommodat¬
ing itself to the several irregularities of surface, which
both in standing and progression, it must encounter. Not¬
withstanding the perfect construction of the ankle-joint and
its powerful ligaments, violent accidents set all these precau¬
tions at defiance, and produce the most painful and formid¬
able displacements.
The greatest extent of the superficies of the astragalus is
covered with smooth cartilage, by which it is rendered much
more movable than any other tarsal bone, and therefore
more liable to dislocation.
The momentum of the body impinging with great force
upon the astragalus, as in jumping from a height, or through
a severe fall, the direction in which the astragalus is sent
off the os calcis depends on the position of the foot at the
time the astragalus receives the whole momentum of the
body. The position of the foot also determines the direction in
which the force acts upon the astragalus. If the foot be
extended the dislocation will be forwards; if extended and
twisted outwards it will be forwards and inwards ; if extended
and inwards it will be outwards; if twisted outwards it
will be inwards ; if bent (flexed) it will be backwards ;
and if bent and twisted outwards it will be backwards and
inwards. A thorough knowledge of practical anatomy, to
be learned only in the dissecting-room, and combined with a
good hospital experience, will enable the practitioner to
diagnosticate, even when swelling has set in, these most
serious cases. The excuse, always ready by those ignorant
of anatomy and surgery — viz., 44 1 cannot diagnosticate until
the swelling or inflammation subsides” — brings discredit
every day, and is the cause of unnecessarily prolonged
suffering, even to the risk of limb or life itself.
244 Dislocations and Fractures of the Astragalus.
Although severe falls or wrenches of the foot have caused
the greater number of the recorded cases, occasionally, as in
Mr. K.’s case, communicated by me in this paper, the simple
slipping off the edge of the footpath (a few inches in height),
and turning the foot inwards, caused a complete luxation
forwards and outwards of the astragalus, with rotation of the
superior articular surface.
Dislocations of the astragalus may he complete or incom¬
plete, simple or compound, the bone being displaced forwards
and outwards, forwards and inwards, directly forwards or
directly backwards. There may be rotation, partial or com¬
plete, on its antero-posterior axis ; the bone may be thrown
transversely or upside down. A large number of such
luxations are compound.
Turner, of Manchester, tabulated a very able and exhaus¬
tive history of cases of astragalus dislocations, collected from
published works.
Sir Astley Cooper, Dupuytren, Fergusson, Williams,
Tufnell (Dublin), Broca, Boyer, Malgaigne, Lister, Lizars,
Guthrie, Desault, Nekton, Hancock, Hutton (Dublin),
Hey and Smith (of Leeds), Abraham Colies, Cline, Syme,
John M‘Donnell, Letenneur, Phillips, Cron, Campbell de
Morgan, Lee, Lonsdale, Pollock, and many others, con¬
tributed cases of these luxations.
Fergusson says — u Dislocation of the astragalus in any direc¬
tion, and under any circumstances, must- be looked upon as a
very serious injury ; for, although many instances have been
seen where life and limb have been preserved, even under
great disadvantages, it must be admitted that such satis¬
factory results have not always followed the praiseworthy
attempts of the surgeon to avoid amputation.”
The first case of dislocation of the astragalus which
came under my notice occurred when I was Purser-student,
residing in the City of Dublin Hospital.
Case I. — A middle-aged man was working on a scaffold at
the building of a house in Lower Baggot- street. He fell from
a considerable height and landed on his left foot on a brick,
turning his foot inwards. He was conveyed to the hospital at
once, and Mr. Williams, one of the surgeons and ex-President
of this College, who was on accident duty, was promptly in
'fiilii
Plate I.
M. R.’s foot at the time of the accident. From original drawing by
Miss Crolv.
245
By Mr. Henry Gray Croly.
%/
attendance ; Mr. Tufnell also came. On examination the foot
was inverted, resembling talipes varus, and the head of the
astragalus formed a projection on the anterior and outer aspect
of the foot. A clove hitch was placed on the foot, the leg was
flexed on the thigh and the thigh on the pelvis ; extension was
made, and Mr. Williams grasped the heel in his fingers and-
made steady pressure with his thumbs on the head of the
astragalus and the bone returned quickly to its normal position.
The patient made a good recovery and had a very useful foot.
That case made an everlasting impression on me, and when
teaching anatomy and surgery, in the school attached to this
College, I never lost an opportunity of teaching my pupils the
astragalus injuries.
The following cases of fracture and dislocation of the
astragalus occurred in my hospital and private practice : —
COMPOUND FRACTURE OF LEFT ASTRAGALUS.
Case II.— A groom, aged twenty-five, was admitted into the
City of Dublin Hospital, under my care, suffering from the
effects of a severe injury to his ankle-joint.
History. — He was riding through one of the streets, the horse
slipped and fell on his side, the man’s foot was caught in the
stirrup, which was bent by the weight of the horse’s body.
The young man was admitted into a surgical hospital and his
foot was placed in a box splint. He suffered much pain for a
couple of months and left the hospital, as he refused to submit
to amputation of his foot. On admission to the City of Dublin
Hospital I observed an opening at the inner side of the ankle-
joint, through which unhealthy and foetid pus escaped. A
probe quickly detected dead bone. Assisted by Mr. Tufnell I
opened the joint and removed a fractured, loose astragalus.
The joint was drained and the patient made a good recovery
and left the hospital walking on the injured foot.
COMPOUND LUXATION OF THE LEFT ASTRAGALUS FORWARDS
AND OUTWARDS ; EXCISION OF THE BONE ; RECOVERY
WITH PERFECT USE OF THE FOOT.
Case III. — M. R., aged twenty-six, was driving a horse in a
high trap across Butt Bridge ; the back band broke, the
shafts fell down, and the man jumped to save himself, and
he landed on his left heel ; he suffered intense pain. Dr.
246 Dislocations and Fractures of the Astragalus.
Fitzgibbon, who was passing at the time, examined the man’s
foot and observed the head and neck of the left astragalus pro¬
jecting forwards and outwards through a wound. He sent the
man at once to the hospital, and I saw him shortly after his
admission.
Appearance of injured foot. — Marked inversion, head and
portion of the neck of the astragalus projecting through a small
wound on the anterior and external aspects of the foot, internal
malleolus completely buried , a deep sulcus taking its place. I
decided to excise the bone, as it was evidently separated from
all its ligamentous connections and its vascular supply cut off.
Patient having been anaesthetised I made an incision over the
displaced bone and removed it without difficulty. On exami¬
nation a detached fractured portion was found involving the
groove of the flexor longus pollicis. A good deal of inflamma¬
tory action followed this very serious foot lesion and abscesses
formed. The patient made an excellent recovery, and is now
employed as a van-driver and the foot is as sound as if no acci¬
dent had occurred. There is considerable movement in the
joint. This is the astragalus, and this cast [exhibited] was
taken before the patient left hospital.
Measurement of legs : —
Injured leg — Inside of patella to ball of great toe, 18J in. ;
sound leg, do., 19-| in. Injured leg — Inside of patella to point
of heel, 17^ in. ; sound leg, do., 18 in. Injured leg — From point
of heel to ball of great toe, 6 in. ; sound leg, do., 6 in.
COMPLETE DISLOCATION OF THE RIGHT ASTRAGALUS FOR¬
WARDS AND OUTWARDS, WITH ROTATION OF BONE ; EXCI¬
SION OF ASTRAGALUS ; PERFECT RECOVERY WITH VERY
USEFUL FOOT ; GOOD FLEXION AND EXTENSION AT JOINT.
Case IV. — Mr. K., aged sixty-nine years, a very healthy
and robust man, was walking down one of the principal streets
about 3 p.m. on 18th Dec., 1897 ; his foot slipped off the kerb¬
stone, twisting the foot inwards ; he suffered severe pain and
fell. He was admitted into a hospital and was attended by
surgeons for eleven days ; his leg, foot, and thigh were placed
in a box splint and Eoentgen rays were employed.
I was summoned to see this gentleman on the 31st December.
He was removed to his residence in an ambulance, as the box
splint was too large to admit of being received into a cab. I
found the patient in a most serious state ; pulse rapid, breathing
Plate II.
Showing M. P.’s foot six months after excision of astragalus. Bone
shown also.
Plate III.
M. R. two years after accident. From photo.
Plate IV.
Mr K.’s foot eleven days after accident. From original drawing by
Dr. Paul Carton.
247
By Mr. Henry Gray Oroly.
oppressed, great nervous prostration. He said he had had
scarcely any sleep from the time of his admission to hospital,
and suffered intense agony. I removed the bandages and large
box, and on exposing the right foot I at once recognised the
case as one of complete luxation of the astragalus forwards and
outwards. The foot was forcibly inverted ; the internal malleolus
was completely buried (a deep sulcus occupied its place ) ; the head
of the astragalus formed a prominent tumour on the anterior and
external part of the dorsum ; the skin over the head of the astra¬
galus was red and shiny ; a large slough formed over the end of
the fibula ; another large slough existed between the deep groove
on the inner side and the os calcis ; bullae formed on the foot also ;
at each side of the knee the skin was broken, due to splint pressure.
The patient experienced immediate relief when all splint and
bandage pressure were removed ; boric stupes were applied to the
oint ; suitable diet and hypnotics were prescribed, the septic bron¬
chitis was attended to ; water cushions were placed under the hips,
and the affected limb was placed and retained on a properly pro¬
tected pillow. For nearly two months this gentleman’s life was in
the balance. His naturally good constitution and very temperate
habits gave hope that his life and limb, with great care, might be
preserved. Bullae and abscesses were opened, sloughs became
detached ; bronchial irritation subsided, and on the 5th of March
(about twTo months subsequent to the patient’s return home) I
operated. The drawing I exhibit was taken by my friend and
former surgical resident, Paul Carton, M.B., B.Ch., and shows
clearly the condition which I have described. The cast, which
I also exhibit, was taken a few days before the operation. On
examining it, and contrasting it with the cast which I show of
the sound foot, it will be observed that the description is in no
way exaggerated. The patient was anaesthetised, and the limb
thoroughly prepared by my son, Surgeon Henry Croly, who wTas my
chief assistant. I made a longitudinal incision, and came down at
once on the head of the astragulus. I then found that the upper
articulating surface was rotated outwards, the bone was firmly
wedged in its abnormal position, and required some dissection and
leverage with a “ lion forceps ” to remove it. Immediately on
removal of the astragalus (which I now exhibit) the foot came
straight. I applied a simple back splint with foot-piece, and
had not any trouble in keeping the foot in a normal position.
The patient bore the operation well, had no temperature worth
recording, and, except a rapid pulse and much broken sleep,
he made in the long run a most satisfactory recovery. He suffered
*248 Dislocations and Fractures of the Astragalus.
from a sharp attack of eczema, chiefly confined to the affected limb,
which is now much better. He walks out in his grounds, enjoys
the fresh sea breeze, has a movable ankle, and very little shortening.
Measurement of legs : —
Injured leg — From inside of patella to ball of great toe, 18 in. ;
sound leg, do., 19 in. Injured leg — From point of heel to ball of
great toe, 7 in. ; sound leg, do., 7 in. Injured leg — From inside
of patella to front of heel, 18 in. ; sound leg, do., 18 in.
Considering the age of this gentleman, the very severe
and dangerous accident from which he suffered, and the
complications which arose, I look on the happy termination
as regards life and limb as one of the most important surgical
triumphs, under Providence, which has occurred in my
practice as a surgeon ; and my best thanks are due to my son,
Surgeon Henry Crolv, M.D., for the valuable assistance which
he rendered at the time of the operation and in the subsequent
dressings. To the patient’s invaluable nurse, “ Mary,” all
praise is due; and to the patient’s brother, Mr. John - ,
for his untiring attention to dietetic comforts.
Dislocations of the astragalus may be divided into twT0
principal classes — those in which the astragalus is displaced
from the os calcis and scaphoid bone, the joint of the ankle
not being affected ; and those in which the astragalus is dis¬
located from these bones and from the tibia and fibula also.
The first are incomplete luxations, the second complete.
The incomplete have been called sub-astragaloid by Broca,
the complete have been called double dislocations by Boyer,
a nomenclature adopted by Malgaigne.
Sub-astragaloid may take place in four directions — for¬
wards, inwards, outwards, and backwards. They are frequently
complete as regards the astragalo-scaphoid articulation, but
incomplete as regards the calcaneo-astragaloid articulation.
In the forward (sub-astragaloid) the head of the astragalus
completely leaves the cavity of the scaphoid bone, and rests on
the scaphoid and cuneiform bones. The body of the astragalus
is thrown more or less forward upon the os calcis, its posterior
sharp edge rests in the groove which separates the two
articular surfaces of that bone, hence the difficulty in effect¬
ing reduction. In this case the joint of the ankle remains
uninjured. The head of the bone being constricted in the
Plate Y.
Showing appearance of inner side of Mr. K.’s foot eleven days after
accident.
isiHIBiifjiiili
Fig. 2.
Plate VI.
Fig. l. — Mr. K 's foot before operation. From cast.
Fig. 2.— Appearance of Air. K.’s foot one year after operation.
Fig 3. — Astragalus removed.
Plate VII.
Mr. K. eighteen months after accident. From photo.
249
By Mr. Henry Gray Croly.
narrow opening in tlie capsule, or the head of the bone
getting between the tendons, or the wedging of the astragalus
between the tibia, os calcis, and os naviculare, may each con¬
tribute towards rendering reduction difficult.
In dislocations inwards (sub-astragaloid) from the os
calcis and scaphoid, many cases are compound at the time
or become so by sloughing, and are often accompanied by
fracture of the malleoli.
In dislocations outwards (sub-astragaloid) from os calcis and
scaphoid the foot is inverted, while the head of the astragalus
causes a prominence upwards and outwards on the cuboid.
In dislocations backwards from os calcis and scaphoid (sub-
astragaloid) the anterior of part of the foot is lengthened.
On reviewing the cases which I have described as occurring
in my own practice, of fractures and dislocations of the
astragalus, and the cases which I have referred to recorded
by surgical writers, I have come to the following conclusions,
that : —
1. The term “ sub-astragaloid’’ is confusing and misleading.
2. In dislocation of the astragalus the bone is either par¬
tially or completely separated from its surrounding articu¬
lations, and if a wound exists, and any portion of the bone
protrudes, it is compound. The direction in which the bone
is displaced is specified by the terms forward, backward,
outward, inward, &c., &c.
3. In compound dislocation, with the head and neck pro¬
truding, the bone is so enucleated that its vascular supply
is cut off, and though reduction might be effected, necrosis
is certain to follow, necessitating the excision of the bone
later on, meantime risking the patient’s life by causing
suppuration and septic trouble.
4. In compound fractures the sooner the bone is excised
the better, the joint being drained.
5. In all simple partial luxations reduction should be
attempted, and most probably success will be the reward
of such praiseworthy efforts on the part of the surgeon.
Tenotomy of the Achillis-tendo or tibial tendons may in
some cases be considered necessary.
In the complete simple or double luxation, where the astra¬
galus has left its box, no efforts on the part of the surgeon
250 Dislocations and Fractures of the Astragalus.
ivill effect replacement of the hone , and if its articular
surfaces have undergone a change of position the bone must
ultimately necrose. I advise immediate excision in these
“ Listerian” days as safer than allowing the bone to slough
out, which always happens except in cases of luxation back¬
wards, when it may be allowed to remain.
Mr. Turner says, in his experience in the majority of
cases of dislocation of the astragalus there is an accompany¬
ing fracture of the bone. The bone may be fractured in
the operation of extracting. Larrey and Boyer are in favour
of extracting at once. It may be summarily stated in simple,
direct, and complete luxation Turner advocates allowing the
bone to remain in its new situation without any operation
until it manifests a tendency to ulcerate the skin. To relieve
tension an incision mav be made over the dislocated bone,
u
but its removal should be postponed. In complete compound
luxation he advocates immediate removal.
Boyer sa}^s after the astragalus is extracted the tibia is
approximated to the os calcis. The movements of the foot
are abolished, and the member loses a part of its length
equal to the height of the astragalus.
Boyer dissected a limb of a patient of Desault’s, and
found the tibia almost ankylosed with the calcaneum, but
it does not follow that ankylosis should result.
Mr. Smith (Leeds) says his patient in each case had an •
excellent hinge- joint of the tibia on the os calcis.
In incomplete luxations of the astragalus the hook-like
process of the astragalus may get fixed in the groove of the
os calcis.
In dislocations backwards, allowing the bone to remain in
its new situation has been most satisfactory.
Broca’s classification of luxations of the ankle-joint has
been adopted by surgical writers — viz.
1. Tibio-tarsal dislocation.
2. Sub-astragaloid dislocation.
3. Astragalus dislocation (or enucleation).
In my paper on compound luxations of the ankle-joint I
entered fully into these important cases. My present subject
is dislocations, simple and compound, of the astragalus proper,
and on fractures of the bone.
251
By Mr. Henry Gray Croly.
Sub-astragaloid luxations are cases where violence having
been inflicted — such as severe wrenches of the foot in
running or jumping — the head of the bone is dislocated
from the scaphoid, and rests on the dorsum of the foot
externally or internally, whilst the body of the astragalus
remains in its bow. The differential diagnosis of sub-astraga-
loid luxations of the foot from partial luxations of the
astragalus is, to say the least, not by any means easy even to
experts. The appearances of the foot are almost identical,
and reduction under chloroform can be effected in many
instances. In each case if reduction cannot be effected the
astragalus must be excised, either at the time or as a secondary
operation.
Fractures of the astragalus as primary accidents are very
rare. Fractures of the neck as a complication of luxation are
not uncommon. The case of fracture which occurred in my
hospital practice was caused by direct violence, the foot being
caught in the stirrup when a horse fell heavily on his side.
I exhibited the astragalus at a meeting of this Section.
Excision of the bone is the proper treatment in such acci¬
dents, a very useful foot being the result.
In dislocations, complete or incomplete, an attempt should
always be made to effect reduction. The patient should
be anaesthetised, the leg flexed on the thigh, and the thigh
on the pelvis, and extension made from the foot, the thumbs
being applied to press back the astragalus. It may be
necessary in very difficult cases to perform tenotomy of the
Achillis-tendo. This practice was advocated and practised
by Mr. George Pollock, Surgeon to St. George’s Hospital,
London. Before the days of aseptic surgery many surgeons
hesitated before excising the astragalus at the time of the
accident , preferring to operate when sloughs formed and
nature attempted to expel the bone as a foreign body.
The vascular supply must be cut off in complete luxations ;
necrosis follows ; operative measures therefore are called for.
DOUBLE OR COMPLETE DISLOCATION OF THE ASTRAGALUS.
In these cases the astragalus is displaced from all its articular
connections — from the tibia and fibula as well as from the
scaphoid and os calcis. These, like the partial or sub-
252 Dislocations and Fractures of the Astragalus .
astragaloid luxations, may take place in various directions —
forwards, inwards, outwards, backwards, and also a rotatory
dislocation — luxation par rotation sur place (Malgaigne)— in
which the bone remains between the tibia and os calcis, but
undergoes a movement of rotation on its vertical axis, and a
dislocation par renversement , in which the bone becomes
turned upside down.
In compound luxations of the astragalus the connection
which the bone maintains is important — that portion of the
bone forming the ankle-joint contributes nothing to its
nutrition, the supply reaching it chiefly from its inferior
surface.
When the astragalus has escaped entirely by the wTcund,
even though it may preserve its connections with the tibia
and fibula, the reduction would be followed by necrosis.
If bony ankylosis occurred the shortening of the limb
should be greater than usually follows where granulations
fill up to a considerable extent the gap left by excision of the
astragalus. The anterior edge of the tibia is received in
the cup of the scaphoid, and the cartilaginous surface of the
tibia is brought into contact with the os calcis — a favourable
condition for the formation of a false joint.
Malposition, or altered axis, are causes rendering insur¬
mountable barriers to reduction. In lateral dislocations there
is usually fracture of the malleoli.
A dislocation of the astragalus forwards occurred to the
late Mr. Carmichael, F.R.C.S., of this^city, caused by a fall
from his horse. Reduction was effected by Messrs. Hutton
and J ohn McDonnell. Result good.
Malgaigne mentions 26 examples of double or complete
luxation — viz., 15 forwards and outwards, 7 directly forwards,
and 4 forwards and inwards. Of the 26, 9 were simple and
17 compound. Forced extension of the foot is the most
frequent cause of the dislocation forwards, and if there is
inversion or eversion the bone takes, in addition, an oblique
direction outwards or inwards. A case of complete simple
dislocation forwards and outwards is recorded by Desault,
and another by Dupuytren. Two others are recorded by
Guthrie. When the astragalus is dislocated obliquely for¬
wards and inwards the sole of the foot is directed outwards
By Mr. Henry Gray Croly. 253
and the outer edge of the foot is raised ; the head of the
bone is directed downwards towards the sole of the foot.
In compound luxations, with fracture of the neck sepa¬
rating the head from the body, the bone should be excised ;
the vascular supply being cut off necrosis would follow.
DOUBLE OR COMPLETE DISLOCATION OE THE ASTRAGALUS
BACKWARDS.
Two cases are recorded by Mr. B. Phillips. The Achillis-
tendo was pressed backwards by the displaced astragalus.
Reduction was impracticable. Liston, Lizars, Nelaton, and
Turner describe similar cases. In one case the astragalus
diminished in size as if by absorption.
ROTATORY LUXATION OF ASTRAGALUS (LUXATION PAR
ROTATION SUR PLACE).
The astragalus in some cases may undergo a rotation on
its vertical axis, so as to be placed transversely, or with its
head directed towards the Achillis-tendo.
Malgaigne gives four cases. In one by L’Aumonier the
head of the astragalus protruded through the skin under
the malleolus internus, between the tendons of the tibialis
posticus and flexor longus digitorum, its trochlea being
situated transversely, holding the tibia and fibula apart. In
another, Denonvilliere found the body of the astragalus sepa¬
rated by a fracture from the head of the bone, and rotated
so as to cross the calcaneum at a right angle, with its
trochlear surface protruding through the integuments.
DISLOCATION “PAR RENVERSEMENT.”
Dupuytren, Malgaigne, and Mr. Smith, of Leeds, describe
such cases.
Mr. Smith, of Leeds, gives two cases of “ excellent hinge
joints.” Phillips gives two cases of hinge joints.
Some authorities recommend the removal of the bone,
even when not irreducible, if it has been much separated
from the surrounding parts, fearing that the loss of vascular
supply would occasion its necrosis. It must be remembered
that the astragalus is peculiarly circumstanced in this respect,
by far the greater part of its surface being articular, and a
254 Dislocations and Fractures of the Astragalus.
very small portion, comparatively with other hones, being avail¬
able for the entrance of blood vessels. On this point Malgaigne
observes that the question of reduction in compound disloca¬
tion of the astragalus depends entirely, in his opinion, upon
the connections which the bone has preserved with the sur¬
rounding parts, and it is important to remember that this
portion of the bone forming the ankle-joint contributes
nothing to its nutrition, the elements of which reach it chiefly
by its inferior surface. When the astragalus has escaped
entirely by the wound, though its tibial and fibular attach¬
ments remain, necrosis is almost sure to follow. Malgaigne
refers to 8 cases of reduction — 3 were fatal and 1 ended in
caries.
Chassaignac mentioned, in 1860, the necessity for ampu¬
tation of the leg in these cases.
In the proceedings of the Surgical Society of Ireland,
Feb. 22, 1865, two cases of dislocation of the astragalus were
communicated by the late Dr. John Pidley, F.P.O.S., Sur¬
geon to the King’s Co. Infirmary. Case I. was one of com¬
pound dislocation forwards and outwards, in which the astra¬
galus was removed at the time of the accident with the most
satisfactory result. Case II. was also compound, in which
reduction was effected with complete ultimate recovery.
In 1843 Dr. Morrison, of Newry, recorded a case of com¬
plete dislocation backwards of the astragalus. The bone was
removed at the time of the accident, with perfect recovery.
The late Professor Williams and Mr. Tufnell placed on
record two cases. Mr. Williams’s case was luxation back¬
wards ; the bone was allowed to slough out. The result was not
good as regards usefulness of the limb. In Mr. Tufnell’s case,
at which I assisted, the bone was thrown forwards, reduction
was effected, and a useful limb resulted.
A case of compound luxation of the astragalus occurred in
the practice of the late Mr. O’Peilly, in which the bone was
reduced.
The late Mr. Jameson mentioned a case of luxation for¬
wards and outwards of the astragalus, in which reduction
was effected under chloroform. The limb was completely
restored to use.
In the Medical Press of March 1, 1865, my friend, Dr.
255
By Me. Henry Gray Croly.
Henry Hadden, F.R.C.S., published a very interesting case
of compound fracture of the astragalus, with dislocation of
its head forwards and outwards. The bone was successfully
removed; the patient recovered, with a most useful foot.
In St. Thomas’ Hospital Reports on sub-astragaloid luxa¬
tions, the writer says: — “Foot violently in-twisted, and
adducted like talipes varus. Outer malleolus very prominent,
inner could not be perceived , so deeply was it buried.”
Surely if the astragalus remained in its box the symptoms
described above as sub-astragaloid could not be present.
Broca collected 78 cases of simple dislocation of the astra¬
galus — of these 59 were irreducible, 19 were reduced.
Twice immediate extraction vras performed — once success¬
fully and once followed by death.
Secondary removal of astragalus was performed 25 times —
24 recovered, 1 amputated.
Broca’s statistics further show that about one-third of
the cases terminated fatally va primary excision of the astra¬
galus, and no death occurred in the secondary operations.
Eighty cases (compound) reduction in 14 ; 9 recovered well ;
5 recovered after secondary extraction ; 3 died : reduction
impossible in 68; 2 died from shock; 5 amputated; 3 died;
2 recovered. Immediate excision gave in 57 cases 41 re¬
coveries, 16 deaths. Complete removal of astragalus — 86
cases, 17 deaths; primary excision 59 times, 17 deaths;
secondary excision 27 times icithout a death.
A case is recorded by Norris, of Pennsylvania, in which
the astragalus vras completely expelled through a wound on
the outside of the ankle, and was picked up from the ground.
The patient died of tetanus.
In a paper on sub-astragaloid luxations of the foot, in St.
Thomas’ Hospital Reports, the writer says: — “Probably in
most cases where it is needful to amputate, Syme’s,
Pirogoffs, or even Dupuytren’s sub-astragaloid operation
could be performed with advantage.” The same writer
says: — “The most desirable result that can follow excision
of the astragalus is ankylosis of the foot to the leg, and the
treatment should aim at procuring this.”
In compound luxation the sooner the bone is excised the
better. No cases demand immediate diagnosis and prompt
256 Dislocations and Fractures of the Astragalus.
treatment more than the luxations and fractures of the
astragalus.
In the compound luxation case which I have described the
neck and head of the bone protruded. I excised immediately.
The bone was detached from all its ligaments, and portion of
the bone near the groove for the flexor pollicis tendon was
fractured. I saw the young man quite recently ; he is driving
a van, and can jump up and down, and is not lame. His
foot is as useful as the uninjured one.
The case of Mr. K., aged sixty-nine years, was one of
unusual severity. When I saw him, eleven days after
the accident, his condition was most alarming; two large
ashy-grey sloughs formed, one at the inner side of the foot,
the second over the external malleolus, and a shiny spot
over the head of the astragalus. The heel also was deeply
ulcerated from splint pressure. The pulse was rapid ;
temperature high ; tongue furred and dry ; considerable
dyspnoea; bronchial rales; and almost sleepless nights. I
dared not operate under such circumstances.
The patient’s residence at the seaside was most favourable
for the improvement of his general condition. He took
plenty of light, nutritious food ; the sloughs were care¬
fully dressed with aseptic dressings ; the limb supported on
pillows ; tonics and bromides were given to quiet the nervous
system. The astragalus was not only displaced completely
from the tibia and os calcis, but was rotated outwards.
There was wedging, and adhesions existed which necessitated
a careful dissection, the bone being held firmly in the lion
forceps. There was not any fracture of the astiagalus, 01 of
the tibia and fibula. This gentleman, whose foot has been
examined by the members, has a movable ankle — -can flex,
extend, and walk well.
It will be seen from the above statistics that, before the
days of Listerism , primary excision of the astragalus was b^
no means favourable as regards life, whilst secondary removal
of the astragalus was very favourable.
I advise immediate excision in all cases of irreducible
luxation of the astragalus in this “ Listerian ” period.
Mercury in Diseases of the Heart .
257
Art. XIII. — Mercury in Diseases of the Heart.*1 By
Wallace Beatty, M.D., F.K.C.P.X. ; Physician to the
Adelaide Hospital.
It is interesting and instructive to note how certain reme¬
dies, which the keen observers among the physicians of the
first h alf of the present century regarded as of great service
in the cure or alleviation of disease, fell into more or less
disrepute with succeeding physicians, but are now regain¬
ing somewhat of the reputation they had lost. I may
mention venesection, antimony, and mercury (in other
diseases than syphilis). Thus .Osier* recommends veiled-
section in cardiac dilatation with cyanosis, and regrets that
he has not adopted this treatment more frequently ; anti¬
mony (tartar emetic) is strongly lauded by Jonathan
Hutchinson and Malcolm Morris in acute inflammatory
cutaneous affections (I can bear my testimony to its utility
in such cases). It is of the use of mercury in chronic
diseases of the heart that I propose to speak at present
Acute endocarditis and pericarditis do not come within the
scope of this communication. It may appear unnecessary
in this city to extol the use of mercury in the treatment of
diseases of the heart, when one of Dublin’s, and the world’s,
greatest physicians — Stokes — has, in his famous work on
diseases of the heart and aorta, borne personal testimony to
its immense value. Yet it is at times well to review the
extent and limits of usefulness of well-known remedies, and
compare one another’s observations ; and, moreover, I have
thought it worth while to bring this subject forward, as I
have from time to time met physicians who have not
appeared to know the full value of mercury in heart diseases,
and in the writings of the present day there does not appear
to be sufficient stress laid upon the utility of this drug.
Thus I can find but scanty allusion to the use of mercury in
Bvrom Bramwell’s admirable work on diseases of the heart.
1/
I propose to consider as briefly as I can —
I. The cases in which mercury is of real value.
II. The modes of its administration.
III. The manner in which it acts.
a Read before the Section of Medicine of the Royal Academy of Medicine *
in Ireland on Friday, December 16, 1898.
R
258 Mercury in Diseases of the Heart.
(i.) THE CASES IN WHICH MERCERY IS OF REAL VALUE.
(1) Of all conditions in which, mercury is useful the one
in which it is most certain to do good is this — general
venous engorgement due to chronic primary mitral valve
disease. In a typical case there is a rapid, irregular, com¬
pressible pulse, physical signs of dilatation of heart, a re¬
gurgitant or obstructive mitral murmur, full and pulsating
cervical veins, an enlarged, congested liver, high coloured,
scanty, and albuminous urine from congested kidneys,
anasarca, and perhaps some ascites ; in short, all the evi¬
dences of back pressure.
(2) The cases of general venous engorgement dependent
upon mitral incompetence (relative incompetence) secondary
to old-standing aortic regurgitation.
(3) Cases of dilatation of the heart with general dropsy,
jbut yet no obvious valvular disease, there being no murmur
and no evidence of kidney disease.
(4) Cases of general venous engorgement from failure of
the right heart, caused by severe emphysema and bronchitis.
(5) Cases of general venous engorgement due to cardiac
dilatation following upon long-continued hypertrophy of
the left ventricle, due to chronic interstitial nephritis.
In all these cases there is general venous congestion due to
back pressure, and it is in such conditions of the heart that
mercury proves most valuable.
(il.) THE MODES OF ITS ADMINISTRATION.
If we select a typical case of general venous congestion
dependent on failure of compensation in chronic mitral
valve disease, there are four 'principal ways in which we may
hope to relieve the heart and remove the congestion.
1. By increasing the power of the heart (digitalis, squill,
strophanthus, and strychnine are the most generally useful
to effect this object). 2. By diaphoretics. 3. By purgatives.
4. By diuretics.
Diaphoresis is of very limited usefulness ; in severe cases
the patient has orthopncea, and the administration, e.g., of
hot air baths to cause sweating is not readily manageable.
Pilocarpine is a depressing and sometimes dangerous
remedy. The depression likely to ensue from diaphoresis,
259
By Dr. Wallace Beatty.
and especially the fact tliat it can at most only give very tem¬
porary relief to the loaded veins, are limits to its possible
usefulness. With regard to purgatives : If the patient
is strong it is well to commence treatment by free purgation,
and repeat the purgation every two or three days. Many
patients are, however, too weak to bear purgatives, and we
must then rely upon cardiac tonics and upon diuretics. The
advantages of diuretics are — their action is continuous , and
is not attended with the depressing effect which follows upon
diaphoretics or purgatives. Our main reliance must, there¬
fore, be placed upon heart tonics and diuretics — in both the
action is continuous.
I leave out of consideration such special treatment as
bleeding, puncture, &c. ; also the questions of rest, diet,
stimulants, as my object is to dwell solely upon the uses and
action of mercury.
Mercury is administered in heart disease for both its pur¬
gative action and its diuretic action.
Most physicians use mercury in purgative doses or com¬
bined with other purgatives, giving it occasionally in the
course of other treatment. It is thus mercury is adminis¬
tered by Sir W illiam Broadbent. He writes8, — “ With venous
obstruction the liver will be enlarged and g’reatly congested,
perhaps pulsating, and one of the first objects of treatment
is the relief of the engorgement of the liver. The best
results are undoubtedlv to be obtained, according- to: mv ex-
penence, from purgatives, in which calomel or other mercu¬
rial preparation is a constituent — such as calomel and com¬
pound jalap powder, calomel, blue pill, or grey powder with
eolocynth and hyoscyamuis, followed or noti by salines.
Hydra gogue cathartics of greater violence may be necessary
in some cases, but the effect on the liver and heart is not
proportional to the degree of purgation, and the relief of
the dropsy is not due simply to the amount of liquid carried
off by the intestinal surface, but is frequently the effect
rather of the diuresis which follows improvement in the
circulation. Digitalis is often useless, and appears only to
add to the embarrassment of the heart, and to produce sick¬
ness until the way has been cleared for its operation by
a mercurial purge, and when its good effects on the heart
a Heart Disease. P. 108.
260 Mercury in Diseases of the Heart.
seem to be expended a fresh start, will often follow a calomel
and colocynth pill.”
Again, Sir William Broadbent, writing on tlie treatment
of dilatation, a observes —
“ Calomel or blue pill or grey powder should be given in
doses of from 1 to 5 grains, according to tlie urgency of tire
case, witli colocyntb and byoscyamus or rhubarb, followed
by some mild saline. After one or more fnll doses at tbe
outset a moderate dose may be given every second or third
night.”
Mercury may be administered almost or exclusively for its
diuretic action, in small doses frequently repeated, and this
is the method which has proved most successful in my hands.
The plan I adopt is as follows : —I give a pill containing half
a grain of calomel usually along with digitalis and squill,
every four hours night and day, for from 10 to 14 days. If
these pills should tend to cause purgation I give them com¬
bined with opium. I commonly order two sets of pills one
set containing calomel half a grain wTith squill and digitalis,
the other set containing the same together with one-eighth to
half a grain of powdered opium. The nurse is directed to give
a pill every four hours either with or without the opium,
according to circumstances ; one or two motions in the 24
hours is all I think well to allow. It often happens that
very few or even no opium pills are needed during the
period of the administration of the mercury. After 5 or
6 days an improvement in the condition of the patient gene¬
rally shows itself, or, if not so soon, in about 8 days, when
free flow of urine, as much as 100 ounces in the 24 hours,
and a concurrent subsidence of the dropsy manifest them¬
selves. In the next few days the symptoms of general
venous engorgement diminish rapidly. At the end of about
14 days the gums may be a little sore ; I then stop the mer¬
cury and order iron (generally citrate of iron and ammonia)
combined or not with digitalis, according to the condition of
the pulse. Once the dropsy has disappeared entirely or almost
entirely, the amount of urine secreted falls to, or almost to,
the normal. This method of administering mercury,
relying on its diuretic action solely, is specially useful
in feeble patients, who would be exhausted by frequent pur-
n Heart Disease. P. 264.
261
By Dk. Wallace Beatty.
gation, and though at the end of a mercurial course some
patients may feel weak, they will be relieved of their dis¬
tressing symptoms, and after some days’ use of iron, &c., the
strength rapidly returns. This treatment may be repeated
again and again every now and then when recurrences of.
general venous congestion manifest themselves, and again
and again complete relief of longer or shorter duration may
be obtained. In this connection I may mention the case of
a lady who was under my care several years ago suffering
from mitral regurgitation, enormous dilatation of the heart,
and general venous congestion, with very marked anasarca.
I treated her for several days with Baillie’s pill (blue pill,
squill and digitalis), and was disappointed to find no im¬
provement in her condition. Dr. Head then saw her with
me. He remarked, “For this case blue pill is too slow;
change it to’ calomel.” After a few days treatment with
calomel the dropsy disappeared, and a course of iron was
followed by some weeks of comparative ease ; she was able
to go out on fine days. Again and again when the circula¬
tion became embarrassed the mercurial course was resorted
to, followed by a course of iron and digitalis, and again and
again the treatment was followed by relief. She lived for
about two years. It is interesting to note that the marked
dropsy of the lower extremities which was present in her
first attack never recurred, but the back pressure was almost
entirely directed into the liver, which, with each attack,
became swollen to an enormous size.
One other case I may allude to. An old gentleman of
about 80 years of age, suffering from mitral regurgitation
with enormously dilated heart, who had been treated with
digitalis, occasional purgative doses of calomel, and nightly
hypodermic injections of morphia, was completely relieved of
his symptoms for a time by a course of calomel given every
4 hours. He lived for about 2 years, and never again re¬
quired morphia for rest and sleep at night. Every now
and then he resorted to the calomel course.
In this case the complete relief afforded by a course of
frequently-repeated doses of calomel, contrasted with the
failure of occasional purgative doses, was very remarkable.
We may, of course, meet with some cases in which
262
Mercury in Diseases of the Heart.
mercury is not well borne, but these are very exceptional' : of
course a time comes wben mercury fails.
The state of the pulse will determine whether mercury is
to be given alone or in conjunction with digitalis and
squill ; most commonly it is best given in combination, and
mercury would appear to1 act as an adjuvant to digitalis,
the action of the digitalis being aided by the diuretic effect
of mercury. Dr. Little, in his lecture on “ The Resources of
the Physician in the Management of Chronic Diseases of
the Heart,” writes — “ If we were compelled to have only one
remedy (in cardiac dropsy) I have no hesitation in saying
that remedy should be the old-fashioned pill of blue pill,
squill and digitalis, yet I think sometimes one and some¬
times another of the ingredients in the time-honoured
Baillie’s pill is unnecessary.” And again, “’As a rule, we
may say : that when the liver is greatly swollen calomel
or blue pill is required, with digitalis if the pulse is frequent
and irregular, without digitalis if the pulse is not frequent
nor irregular.”
In the Lancet of Sept, 28th, 1895, p, 779, Dr. William
Murray, of Aewcastle-on-Tyne, extols the use of mercury in
heart disease, and illustrates his remarks by a notable case.
The beneficial effect of mercury in heart disease is thus
graphically described by Stokes — “I do not wish it to be
believed that by mercury we can cure dilatation of the heart,
but many years’ experience has convinced me that by the
use of this remedy wre can delay its production, remove the
irregular action which assists in causing the disease, and, above
all, prolong the patient’s life, and, again and again, relieve him
from dropsy, and from pulmonary and hepatic congestion,
even when they have arrived at a point which threatens a
speedy dissolution.” And again in describing the action of
mercury in patients suffering from general venous conges¬
tion from heart disease1— Tinder all these terrible sym¬
ptoms it happens again and again that the exhibition of
mercury will, as by enchantment, remove the anasarca, re¬
duce the hepatic tumour, restore the heart to- its ordinary,
though not its normal, condition, and for a. period of time,
more or less long, enable the patient to pursue the avoca¬
tions of an active and laborious life. ”
Mercury acts well in the other conditions mentioned in
263
By Dr. Wallace Beatty.
•/
the early part of this communication, and I prefer gene¬
rally to administer it in the same way as in primary mitral
valve disease with general venous congestion. I need not
allude to the treatment of these conditions, except to1 the
cases of dilatation of the heart secondary to hypertrophy of
the left ventricle which occurs in chronic Bright’s disease.
When the heart begins to fail and dilatation occurs in
chronic interstitial nephritis, and the symptoms of general
venous congestion from back pressure make themselves
manifest (a desperate case indeed), mercury often acts ex¬
tremely well, and though one cannot look forward with the
confidence that one may in primary cardiac disease to a good
result, still a temporary good result often is effected. In this
complication of Bright’s disease mercury is certainly not
contraindicated.
(ill.) THE MANNER IN WHICH MERCURY ACTS.
Clinically the good effect of mercury in cardiac disease is
recognised by a copious flow of urine, with concurrent dis¬
appearance of the dropsy, but how this diuresis is brought
about is still a matter of conjecture. If we study the action
of diuretics we find that they act mainly in one of three
ways : —
1. By increasing the force of the left ventricle, and so in¬
creasing the pressurepn the renal arterioles.
2. By dilating the afferent arterioles of the kidney, and
so bringing more blood to the kidney, with consequent in¬
creased secretion.
o. By stimulating the renal epithelium to increased
secretory activity.
tJ
W e know that mercury stimulates the salivary glands ; it
is probable that a similar action of mercury on the renal
epithelium partly accounts for the increased secretion. Yet
this does not appear to explain fully the action of mercury
in cardiac dropsy, as it is a notable fact that the remarkable
increase of secretion which is brought about by mercury in
cases of cardiac dropsy (amounting to a flow of 80 to 100
ounces or even more of urine in the 24 hours) only continues
as long as there is dropsical fluid to be absorbed. Mercury
may, therefore, act by increasing the activity of absorption,
and so the diuresis which follows may be simply the removal
264 Mercury in Diseases of the Heart.
of tlie excess of fluid re-absorbed. However, from tlie cir¬
cumstance that the back pressure from the heart must be
felt not only by tlie veins but by tbe lymphatics, which
eventually open into the veins, tbe circulation tin ougli tin
absorbing lymphatics must be largely interfered with,
therefore the probability of the action of mercury being ex¬
clusively one of stimulating absorption is hardly likely. . If
mercury acts both by increasing the activity of absorption
and at the same time increasing the activity of renal secre¬
tion its good effect in cardiac dropsy can be partly under¬
stood.
But the action of mercury on the liver must also be taken
into account.
Sir William Broadbent explains the good effect of
mercury in heart disease by its action on the liv er. He
write«sa — ■“ Mercurial purgatives have the effect of diminish¬
ing arterio-capillary resistance and of lowering arterial ten¬
sion, and therefore of relieving the heart. The hypothesis
by which it seems to me it is best explained is that mercury,
influences the liver chemistry and promotes the elimination
of impurities which when retained in the blood gfv e rise to
resistance in the capillaries. Mercurial purgatives then
have the double effect of depleting the portal system while
relieving the enlargement of the liver and the distension of
the right side of the heart, and of diminishing the resist¬
ance in the peripheral circulation and so relieving the left
ventricle of stress/’
This hypothesis is a very plausible one, but a difficulty I
find in its acceptance is that in a large number of cases in,
which the good effects of mercury are observed the pulse is
both small and very compressible ; no evidence of arterial
resistance.
In conclusion, I do not wish to be understood to advocate
mercury in every case of mitral valve disease with symptoms
of imperfect compensation. In many cases occasional re¬
sort to digitalis and other cardiac tonics is sufficient to
restore the deranged circulation ; but when digitalis and
other cardiac tonics fail, the use of mercury is often attended
with the happiest results.
I have dwelt, accordingly, at length upon the action of
a Heart Disease. P. 263.
Reaction of the Intestinal Contents Jn Man. 265
mercury in chronic heart disease, because I wish to bear my
testimony to its immense usefulness, and because I wish to
emphasise the fact that while in some cases it may be ad¬
ministered with advantage in occasional purgative doses, in
a large number it is best and most successfully given in
small, frequently-repeated doses for about a fortnight at a
time, with the object of causing free diuresis, any tendency
to purgation being kept in check by combining the mercury
with opium.
ART. XIV. — The Reaction of the Intestinal Contents in Man.
By J. J. Charles, M.D., F.R.S.E. ; Professor of Anatomy
and Physiology, Queen’s College, Cork.
There has been much difference of opinion amongst
physiologists as regards the reaction of the intestinal
contents in the higher animals. Litmus, methyl orange,
and phenolpthalein have been used by some investigators
to test the reaction, whether acid or alkaline, and if acid,
to determine whether the acidity is due to an organic or
an inorganic acid. But as in most cases litmus only has
been employed as the indicator, I shall in this communica¬
tion refer to the results which have been obtained with it
alone.
The reaction of the contents of the small intestine was
carefully examined by Moore and Rock wood1 in the rabbit,
guinea pig, and white rat, and was found by them to be
alkaline the whole way ; but in the dog it was observed
to change from above down, being neutral or faintly acid
or alkaline near the pylorus, acid lower down, and less
acid or even alkaline near the caecum. They say that by
analogy “the small intestine in man cannot have an acid
reaction under normal conditions in any considerable part
of its length.” Gillespie,2 from recent observations, has
come to the conclusion that in the dog and calf the contents
are acid throughout, the acidity being greatest in the
duodenum, where it exceeds that of the stomach, and that
the reaction in man is probably acid. But the most
important results are those which were obtained some
years ago by Ewald and byMacfadyen3 from two patients
who had each a fistula of the ileum at its junction with
‘266 Reaction of the Intestinal Contents in Man.
the colon. The reaction of the discharge from the fistula
in both cases was acid. Moore and Rockwood are of
opinion that these observations are not conclusive in their
application to normal cases, because the lower end of the
ileum in its relation to the fistula or outer world corres¬
ponds, they say, to the large intestine in its relation to the
anus, and that as bacterial action should on that account
be there well pronounced, the acid reaction ascertained by
Ewald and by Macfadyen is readily explained. But in
reply to this criticism it may be remarked that there is no
proof that bacteria pass into the intestine to any appre¬
ciable extent either through a fistula or through the anus.
The reaction of the contents of the large intestine , accord¬
ing to Moore and Rock wood, is mostly alkaline in the
rabbit and white rat, but acid in the guinea pig ; whereas
in the dog it varies, being acid or alkaline. However, in
all these animals they found the reaction of the contents
of the caecum to be usually acid. Gillespie has ascertained
that the reaction in the dog and calf is acid, even more so
than in the stomach or duodenum ! He believes the
reaction in man is acid.
I have made observations on rabbits and kittens, but I
have not always obtained the same results. Without enter¬
ing into the details of each case, I may mention that the
contents of the small intestine in rabbits in some cases were
acid, and in others alkaline, and those of the large intestine
were less acid and even alkaline towards the lower end.
The contents of the caecum were usually acid. I have
also tested the reaction of the contents in human bodies
before they have been injected for use in the dissecting
room. ISJo doubt, such results are not by themselves to be
relied on, because changes due to fermentation take place
in the alimentary canal soon after death. But it is worthy
of note that these results fairly coincide with those obtained
by Macfadyen and others on man during life. Thus I
found the contents of the small intestine acid, those in the
duodenum being perhaps somewhat less acid than in other
parts, the contents of the csecum acid, of the tranverse
colon alkaline or acid, of the sigmoid flexure alkaline or
neutral, and of the rectum alkaline. But I am convinced
that the reaction in man as well as in other animals is not
267
By Dr. J. J. Charles.
constant, and this may account in part for the marked dis¬
crepancy in the results of different observers. The differ¬
ence in reaction may be produced either by an alteration in
the character of the food, or in the length of time at which
the examination is made after food has been taken, or by a
possible variation in the activity of the ferments of the
pancreatic juice in setting free fatty acids from fat, or by
fermentation, especially if the digestion at the time should
be abnormal. In man I believe the reaction of the contents
of the small intestine in normal digestion is mostly acid.
The acidity, according to Macfadyen, is equivalent, as a
rule, to a solution of acetic acid, 1 : 1,000, and is probably
due in the duodenum to hydrochloric acid, and lower
down to lactic and other organic acids, the product of
fermentation. The reaction of the large intestine is, I
think, generally alkaline, because the secretion of the colon,
which exceeds in alkalinity that of the small intestine,
more than neutralises the acid produced in the contents by
fermentation.4 This is interesting as affording an explana¬
tion of the way in which the action of bacteria is hindered
in the small intestine by the acid medium, and perhaps by
the antiseptic bile acids (at least in the duodenum) ; whereas
it is, for the most part, not much interfered with in the
large intestine. There is now no longer any difficulty in
understanding the action of trypsin in an acid medium,
for there is experimental evidence to show that it will
digest proteids in the presence of 0*012 per cent, of hydro¬
chloric acid, or of 0'05 per cent, of lactic acid.
The faeces are almost invariably alkaline. They may be
acid, but this reaction generally indicates abnormal diges¬
tion, with much acid fermentation. The reaction of the
faeces is a test which might be more employed by physicians
in forming an opinion as to the state of the digestion in
the intestines. Escherich has directed attention to this
matter, and has given directions regarding the diet to be
used in accordance with the reaction of the fasces.
REFERENCES.
1 Journal of Physiology, 1897 ; and Proceedings of Royal Society, 1897.
2 Proceedings of Royal Society, 1897.
3 Gamgee’s Physiological Chemistry. Vol. II. P. 449.
4 Gamgee’s Physiological Chemistry. Vol. II. P. 457.
PART II.
REVIEWS AND BIBLIOGRAPHICAL NOTICES.
— - -
The Exceptions to Colies's Law . By George Ogilvie,
B.Sc., M.B., Eclin. ; M.R.C.P., London; Physician to
the Hospital for Epilepsy and Paralysis, Regent’s Park.
From Vol. 79 “ Medico-Chirurgical Transactions.”
This paper, which has been republished as a pamphlet, is of
special interest to the readers of the Dublin J ournal of
Medical Science on account of the association of the
great teacher, Abraham Colles, with the Medical School of
Dublin. Indeed, some apology is due to the author that
through an accidental oversight an earlier notice has not
appeared in our journal. From 1887, when Codes pro¬
pounded the doctrine that the healthy mother of a con¬
genitally syphilitic child might safely nourish her own
infant, the medical profession throughout the wdiole world
has, up to a very recent date, unanimously accepted his
authority as sufficient to justify the medical attendant in
permitting a healthy mother to nurse her own syphilitic
offspring. Although some 25 cases of so-called exceptions
to Codes’s law have been reported within the last quarter of
a century, in 1881 Berkley Hid said it had never been con¬
clusively controverted, and in this statement we fully concur.
Mr. Ogilvie gives two selected cases as examples, which he
considers as conclusive as any recorded clinical facts can be
of the possible fallibility of Colles’s law. The first is Rankes
case, the second Merz’s case. In the former the mother had
borne a syphilitic child in the first year of her married life,
but remained free from any evidence of syphilis herself
until after her second confinement at the end of her third
year of married life. The second child developed a macular
syphilitic eruption when only two weeks old, and ulcers at
the angles of the mouth. Whilst suckling this child the
mother got a sore breast, which developed into what appeared
to be a typical hard chancre, followed by complete syphilis.
269
Ogilvie — Exceptions to Colies' s Law.
Merz’s case appears more conclusively to controvert
Colles’s law. Here a healthy woman, married to an ad¬
mittedly syphilitic husband, became pregnant in the first
year of her married life, and was delivered of an apparently
healthy child at full time, both mother and child being ad hue
free from any evidence of syphilis. In about two weeks the
child became the subject of obviously syphilitic sore mouth.
The mother was permitted to continue to nurse it on the
faith of the infallibility of Colles’s law. She got a sore on
her breast, which became hard, and was followed by complete
syphilis.
To anyone not familiar with the inexhaustible vagaries of
syphilis, and particularly of latent syphilis, these cases must
appear as conclusive evidence that it is not safe to rely
implicitly upon Colles’s law, and allow apparently healthy
mothers to nurse their own syphilitic offspring. To us
they do not bring conviction that Colles’s law has been con¬
troverted by them. In Ranke’s case we have no doubt the
mother was the subject of latent syphilis from her first
pregnancy, and that the fever consequent upon the con¬
traction of a sore breast roused the latent syphilis into
activity.
The same explanation would account for the development
of complete syphilis in the mother of the second or Merz’s
case, apparently through infection from a sore breast, wdiich
assumed the outward appearance of a hard primary sore,
when in reality it was only an excoriation, which, from
the presence of latent syphilis contracted by the woman
during pregnancy, assumed syphilitic characters, which were
followed by complete syphilis.
For our part we do not think that Colles’s law has been
controverted by any cases yet published, as it is impossible
to know whether the mother of a syphilitic child is or is not
the subject of latent syphilis, which may become active upon
any provocation such as the febrile disturbance occasioned by
a sore breast. We should be sorry to see the syphilitic children
of apparently healthy women deprived of their only chance
of life, by denying them their mother’s milk, on the feeble
evidence that we have of the possibility of their transmitting
the disease to her contrary to the law of Colles.
270
Reviews and Bibliographical Notices.
We have also a work before us by Mr. Ogilvie on the
so-called “ Law of Profeta,” which is the converse of Colles’s
law. It is of interest also to any one engaged in the study
and observation of venereal diseases.
Syphilitic Diseases of the Spinal Cord . By R. T. WILLIAMSON,
M.D. Manchester : Sherrett & Hughes. 1899. Pp.
127.
This valuable monograph gives a detailed account of the
syphilitic affections of the spinal cord, founded largely on
cases observed by the author in the Manchester Infirmary,
either under his own care or under the charge of the other
physicians. It deals only with diseases produced by
acquired syphilis — those resulting from hereditary syphilis
are very rare, and examples of them have not occurred in
the author’s practice. The text is illustrated by several
drawings, which with one exception are original.
The text is divided into thirteen chapters. In the first,
devoted to mtiological considerations, the rarity of syphi¬
litic spinal disease is pointed out. In ten years 14,575
medical cases were treated in the Infirmary. \ Of these
2,456 were diseases of the nervous system, among which
there were 118 cases of locomotor ataxy, and only 32 of
spinal syphilis. Pure spinal syphilis is rarer than cerebral,,
or cerebro-spinal syphilis. The disease is more common
in males than in females, is most frequent between the
twentieth and fortieth years of age, and while it may
occur at any date after infection, is met with in more than
half the cases within the first five years. The early
syphilitic symptoms may have been slight or severe, but
in general the antisyphilitic treatment was continued for
only a short time. The influence of predisposing causes,
as cold, injury to back, &c., is doubtful.
In the second chapter are general considerations re¬
specting the pathological anatomy and clinical forms of
spinal syphilis. The following are the most important
pathological changes produced in the cord by syphilis —
(a), diseases of the blood-vessels— endarteritis and peri¬
arteritis, endophlebitis and periphlebitis ; (5), partial or
Williamson — Diseases of the Spinal Cord. 271
complete obstruction of the blood-vessels by thrombosis or
thickening of the vessel wall, and changes resulting there¬
from — e.g.y softening, degeneration, haemorrhages ; (c),
inflammation of the meninges or of the cord ; (d), gumma¬
tous infiltration of the cord or membranes ; (e), true
circumscribed gummata of the cord or membranes; (/),
sclerosis, secondary to destruction of nerve- elements, pro¬
duced by the processes previously mentioned ; ( g ), a
chronic post-syphilitic degeneration — locomotor ataxy. Of
these gummata are the clearest indication of the syphilitic
nature of the disease, while the vascular changes are
somewhat less conclusive.
A useful table is given of the different clinical forms of
spinal syphilis, and of the pathological conditions associated
with each.
Of the 32 cases of spinal syphilis observed, 16, or one-
half, were examples of meningo-myelitis, 6 of acute para¬
plegia (“acute myelitis”), 4 of chronic syphilitic spinal
paralysis (Erb’s), 3 of chronic syphilitic meningitis, and
1 each of gummatous tumour of cord, hemiplegia, and
pseudo-tabes.
The third chapter contains general remarks on the
diagnosis of spinal syphilis. The most important points
are — the history of previous syphilitic infection, signs of
present or previous syphilitic disease in various parts of
the body, the presence of cerebral symptoms, the relatively
slight intensity of the cord disease as compared with the
extensive area involved, the temporary presence of Brown
Sequarcfs symptom — i.e., paralysis of one leg and anaes¬
thesia of the other, the peculiar fluctuation of the symptoms,
indications of a multiplicity of lesions, the presence of
symptoms of meningitis and irritation of nerve roots, and
improvement under antisyphilitic treatment.
In the following chapters the different clinical forms of
spinal syphilis are described, and numerous cases detailed.
As a result of a critical inquiry into the connection
between syphilis and locomotor ataxy, the author con¬
cludes, “ though tabes may be regarded as a post-syphilitic
degeneration in the majority of cases, it can scarcely be
looked upon as a form of spinal syphilis in the strict sense.’*
272
Reviews and Bibliographical Notices.
A condition, however, in which at one stage tabetic
symptoms manifest themselves, has been occasionally ob¬
served in spinal syphilis. In such cases of pseudo-tabes
the symptoms, which are transitory, are probably due to
syphilitic lesion of the meninges invading the posterior
columns of the cord and the posterior nerve-roots.
The prognosis in spinal syphilis depends very much on
the form of the affection. Of the 32 cases observed by
the author 9 died, 10 recovered, and 13 remained stationary,
or varied from time to time until the patient passed from
observation. Of the fatal cases 5 were acute myelitis, 1
Erb’s syphilitic paralysis, 1 gumma in cord, 1 hemiplegia,
and 1 meningo-myelitis. The 10 cases which recovered
included 5 of meningo-myelitis, 3 of meningitis, 1 of acute
myelitis, and 1 of pseudo-tabes.
As regards treatment, a combination of mercury and
iodide of potassium is recommended.
Chemical and Microscopical Aids to Clinical Diagnosis :
being a Guide to Urinary, Gastric, and other Analyses
employed in Practical Medicine. By Carstairs C.
Douglas, M.D., B.Sc. Glasgow: James Maclehose &
Sons. 1899. Pp. 258.
This is a useful summary of the more .important applica¬
tions of chemistry and microscopy to clinical research.
The methods of analysis are, on the whole, well chosen, the
details of the different operations are clearly given, and the
reactions are explained, so that the processes may not be
merely an exercise of empiricism.
The subject of bacteriology is not dealt with, the author
rightly thinking that it is sufficiently large to claim a
separate work for itself.
The greater part of the volume is occupied with the urine,
whose general characters and normal and pathological con¬
stituents are treated of in successive chapters in a satisfactory
manner. We note that the only method given for the
quantitative estimation of urea is the hypobromite. The
method of Morner and Sjoqvist is not mentioned, although
Kjeldahl’s method for the estimation of nitrogen is described.
273
Douglas — Aids to Clinical Diagnosis.
The uric acid is directed to be estimated by Hopkins’s
method, while the views of Roberts, that the uric acid exists
in the urine as quadrurate, are accepted.
A chapter is devoted to the detection of the different
proteid bodies which are met with as pathological con¬
stituents in the urine. The methods of detection, and the
precautions which must be taken in order to escape fallacy,
are fully and clearly laid down.
In the chapter on the sugars most space is, of course,
devoted to glucose, but the characters of levulose, lactose,
pentose, iso-maltose, and glycuronic acid are given, as well
as the methods for the detection of acetone, aceto-acetic acid,
and oxybutyric acid.
In the account of the blood pigments in the urine a chart
of spectra, reproduced from Halliburton, is given, but the
description of the use of the spectroscope is rather meagre.
It is rightly stated that Pettenkofer’s reaction for bile acids
is useless when applied directly to the urine suspected to
contain these bodies. A method of Oliver and one of
Dragendorff are described for the detection of bile acids.
The latter consists in removal of the bile salts by prolonged
agitation with chloroform, extraction of the chloroform bv
alcohol, evaporation of the alcohol, and the application of
Pettenkofer’s test to the residue.
The diazo reaction is described, but treated as of little
value. Good directions are given for the examination of
the different urinary deposits and calculi, and a useful
section on the preparation, for teaching purposes, of artificial
pathological urines concludes the first section.
In the second section are two chapters which deal with
the analysis of the gastric fluids. The methods for obtaining
the contents of the stomach by the tube are given, and the
use of test meals is fully described. The general characters
of the gastric juice, the acid, the ferments, and the abnormal
substances found in the gastric contents all receive sufficient
description. Leo’s and Toeffer’s methods for the quantitative
estimation of hydrochloric acid, and the methods of Hiibner
and Seeman for that of organic acids generally, are given
in detail. The absorptive power of the stomach is directed
s
274 Reviews and Bibliographical Notices.
to be determined by Penzoldt’s iodide of potassium method,
and the motor power by Ewald s salol method.
The third section is on the examination of the saliva and
sputum. Here the author gives some bacteriological methods
for the detection of tubercle, pneumonic, and diphtheritic
bacilli, as well as for leptothrix, thrush, and actino-mycosis.
The following section is on the blood. It is stated that
the blood is isotonic with a solution of common salt of from
0-44 to 0*48 per cent. This is too low ; human blood is
isotonic with a solution of the strength 0*9 per cent.
In the section on faeces some account is given of the
different intestinal parasites. We should like to have seen
this somewhat fuller, and figures given of the ova of the
different worms.
There is a section on the pathological fluids, and one on
the animal and vegetable parasites met with in the skin and
hair concludes the volume. This last section is rather in¬
adequate to the importance of the subject, consisting as it
does of only six pages and one drawing.
On the whole we would strongly recommend this book to
our readers. The brevity, clearness, and orderly arrange¬
ment will make it most useful to every practitioner.
Notes on the Feeding of Infants. By Langford Symes,
F.R.C.P. (Irek); Physician to the Dublin Orthopedic
Hospital ; Physician to the Homes for Destitute Children,
&c., &c. Dublin: Fannin Co. 1899. Pp. 43.
An admirably simple pocket note book on “ The Feeding
of Infants ” is this little treatise by Dr. Langford Symes.
Master of the subject, the author has succeeded in com¬
pressing into some three dozen pages of long primer type
a wonderful amount of information on infant feeding —
information which is founded equally on science and on
common sense.
The key to the character of the book is contained in
the triplet of quotations from Hippocrates and Sydenham
which Dr. Symes has adopted as the motto of his useful
little work. “With NATURE for my guide,” wrote Sydenham
more than two centuries ago, “ I should swerve not a nail’s
275
Burdett's Hospitals and Charities , 1899.
breadth from the true way.” Dr. Symes has taken Nature
for his guide, and so he has produced a safe and useful
note-book on an intricate and important subject.
for convenience, the note-book is divided into three
paits. I he first describes the proper feeding of infants
under one year, the second is for infants over one year,
and the third offers suggestions for the management of
cases in which the food disagrees. If dyspeptic conditions,
vomiting, pain, flatulence, or colic, should arise, it is
evidence that the food is disagreeing. The author lays
down the golden rule that delicate infants and these show¬
ing signs of feeble digestion must be fed under their age.
There is no opening for adverse criticism in these
" Notes, which should be in the hands of all nursing
mothers and children’s nurses, as well as in those of medical
practitioners.
Burdett's Hospitals and Charities , 1899. Being the Year
Book of Philanthropy and the Hospital Annual. By Sir
Henri Burdett, K.C.B. London: The Scientific Press.
1899. 8vo., Pp. 1103.
REALLY the best way to describe the special features and
scope of this work is to quote verbatim the first of two
inverted pyramids which decorate its title page. The
second inverted pyramid contains a catalogue of the
author’s contributions and work. Well, then, this annual
contains “ a review of the position and requirements, and
chapters on the management, revenue, and cost of the
charities, an exhaustive record of hospital work for the
year. It will also be found to be the most useful and
reliable guide to British, American, and Colonial hospitals
and asylums, medical schools and colleges, religious and
benevolent institutions, dispensaries, nursing and con¬
valescent institutions.”
In his preface the author apologises for the too late
publication of this most useful year-book, and he somewhat
curiously observes that “ it shall in future be published
without fail in March, 1900, and early in each succeeding
year.” Brackets to separate the words “in March, 1900,
276 Reviews and Bibliographical Notices.
and,” from the rest of the sentence would much improve
the grammar.
Unlike many a preface, the one before -us contains much
valuable food for thought, and is eminently practical
as well as suggestive. Sir Henry Burdett states that there
is evidence in favour of the view that the principle of pay¬
ment by patients at all hospitals is gaining in public favour,
lie entirely agrees in the view that if payment of any kind
is taken the medical attendant must receive a fee. He
proposes a plan by which this could be equitably done.
Sir Henry also strongly insists that the services of a skilled
or expert assessor should be requisitioned when it is pro¬
posed to build a new hospital or similar institution. In
this we are altogether in accord with his views.
This is a volume which should lie on the desk of every
hospital secretary, and be consulted by the governing body
of every philanthropic institution.
Archives of the Rontgen Ray. Edited by Thomas Moore,
F.R.C.S., and Ernest Payne, M.A. (Cantab.). Yol. III.
No. 4, May, 1899. No. 5, August, 1899. London : The
Kebman Publishing Company.
The numbers of the Archives which lie before us are of
the usual high standard. The letterpress is interesting, and
the plates are, as a rule, artistic. The radiographs illustrate
in a forcible way the diagnostic and also the curative value
of the Rontgen ray. The proceedings of the Rontgen
Society are, as usual, fully reported, and will be found both
interesting and instructive. The work is admirably brought
out by the Rebman Publishing Company, 1 29 Shaftesbury-
avenue, London, W.C.
Materia Medica and Therapeutics : An Introduction to the
Rational Treatment of Disease. By J . Mitchell Bruce,
M.D. London : Cassell & Co. 1899.
This book, so well known and so thoroughly appreciated,
has been brought out by the author, modified in accordance
with the changes made in the Pharmacopoeia of 1898.
There is no radical alteration from the first edition in
Hoblyn — Price — Terms Used in Medicine.
277
the arrangement of the subjects. In its 609 pages the
author has succeeded in making the subject of Materia
Medica an attractive science.
We recommend the book to students, of medicine who are
studying for examination, and also to students of medicine
who are engaged in the practice of their profession.
A Dictionary of Terms used in Medicine and the Collateral
Sciences. By the late Richard D. Hoblyn, M.A. Oxon.
Thirteenth Edition, revised throughout, with numerous
additions by John A. P. Price, B.A., M.D. Oxon., late
Physician to the Royal Hospital for Children and Women.
London : Whittaker & Co. 1899. Post 8vo. Pp. 838.
A work which has reached its thirteenth edition leaves
little scope for a reviewer’s criticism. It has evidently come
to stay. Originally compiled by a distinguished Oxford
graduate and an able philologist, “ Hoblyn’s Dictionary” has
not lost, but gained, at the hands of the Editor of the present
issue.
In his brief preface, Dr. Price points out that the changes
in the present edition are mainly those of addition, and he
expresses the hope that the selection of several new words and
phrases, more particularly those relating to bacteriology, will
render the work even more useful than it has been in the past.
A glance through the pages of the book will show how
well its information has been kept up to date. Such entries
as “ Koplik’s spots” and “ Rontgen rays” are essentially
modern, and, by the way, excellent definitions of these
additions to medical terminology are given.
There are, of course, some slips — “ Put amen,” on page
622, should be “ Putarnen.” “ Myosis,” “ Myoma,” on page
485, should more correctly be “ Meiosis ” or “ Miosis ” and
“Meioma” or “ Mioma ” — the word being derived from
jaelcov, smaller — the comparative of / u/cpos , small.
We are glad to see the correct quantity of “ Angina ”
given even as an alternative to the incorrect “ Angina.”
“ Hoblyn’s Dictionary ” is, in our opinion, one of the best
medical lexicons extant. The published price of the work
is half a guinea.
part nr.
♦
MEDICAL MISCELLANY.
Reports , Transactions , and Scientific Intelligence.
- -
Transmission of the Agglutinative Substance of the Bacillus of Eberth
by the Mother's Milk. A Translation by George Foy, M.D.,
F.R.C.S.I.
A paper under the above title, by MM. Paul Commont and Coll,
appears in the Lyon Medical , No, 92, 1899.
After the researches of d’Archard and Bensaude, confirmed by
the work of a large number of experimenters, it is admitted that
the milk of a woman suffering from typhoid fever acquires the
property of agglutinating the bacilli of Eberth. The same property
is possessed by cholestrum, as shown by Mr. Mosse (Societe
Medicate des Hopitaux, 1896). This property of agglutination by
the secretion of the mammary gland is constant, though always
inferior to that of the blood serum. It is variable in amount, being
sometimes very active and at other times very weak.
MM. Mosse and Frankel reported a short time ago to the Societe
Medicale des Hopitaux (1899) a case in which the agglutinative
power of the milk of a typhoid patient was one in five hundred. A
question here occurs. Does the serum of a baby breast-fed by a typhoid
patient acquire the property of agglutinating the bacilli of Eberth ?
This is one of the sides of the question so important in considering
the effect of the milk on the tissues of the child, and the part it
may play in immunising or predisposing to maladies.
Bensaude, in his thesis (Paris, 1897), expresses the general
opinion of his day in the conclusion that the property exists in the
milk of the typhoid patient, but not in the blood serum of the
suckling baby. This theory he supports by experiments giving
negative results with the blood serum.
In 1896, d’Archard and Bensaude reported to the Societe Medicale
des Hopitaux their observations on a case of a patient who con¬
tinued to nurse her baby notwithstanding the development of
typhoid fever, and, during the first ten or fifteen days of the fever,
the milk of this patient agglutinated feebly the bacilli of Eberth,
279
Transmission of tlie Bacillus of Eberth.
more feebly than others (in the proportion of one to ten) ; the serum
reaction sought for in the child’s blood was not obtainable.
Hiercelin and Lenoble ( Presse Medicate , 1896), arrived at a
similar conclusion. A patient continued to nurse her baby to the
twelfth day of her sickness (typhoid fever). The milk of the woman
gave a positive agglutinative reaction, though of feeble action (one
in six only)i As for the serum of the infant’s blood, it was not
negative in reaction, but four drops of it were required for
twelve of the culture.
Widal and Sicard (Societe de Biologie, 1897), pointed out that
in the mouse the property of agglutination is transmitted by suck¬
ling. This transmission, on the contrary, does not occur in the
guinea-pig or the cat. They were also disappointed in their search
for it in the human being.
On these facts being published, Landouzy and Griffon brought
before the Societe de Biologie (November 6tli, 1897), the following
positive observation A suckling child, in perfect health, three
months old, breast-fed by the mother, who was suffering from
typhoid fever of moderate intensity, to the end of the second week
of her sickness, gave agglutinative serum, and the serum of the
mother’s milk gave a similar reaction.
Castaigne ( Medecine moderne , November, 1897), publishes two
cases — one negative and one positive. In the first the blood serum
of the child gave no reaction ; it is true that the milk of the mother
gave a very feeble reaction in that case, not more than one in
twenty. The positive observation of Castaigne is very interesting.
The mother had reached the end of the second week of a severe
attack of typhoid fever ; the baby, who was suckled on this date,
agglutinated to one to forty on the same day that it was taken from
the breast. The following day the agglutinative power was only
one in twenty, and the day following one in ten ; on the fourth day
the reaction could not be obtained. The infant was now put back
to the breast, and the reaction reappeared but feebly, being only
one in ten ; but the day following it rose to one in fifty.
These observations, all sources of error being eliminated, show
the possible transmission of the power of agglutination by feeding,
and their variations and the rapidity of their attainment in babes.
Lastly, we have been able to study an analogous case, which we
believe to be sufficiently interesting to report. A woman, aged
twenty-six years, was admitted to the Hotel Dieu, on the 7th day
of July, by M. Bard. This patient had been nursing a baby for two
months when she was seized with a feeling of prostration, headache,
pain in the small of the back, and shivering. These were followed
280 Transmission of the Bacillus of Eberth.
by profuse diarrhoea without colic or tenesmus ; there was a com¬
plete loss of appetite. On examination on admission to hospital
there were found tympany, gurgling in the right iliac fossa, well-
marked splenic enlargement, the typical rose rash, and some
bronchial rales. The temperature ranged from 102° F. to 104° F.
It was diagnosticated as a case of typhoid fever of ordinary severity.
Well, this patient continued to suckle her baby for the two first
weeks of her sickness. We examined the blood serum of the baby
for serum reaction. On the 10th of July, three days after the babe
was taken from the breast, we obtained the following result : — The
blood serum of the mother agglutinated the bacilli of Eberth one
in two hundred ; the milk of the mother produced the reaction by
one in thirty. The blood serum of the baby agglutinated in the
proportion of one in ten only. On the 15th of July, that is eight
days after the child was taken from the breast, its blood serum had
lost all power of agglutination.
In conclusion, positive serum reaction in the suckling child of a
typhoid patient is but temporary. This serum reaction bears testi¬
mony to the transmission by the milk of a power of agglutination.
We find (1) that the serum of the healthy suckling is deviated
only slightly from its normal condition, and to a feeble degree to
produce a positive reaction face to face with the bacilli of Eberth.
On the other hand we have been unable to detect here any intra¬
uterine transmission, because of the many difficulties attending the
research, the period of intra-uterine life, and the absence of evidence
at birth of the mother having had the disease.
Lastly, as to the rapid disappearance of the agglutinative property
of the serum of the child — we teach that this itself may be acquired
as a temporary property of the serum. Wre do not think that a
typhoid-nursed child will, after it has been weaned and separated
from its mother, show evidence of the disease. Its tempeiatuie
remains normal, there is no diarrhcea, and the illness which some¬
times results may be ascribed to change of food.
The case we have reported is a good instance of the transmission
from mother to child of the property of agglutination by suckling,
and it is a contribution to the cases already given by Landouzy,
Griffon, and Castaigne.
In considering the different results obtained by other investi¬
gators we must ask ourselves are the conditions the same ?
<D
Remarkable, also, is the rapid disappearance of the agglutinative
property from the serum of the breast-fed. In Castaigne s positive
case the rate of diminution of the property was so great that on
the fourth day after weaning the serum gave no reaction. In one
Transmission of the Bacillus of Eberth . 281-
case the serum, three days after weaning the baby, did not give
more than a feeble reaction, and in five days the property was wholly
gone. It is, however, possible that sometimes the substance which
is agglutinative passed by the milk may have a negative reaction,
and thus not respond to the test. But leaving out this source of
error, it is very certain that the transference is not constant. We
inter- d, therefore, to account for the reasons for believing that the
effects are not constant.
We attribute no importance whatever to the chemical condition
of the gastric secretion, although Widal and Sicard attach so much
importance to its difference in animals.
We admit the existence of gastro-intestinal lesions common to
breast-fed children — necessary, according to the experience of
d’Arcliard and Bensaude (Societe Medicale des Hopitaux, 1896) to
explain the absorption of the agglutinative substance of the milk !
We do not think the explanation a good one, for in one case such
lesions were not present.
It appears essential to provoke an intensity more or less great
(of the fever) to give the agglutinative property to the serum and
milk of the mother. Though in our case the milk attained a rate
of one in thirty, in the case of Castaigne it reached one in six
hundred. On the other hand, in the negative case of d’Archard
and Bensaude, it realised no more than one in ten, and even less
(one in six) in those of Thiercelin and Lenoble.
Widal and Sicard (Socidte de Biologie, 1897) say, in detailing
their negative cases of cats and guinea pigs, that they succeeded by
injecting a liquid of high agglutinative power in producing the
peculiar property in the serum of those who previously gave no
serum reaction. The variability of the strength of the milk in
agglutinative power, therefore, may explain the inconstancy of the
transmission of this property of the mother or foetus.
According to d’Archard and Bensaude the inconstancy in the
transmission of the agglutinative property from the foetus to the
mother by the placental circulation is due to the greater intensity
of agglutinative conditions required. Mosse and Frankel, in a
recent communication to the Societe Medicale des Hopitaux de
Paris (1899) concludes, also, that the strength of the property in
the mother’s serum is one of the conditions for the serum reaction
in the foetus ; but they consider another condition necessary — that
those agglutinative bodies or agglutinogenetic bodies should be
carried by the mother’s blood freely to the placenta during a suffi¬
cient time.
For the transmission to the babe of the agglutinative property
282 Transmission of the Bacillus of Eberth .
the blood of the mother has to pass two barriers. There is, first,
the filter of the mammary gland, which explains that the milk of
the mother has not always the same proportional amount of agglu¬
tinative power as her blood. Then follows the epithelium of the
digestive tract of the child, the second barrier which the substance
has to pass ; in some cases it has here been destroyed — not trans¬
mitted. Then there are so many other substances, probably of the
same order (divers toxins and antitoxins), which are arrested at
this point. At each barrier some portion of the agglutinative
substance appears to be arrested ; this may explain why each of
the three fluids under consideration — the blood of the mother, the
mother’s milk, and the blood of the suckling — possess an agglutina¬
tive power of relatively less proportionate activity, which in our
case was as follows : —
Serum of the mother’s blood
• • •
1 in
200
Serum of the mother’s milk
• • •
1 „
30
Serum of the child’s blood
• • •
1 „
10
These facts make it clear that it is possible to transmit to the blood
of the child certain of the properties of the blood of the nurse, and
that they pass the barrier of the digestive epithelium. To effect
this, two factors are requisite— -The necessary strength of the pro¬
perty to be transmitted, and a sufficient duration of the period of
transmission. This acquired property is always a temporary one,
and disappears a few days after the cessation of the supply.
FATAL OBSTRUCTION FROM THE MURPHY BUTTON.
Tieber ( Wien. Min. Woch ., Oct. 6) reports a fatal case of obstruc¬
tion of the lumen of the Murphy button by a plum stone, and
comments on several other cases in which the button became
blocked with hard fmcal lumps. He concludes that the use of the
button should always be preceded by washing out the stomach and
evacuating the intestines to remove foreign bodies, and that liquid
food should afterwards be given for some considerable time.
POISONING FROM A CARBOLIC DRESSING OF THE UMBILICAL CORD.
M. Coste ( Gazette des Hopitaux , Nov. 5, p. 1167). — A dressing of
glycerine and carbolic acid applied to the umbilical cord of a new¬
born child soon provoked symptoms of poisoning, to which it
succumbed. A dressing of glycerine strongly coloured with me¬
thylene blue applied to the umbilical cords of lambs produced
greenish discoloration of the urine.
KOYAL ACADEMY OF MEDICINE IN IRELAND.
President — Edward II. Bennett, M.D., F.R.C.S.I.
General Secretary — John B. Story, M.B., F.R.C.S.I.
SECTION OF PATHOLOGY.
President — J. M. Purser, M.D.
Sectional Secretary — E. J. McWeeney, M.D.
Friday , May 5, 1899.
The President in the Chair.
Pathological Clavicles.
Dr. Knott exhibited a large series of pathological clavicles.
Prof. E. H. Bennett said that the two specimens of fracture of
the sternal end of the clavicle were very rare. They were of exactly
the same type as he had himself obtained, namely, that the fracture
was oblique, passing through the sternal end and produced by a
force acting in the axis of the clavicle. The anatomical varieties
of the clavicles shown conformed to the great varieties of shoulders.
He had never seen an epiphysis on the outer end of the clavicle.
Mr. R. C. B. Maunsell asked Dr. Knott if he had ever seen an
example of ununited fracture of the clavicle. He had a patient
who sustained a fracture of the clavicle, and a false joint was the
result, owing to non-union.
Dr. Knott, in reply, said that he had never seen an ununited
fracture of the clavicle.
Another Case of Infective Endocarditis , due to the Pneumococcus.
The Secretary (Professor E. J. McWeeney, M.D.), described
a case of this disease. Into the left auricle projected a greyish
friable mass of fibrinous material as big as a large hazel nut,
and springing from the aortic cusp of the mitral. The
chordae tendinem were involved in a mass of similar character,
and were much softened and ulcerated. Microscopically and
culturally the diplococcus of Fraenkel was the only organism
found. The edges of the fibrinous mass contained it in prodi¬
gious numbers, aggregated in small circular colonies. Both
kidneys were found extensively infarcted, but not the spleen.
284 Royal Academy of Medicine in Ireland.
Two months previously the patient had developed a slight consolida¬
tion of both bases, consequent on a laparotomy successfully performed
for the relief of pyloric obstruction by Mr. Chance. The tempera¬
ture had been elevated at that time for two days only, and the case
was regarded as one of so-called “ ether pneumonia.” She was
discharged cured of her gastric troubles, and re-admitted a month
afterwards with the symptoms of ulcerative endocarditis. Exhibitor
desired to draw attention to the facts (1) that cases of so-called
ether pneumonia may be due to pneumococcus infection, and (2) that
pneumococcus infection of the lungs spreads more often than is
generally supposed to the general circulation, giving rise to
ulcerative endocarditis. This was the second case of the kind he
had shown within the last five months to that section. In the
previous case the heart affection had supervened on the pneumonia
nine days after an imperfect crisis, and the blood withdrawn during
life was proved culturally to contain the pneumococcus, whilst
abundant colonies were obtained post-mortem from the clot in the
right auricle. Illustrative slides and cultures were shown.
Dislocations of the Metatarsus on the Tarsus.
Professor Bennett submitted the accounts of two cases of
dislocation of the metatarsus on the tarsus which he had met with.
One the complete dislocation of the bases of the metatarsals upwards
and outwards ; the second an example of dislocation of the first,
second, and third metatarsals downwards beneath the tarsus. Of
this he showed a cast, and of the former the skiagraph, showing
that the dislocation had occurred without fracture of the base of
the second metatarsal. Having stated the facts of the cases, he
briefly reviewed the literature of the subject and described the
method of treatment of his cases.
Dr. Knott had seen one of Dr. Bennett’s cases. In Dr. R. Smith’s
cases the five metatarsal bones were displaced upwards and back¬
wards en masse on the tarsus, and the first metatarsal bone was
accompanied by a piece of the internal cuneiform bone. The
deformity was similar in each case. In Professor Bennett’s case
he thought that the displacement became more exaggerated, as it
travelled from the inside to the outside, that the first metatarsal
Avas least displaced, and also that the bones were somewhat
u scattered.” There was no over-riding which would cause fore¬
shortening of the foot, nor Avas the displacement upwards quite
complete.
Central Sarcoma of Bone.
Mr. W. I. De Courcy Wheeler read a paper on this subject.
285
Section of Pathology.
Dr. E. J. McWeeney said that the two microscopical sections
which he had prepared for Mr. Wheeler showed an enormous
number of giant cells or myeloplaxes. .The tissue resembled
normal bone marrow, with an extreme multiplication of the
myeloplaxes. The cells were of positively gigantic proportions,
and some possessed about a hundred nuclei. The nuclei of
many of the smaller round cells showed the mitotic figures,
but there was no evidence of the mitosis in the nuclei of the
myeloplaxes. Concerning the origin of the myeloplaxes,
Schafer’s picture represented the nuclei lobulated as though under¬
going direct division, but he (Dr. McWeeney) thought this very
improbable. Mr. Wheeler’s suggestion that such tumours should
be removed out of the class of sarcoma and called myelomata was
impossible, because the term myeloma was already appropriated
to a kind of tumour which is not identical with Mr. Wheeler’s.
Weichselbaum’s book described myeloma as a variety of small
round-celled tumours growing from the marrow of bones, but not
reproducing the giant-celled structure of marrow. It was multiple,
and originated either from skull bones or jthe bones of the vertebral
column, occurring in elderly people, and was often associated with
blood abnormality, so that Weichselbaum looked upon it as a
part of leukaemia or pseudo-leukaemia rather than a distinct tumour.
Regarding the tissue from which they originate, Mr. Bland Sutton
laid stress on the fact that periosteal sarcoma never contains giant
cells. Mr. Jackson Clarke states that some periosteal sarcomata
have a giant-cell character, and this was also the speaker’s opinion,
based on experience of a good many such growths. As for the
proposition of removing such tumours out of the sarcomata, he
thought it impossible, for the simple reason that there was an un¬
broken chain of intermediate links between a round or spindle-
celled sarcoma, with a very few giant cells, on the one hand, and
a sarcoma crowded with such cells on the other hand. In Mr.
Wheeler’s specimen there was no tendency whatever to the forma¬
tion of spicula of bone often characteristically formed in myeloid
sarcomata.
The President said that in the marrow of normal bones the
cells resembling the myeloplaxes are most commonly met with in
young bones, and are very rare in the marrow of adult animals.
Large cells were exceedingly common, but had not multiple nuclei,
but generally one nucleus of very irregular shape, and ex¬
tremely lobed and bossy, many of the lobes often connected
together by small threads or processes, but they were not nuclei
dividing. He thought that the pathological myeloplaxes were
286 Royal Academy of Medicine in Ireland.
something different from the normal giant cells of the marrow,
vdiich he looked on as osteoclasts. These cells showed multiple
nuclei, and very rarely karyokinetic figures. How the nuclei
divided in giant-celled sarcomata he did not know. He lately saw
a tumour which grew from a goat’s jaw which proved to be a
fibrous sarcoma, in which there were enormous numbers of giant
cells often arranged around bone undergoing absorption, while in
other places the bone had entirely disappeared, and there was
nothing but giant cells.
Mr. Wheeler, in reply, said there were no bony growths thrown
out in the tumour. He would like to know if material like that
occurring in the tumour shown by him was taken out of a similar
case, could it be possible, seeing that there was so much spindle-
celled element, to say positively that it was not a spindle- celled
sarcoma, but a myeloid sarcoma.
Two Vascular Tumours of Abdominal Wall.
Mr. R. Charles B. Maunsell showed two specimens which had
been successfully removed by operation. The first was removed
from the left lumbar region of a young lady aged 22, and had been
gradually growing from early childhood. It was as large as an adult
hand, and on examination proved to be formed of dilated lymphatic
spaces, and of the same character as the congenital cystic hygro¬
mata of the neck.
The second was removed from a baby 11 months old, and proved
to be a venous naevus. It had -been noticed shortly after birth
when it was not bigger than the head of a pin, and had rapidly
grown until at operation it measured 16 J X ll| cms., and covered
fully a third of the baby’s abdomen. It was ulcerated and con¬
stantly oozing blood. Mr. Maunsell removed it en masse , very little
blood being lost during the operation, the patient making an
uninterrupted recovery notwithstanding its tender age.
Pathological Conditions of the Tunica Vaginalis Testis.
Mr. Fagan, F.R.C.S.L, showed the following specimens: —
1. A large hydrocele opened longitudinally showing the relation
of the tunica vaginalis to the testis, and demonstrating the several
coverings of the tunica vaginalis, all of which were clearly shown
by dissection. The external spermatic and transversalis fasciae
were thin, the cremasteric fascia was thick and strong, and the
tunica vaginalis was thick.
2. A hydrocele associated with syphilitic disease of the testis.
The tumour was removed for pain from a man aged 50 who had
287
Section of Pathology,
syphilis 17 years previously. The testis felt stony hard ; the tunica
vaginalis was moderately distended, pain constant and unbearable.
3. A large hydrocele due to malignant papillary neoplasm of the
tunica vaginalis. Growth began first in the summer of 1898.
Hydrocele was tapped twice ; filled very rapidly after last tapping,
and lost its translucency. Scrotum became purplish and was covered
with distended veins. No history of injury, syphilis, or gonorrhoea;
patient in 66th year and healthy, not even suffering pain from tumour.
When tumour was opened a large quantity of yellowish black fluid
poured out, and the papillary growth became apparent. Castration
was performed April 12th, 1899. Patient left hospital April 22nd.
The microscopic characters were described by Professor
McWeeney, who pointed out how very interesting it was to see a
typical papillomatous carcinoma originating from an endothelial
membrane like the tunica vaginalis. The shape and appearance of
the cells were almost identical with those composing a villous
papilloma of the urinary bladder.
The President said that the specimen referred to by Dr.
McWeeney was interesting, because the epithelium covering the
sexual glands is, in the early stage, columnar in shape, and several
layers thick, and grows down to form the tubes of the ovary and
the tubes of the testicle, so that the specimen might be a recurrence
to the primitive type.
The Section then adjourned.
£
i
DISLOCATION OF BOTH HIPS.
Mauclaire and Preyost ( Gaz . des Hopitciux , October 29, 1898,
' p. 1144). A lighterman seeing another boat about to collide with
his, endeavoured to push it back with his extended legs, and was
thrown backwards. He sustained symmetrical iliac dislocations of
the hips.
ROYAL ARMY MEDICAL CORPS.
The Director-General of the Army Medical Service has forwarded
for publication the following list of successful candidates for com¬
missions in the Royal Army Medical Corps at the examination
held in London in July and August, 1899 : —
Marks
Marks
1
Harrison, L. W.
2,875
8 Harvey, F.
2,102
2
Irwine, F. S.
2,284
9 Trimble, C. E.
2,086
O
O
Morton, H. M.
2,260
10 Matthews, J.
2,084
4
Babington, M. H.
2,231
11 McLoughlin, W. M.
1,940
5
Richards, F. G.
2,150
12 Siberry, E. W.
1,816
6
Knox, E. B.
2,121
13 Wingate, B. F.
1,805
7
Roch, H. T.
2,115
14 O’Reilly, P. S.
1,800
MEDICAL EDUCATION AND EXAMINATIONS
IN IRELAND.
1899-1900.
Medical students in Ireland, as elsewhere, have in the first
instance to choose between University Degrees and Non-
University Qualifications or Diplomas. Should they elect
to try for an University Degree, their choice must lie
between the University of Dublin, which requires a Degree
in Arts before registrable Degrees in Medicine, Surgery, and
Midwifery are conferred, and the Royal University of Ireland,
which — while not requiring a full Arts Degree — yet rightly
insists on a liberal education in Arts, tested by more than
one searching examination in the same, before a candidate
graduates in the three branches of medicine already men¬
tioned — Medicine, Surgery, and Midwifery.
Outside the Universities, the chief Licensing Bodies are
the Royal Colleges of Physicians and Surgeons. The Con¬
joint Examination Scheme between the Royal College of
Surgeons in Ireland and the Apothecaries’ Hall of Dublin
has ceased to exist. The position of the latter body as a
Licensing Corporation under the Medical Act of 1886 has
been defined by the appointment of Examiners in Surgery
by the General Medical Council at the bidding of Her
Majesty’s Privy Council. The Royal Colleges are in a posi¬
tion to give a first-class working qualification in Medicine,
Surgery, and Midwifery— a qualification which is registrable
under the Medical Acts, which is universally recognised as one
of high merit, and the possession of which is attended by no
disabilities, such as preventing its possessor from dispensing
medicines or keeping open shop for the sale of medicines if
he is legally qualified to do so.
The Medical Schools in Ireland are — (1.) The School of
Physic in Ireland, Trinity College, Dublin ; (2.) The Schools
of Surgery of the Royal College of Surgeons in Ireland
(including the Carmichael College of Medicine and the
Ledwich School of Medicine) ; (3.) The Catholic University
Medical School, Cecilia-street, Dublin ; (4.) The School of
Medical Education and Examinations in Ireland . 289
Medicine, Queens College, Belfast; (5.) The School of
Medicine, Queen’s College, Cork; and (6.) The School of
Medicine, Queen’s College, Galway.
Facilities for Clinical Instruction in fully-equipped Medico-
Chirurgical Hospitals exist in Dublin, Belfast, Cork, and
Galway ; but, as a rule, the Schools of Medicine in Ireland
are not attached to a given hospital, or vice versa , as is the
case in London and other large centres of medical education.
The student will, however, have little difficulty in selecting
a hospital in the wards of which he will receive excellent
bedside teaching, and have ample opportunity of making
himself familiar with the aspect and treatment of disease.
The detailed information which follows is authentic, being
taken directly from the published calendars of the respective
licensing bodies.
REGULATIONS PRESCRIBED BY THE GENERAL
MEDICAL COUNCIL.
With regard to the course of Study and Examinations, which
persons desirous of qualifying for the Medical Profession shall go
through in order that they may become possessed of the requisite
knowledge and skill for the efficient practice of the Profession,
the General Medical Council have resolved that the following con¬
ditions! ought to be enforced without exception on all who com¬
mence their Medical Studies at any time after Jan. 1, 1892 : —
(a.) With the exception provided below, the period of Pro¬
fessional Studies, between the date of registration as a, medical
student and the date of Final Examination for any Diploma
which entitles its bearer to be registered under the Medical Acts ,
must be a period of bond fide study during not less than five
years.
(b.) In every course of Professional study and Examinations,
the following subjects must be contained : —
(I.) Physics, including the Elementary Mechanics of Solids and
Fluids, and the rudiments of Heat, Light, and Electricity.
(II.) Chemistry, including the principles of the Science, and the
details which bear on the study of Medicine.
(III.) Elementary Biology.
(IV.) Anatomy.
(V.) Physiology.
(VI.) Materia Medica and Pharmacy.
(VII.) Pathology.
(VIII.) Therapeutics.
T
290 Medical Education and Examinations in Ireland.
(IX.) Medicine, including Medical Anatomy and Clinical Medicine.
(X.) Surgery, including Surgical Anatomy and Clinical Surgery.
(XI.) Midwifery, including Diseases peculiar to Women and New¬
born Children.
(XII.) Theory and Practice of Vaccination.
(XIII.) Forensic Medicine.
(XIV.) Hygiene.
(XV.) Mental Disease.
The first four of the five yearsi of Medical Study should be
passed at a School or Schools of Medicine recognised by any of
the Licensing Bodies, provided that the First Year may be passed
at a University, or Teaching Institution recognised by any of
the Licensing Bodies, where the subjects of Physics, Chemistry,
and Biology are taught.
A student who has, previous to registration, attended a course
or courses of study in one or all of the subjects, Physics, Chemistry,
or Biology, in any University, School of Medicine, or Teaching
Institution recognised by any of the Licensing Bodies, may without
further attendance be admitted to examination in these subjects :
provided always that such course or courses shall not be held to
constitute any part of the five years’ course of professional study.
The exception referred to above in (a) is as follows : —
Graduates in Arts or Science of any University recognised by
the General Medical Council who shall have spent a year in the
study of Physics, Chemistry, and Biology, and have passed an
Examination in these subjects for the Degrees in question, are held
to have completed the first] of the five years of Medical Study.
The Examinations in the Elements of Physics, Chemistry, and
Biology should be passed before the beginning of the Second
Winter Session.
I.
University of Dublin.
DEGREES AND DIPLOMAS IN MEDICINE, SURGERY, AND
MIDWIFERY.
The Degrees and Diplomas in Medicine, Surgery, and Midwifery
granted by the University are as follows : — <
The Degrees are: —
1. Bachelor in Medicine.
2. Bachelor in Surgery.
3. Bachelor in Obstetric Science.
4. Doctor in Medicine,
5. Master in Surgery.
< 6. Master in Obstetric Science.
Medical Education and Examinations in Ireland. 291
The Diplomas are: —
1. Diploma in Medicine.
2. Diploma in Surgery.
3. Diploma in Obstetric Science.
Besides these Degrees and Diplomas, the University also
grants a — •
Qualification in Public Health or State Medicine.
REGULATIONS FOR STUDENTS WHO MATRICULATED ON OR
BEFORE 25th NOVEMBER, 1891.
As the number of students who matriculated before November,
1891, is now small, it seems unnecessary to print in full the con¬
ditions which must be fulfilled in order that such candidates should
qualify for the Degrees in Medicine (M.B.), Surgery (B.Ch.), and
Midwifery (B.A.O.). The Registrar of the School of Physic in
Ireland will supply all information on application to him.
REGULATIONS FOR STUDENTS WHO MATRICULATED
SINCE 1891.
The following conditions musit be fulfilled in order to qualify
for the Degrees in Medicine (M.B.), Surgery (B.Ch.), and Mid¬
wifery (B.A.O.) : —
I. The Student must be of B.A. standing, and his name must
be for at least five (Academic) years on the Books of the Medical
School, reckoned from the date of his Matriculation. He may
carry on his Arts Course concurrently with his Medical Course,
and he need not, have, taken his B.A. before presenting himself
for his Final Medical Examination, but he cannot have the Medi¬
cal Degrees conferred without the! Arts Degree.
II. The following Courses must have been attended: —
[Note. _ The Courses marked thus (*) must have been taken out before'
the Student can present himself for any part of the Final Examina¬
tion. In addition, the Courses marked thus (+) must have been
taken out before he can present himself for Section B ; the Courses
marked thus (J) before he can present himself for Section C ; and the
Courses marked thus (§) before he can present himself for Sections
D and E.]
1. LECTURES.
WINTER COURSES.
* Systematic Anatomy.
* Practical Anatomy (with Dis¬
sections), ls£ year.
* Practical Anatomy (with Dis¬
sections), 2 nd year.
* Applied Anatomy (with Dis¬
sections).
* Chemistry .
f Surgery .
* Physiology ( two Courses).
f Practice of Medicine.
\Midwif ery .
f Pathology .
292 Medical Education and Examinations in Ireland.
* Practical Chemistry.
* Practical Histology.
* Botany .
* Zoology .
SUMMER COURSES.
* Materia Medica and Thera¬
peutics.
i Medical Jurisprudence and
Hygiene.
§ Operative Surgery.
TERM COURSES.
* Physics. — Michaelmas, Hilary, and Trinity Terms.
§2. HOSPITAL ATTENDANCE.
1. Three Courses of nine months’ attendance on the Clinical
Lectures of Sir Patrick. Dun’s or other Metropolitan Hospital
recognised by the Board of Trinity College.
Students who shall have diligently attended the practice of a
recognised London or Edinburgh Hospital for one year, of a
recognised County Infirmary, or of a recognised ColoniarHospital,
for two' years previous to the commencement of their Metropoli¬
tan Medical Studies, may be allowed, on special application to
the Board of Trinity College, to count the period so spent as
equivalent to one year spent in a recognised Metropolitan Hos¬
pital.
§3. PRACTICAL VACCINATION.
One month’s instruction in Practical Vaccination to* be attended
at the Vaccine Department, Local Government Board for Ireland,
45 Upper Sackville-street ; at No. 1 East Dispensary, 11 Emerald-
street; or, until further notice, at the Grand Canal-street Dis¬
pensary.
§4. MENTAL DISEASE.
. A Certificate of attendance on a three months’ Course of Practical
Study of Mental Disease in a recognised Institution.
if 5. PRACTICAL MIDWIFERY.
A Certificate of attendance on a six months’ Course of Practical
Midwifery with Clinical Lectures, including not less than thirty
cases.
§6. OPHTHALMIC SURGERY.
A Certificate of attendance on a three months’ Course of
Ophthalmic Surgery.
III. The following Examinations must be passed : —
The Previous Medical or Half M.B. Examination.
The Final Examination.
The! Previous Medical Examination must be passed in all its
Medical Education and Examinations in Ireland. 293
parts before any part of the Final can be entered for, except' in
the case of Candidates for Diplomas.
A. - PREVIOUS MEDICAL EXAMINATION.
This Examination isi divided into —
1. Physics and Chemistry.
2. Botany and Zoology.
3. Anatomy and Institutes of Medicine (Practical Histology
and Physiology).
The Examination in Anatomy includes examination on the
dead subject.
Before presenting himself for examination in any of the sub¬
jects the Student must have obtained credit for the corresponding
Courses of Lectures and Practical Instruction.
The Final Examination is arranged as follows: —
FIRST PART.
Section A.
Applied Anatomy (Medical and Surgical), paper.
Applied Physiology, viva, voce.
Materia Medica and Therapeutics, paper and viva, voce.
Section B.
Medical Jurisprudence and Hygiene, paper and viva, voce.
Medicine, paper and viva voce.
Surgery, paper and viva voce.
Pathology, paper and viva voce.
Section A may be passed in any part of the Fourth Year, pro¬
vided the corresponding Curriculum shall have been completed ;
Section B not before Trinity Term of the Fourth Year.
Section A must be passed before the Candidate can present him¬
self for Examination in Section B. Both Sections must be passed
at least one Term before the Candidate can present himself for
Exmination in Sections C, D, or E.
Fee for the Liceat ad Examinandum £5, to be paid when the
Candidate enters for Section A.
SECOND PART.
Section C.
Midwifery , paper and viva voce.
Gynaecology, paper and viva, voce.
Obstetrical Anatomy, paper.
Section D.
Clinical Medicine.
Mental Disease.
294 Medical Education and Examinations in Ireland.
Section E.
Clinical Surgery.
Operations.
Ophthalmic Surgery.
One Section of die Second Part must be passed in Trinity Term
of the Fifth Year, or subsequently. The other two> may be passed
in any Term of the Fifth Year, provided the corresponding Cur¬
riculum shall have been completed. Subject to this provision
the Sections may be taken in any order.
Fee for the Liceat ad Examinandum £5, to be paid when the
Candidate enters for the Section for which he first presents him¬
self.
UNIVERSITY DIPLOMAS.
Candidates for the Diplomas in Medicine, Surgery, and Obste¬
tric Science must be matriculated in Medicine, and must have com¬
pleted two1 years in Arts, and five years in Medical Studies.
The datesi, regulations, and subjects, of Examination are. the
same as for the Final Examination, except that it is not necessaiy
to attend the Courses of Lectures in Botany and Zoology, nor to
pass the Previous Medical Examination in these subjects.
A Diplomate on completing his Course in Arts, and proceeding
to the Degree of B.A. may become a Bachelor, by attending the
Lectures, on Botany and Zoology, passing the Previous Medical
Examination in those subjects, and paying the Degree Fees.
The Liceat fees are the same as for the Degrees.
Each Candidate who has completed the prescribed Courses of
study and passed all the Examinations will be entitled, if a
Graduate in Arts, to have conferred on him the Degrees of M.B.,
B.Ch., B.A.O., on payment to the Senior Proctor of the Degree
Fees amounting to <£17. A corresponding regulation applies to
the Diplomas, the Fees for which are <£11. He will also obtain
from the Senior Proctor a Diploma, entitling him to be entered
on the Register of Medical Practitioners under the Medical Act,
1886.
QUALIFICATION IN PUBLIC HEALTH OR STATE MEDICINE.
The Diploma in Public Health is conferred, after examination,
by the University of Dublin, upon Candidates, fulfilling the follow¬
ing conditions, : —
1. The Candidate must be a Doctor in, Medicine, or Graduate
in Medicine and Surgery, of Dublin, Oxford, or Cambridge.
2. The name of the Candidate must, have been on the Medical
Register at least twelve months before the Examination.
Medical Education and Examinations in Ire, land. 295
3. TI10 Candidate must have completed, subsequent to Regis¬
tration, six months in a Laboratory, recognised by the Provost and
Senior Fellows, in practical instruction in Chemistry and Bacteri¬
ology applied to Public Health, and also have attended, practically,
outdoor Sanitary work for six months, under an approved Officer
of Health.8,
The Examination for 1899 will begin on December 11th.
II.
Royal University of Ireland.
COURSES FOR DEGREES IN MEDICINE, SURGERY, xANI)
OBSTETRICS.
General Regulations.
The Course for these Degrees! shall be of at least five Medical]
years’ duration ; but Graduates in Arts or Science who shall have
spent a year in the study of Physics, Chemistry, and Biology, and
have passed an Examination in these subjects for the Degrees in
question, shall be held to have completed the first of the five years
of Medical Study.
Students who commenced their Medical Studies after Jan. 1,
1892, must furnish evidence of having been registered by the
Medical Council, as Students in Medicine, for at least 57 months,
before being admitted to the M.B., B.Ch., and B.A.O. Degrees
Examination.
No one can be admitted to> a Degree in Medicine who is not
twenty-one years of age.
All Candidates for these Degrees, in addition to- attending the
lectures and complying with the other conditions to be from lime
to time prescribed, must pass the following Examinations: —
The Matriculation Examination.
The First University Examination.
The First Examination in Medicine.
The Second Examination in Medicine.
The Third Examination in Medicine.
The Examination for the M.B., B.Ch., B.A.O. Degrees
The Course of Medical Studies shall be divided into five Periods
of one Medical Year each.
Candidates shall furnish proper Certificates of attendance at
the several Courses of Medical Instruction prescribed for the
different years of the curriculum.
a This condition does not apply to Practitioners registered, or entitled to
be registered, on or before 1st January, 1890.
296 Medical Education and Examinations in Ireland.
No such certificate will be received unless it attests! a bona fide
attendance at three -fourths of the whole Course. Students are
reminded that certificates of attendance at Eight lectures will
not be accepted.
No* Certificates! of instruction in any of the Courses of Medical
Studies, in connection with either Lectures or Hospitals, can be
received, unless issued by an Institution which has been formally
recognised by the Senate.
The prescribed courses in Natural Philosophy, Chemistry, Bio¬
logy, Anatomy and Physiology must be attended in Institutions
provided with the appliances required for the performance by the
Students of proper Experimental Courses and Practical Work in
those subjects.
Where Certificates in a special department (Fever, Mental
Diseases, Ophthalmology, Ac.) are presented, they must be signed
by the Physician or Surgeon in charge of such department.
THE EXAMINATION FOB THE M.B., B.Ch., BA.O. DEGBEES.
Candidates may present themselves for this Examination after
an interval of such period, not being less than one Medical
Year from the time of passing the Third Examination in Medi¬
cine*, as the Senate may from time to time prescribe, provided
they shall have completed the entire Medical Curriculum.
Printed forms of application for admission to this Examination
may be had from “the Secretaries, the Royal University .of
Ireland, Dublin.”
This Examination consists of three parts : — •
(a.) Medicine, Theoretical and Clinical, including Therar
peutics, Mental Diseases, Medical Jurisprudence,
Sanitary Science, and Medical Pathology.
(b.) Surgery, Theoretical, Clinical, and Operative, including
the use of Instruments and appliances; Surgical
Anatomy; Ophthalmology and Otology,51 Surgical
Pathology.
(c.) Midwifery and Diseases of Women and Children.
All Candidates must enter for and go through the entire
Examinajtion, but a Candidate may be* adjudged to have passed
in any of the foregoing parts; in which’ he , satisfies* the Examiners.
Upon completing satisfactorily his Examination in all three
a Candidates at this Examination must exhibit reasonable proficiency
in the use of the Ophthalmoscope and Laryngoscope.
Medical Education and Examinations in Ireland . 297
divisions, the Candidate will receive, in addition to the parch¬
ment Diplomas recording hisi admission to the M.B., B.Ch.,
B.A.O. Degrees, a Certificate of having passed a Qualifying Ex¬
amination in the subjects of Medicine, Surgery, and Midwifery.
The fee for this Certificate is Ten Pounds , which must be paid
before admission to these Degrees.
DIPLOMA IN SANITARY SCIENCE.
This Diploma is conferred only on Graduates in Medicine of the
University.
Candidates may present themselves for this Examination after
an interval of twelve months from the time of obtaining the M.B.,
B.Ch., B.A.O. Degrees.
Printed forms of application for admission to this Examination
may be had from “ the Secretaries, the Royal University of Ireland,
Dublin.”
Every Candidate must, when entering for the Examination,
produce — a
(a.) A Certificate of having, after obtaining the M.B. , B.Ch.,
B.A.O. Degrees , attended during a period of six months
Practical Instruction in a Laboratory approved by the
University. The nature of this course is fully indicated
by the detailed Syllabus' of the Examinations in Phy¬
sics, Climatology, Chemistry, Microscopy, Bacteriology,
&c.
(b.) A Certificate of having, after obtaining the M.B. , B.Ch.,
B.A.O. Degrees, for six months practically studied the
duties of out-door Sanitary work under the Medical
Officer of Health of a County or large Urban District.
The Subjects of this Examination are : —
Physics ;
Climatology ;
Chemistry ;
Microscopy ;
Bacteriology ;
Geology;
Sanitary Engineering ;
Hygiene, Sanitary Law, and Vital Statistics.
The Candidaite must draw up reports on the Sanitary condition
of Dwelling Houses, or. other buildings selected for the purpose.
a These rules (a), (b), shall not apply to Medical Practitioners registered
or entitled to be registered on or before Jan. 1, 1890.
298 Medical Education and Examinations in Ireland.
N.B. — Proficiency in practical work and an adequate ac¬
quaintance with the instruments and methods- of research which
may be employed for Hygienic investigations are indispensable
conditions! of passing the Examination.
DIPLOMA IN MENTAL DISEASES.
This Diploma is conferred only on Graduates in Medicine of
the University.
Printed forms of application for admission to this Examination
may be had from “ the Secretaries, the Royal University of Ireland,
Dublin.”
The subjects! for this Examination are those prescribed for
the Hutchinson Stewart Scholarship for proficiency in the treat¬
ment of Mental Disease.
Belfast.
Queen’s College.
Clinical instruction is given at the Belfast Royal Hospital. The
Ulster Ho-spital for Diseases of Women and Children, the Belfast
Maternity Hospital, the Belfast Ophthalmic Ho-spital, the Ulster
Eye, Ear, and Throat Hospital, the Belfast District Lunatic
Asylum, and the Belfast Hospital for Sick Children are open to
students.
A pamphlet containing full information can be had free on
application to the Registrar, Queen’s- College, Belfast.
Cork.
Queen’s College.
Clinical instruction isi given at the North and South Infirmaries
(each 100 bedsp Students also can attend the Mercy Hospital
(60 beds), the Cork Union Hospital, the County and City of Cork
Lying-in-Hospital, the Maternity, the Hospital for Diseases of
Women and Children, the Fever Hospital, the Ophthalmic and
Aural Hospital, and the Eglinton Lunatic Asylum. The session
at Queen's College extends from October to April inclusive (twenty-
seven weeks), but the hospitals are open to students in May, June,
and July also, and arrangements have been made for the delivery of
siome of the three months’ Courses! of lectures during the mouths
of April, May and June.
Medical Education and Examinations in Ireland. 299
Galway.
Queen’s College.
Clinical instruction is given at the Galway County Infirmary
and the Galway Town Hospital.
Prizes. — Attached are eight scholarships! of the value of <£25
each. The Council may award Exhibitions to matriculated
students at the examinations for junior scholarship. All scholar¬
ships and exhibitions of the second, third, and fourth years may
be competed for by students who have attained the requisite stand¬
ing in any medical school recognised by the College Council, and
have passed the Matriculation Examination in the College, or in
the Royal University of Ireland.
III.
Royal Colleges oe Physicians and Surgeons,
Ireland.
OUTLINE MEDICAL COURSE APPLICABLE TO CANDIDATES
FOR THE LICENCES OF THE ROYAL COLLEGES.
These Regulations apply to Candidates commencing Medical Study
after 1st January , 1892.
1. Enter for and pass a Preliminary Examination recognised by
the General Medical Council.
2. Register as a Medical Student on a form obtainable at
Royal College of Surgeons from the Registrar.
(Dissections
the
o
O.
Enter for and
attend Courses for the
First Professional Ex¬
amination.
Winter
six months
>
-(Chemistry
(Physics
(Practical Chemistry
Summer )phar
three months |Biology
£5
o
O
3
5
3
3
o
3
o
O
5
3
Q
£23 2
4. Enter for and pass the First Professional Examination.
Subjects of Examination.
jl. (a) Chemistry; ( h ) Physics.
Fee, £15 15s. (2. Practical Pharmacy.
(Matriculated Pupils, )S. Elementary Biology. .
4. Anatomy, viz. — Bones, with attach¬
ments of muscles and ligaments
— Joints.
R.C.S., £10 10s. See note,
page 304).
300 Medical Education and Examinations in Ireland .
Candidates may take this Examination as a whole at one time , or in
four parts , hut no portion earlier than the end of the first Winter Session.
(Hospital (9 months) £12 12
Anatomy
Dissections
Physiology
Examination. I Summer (Histology
xhree months [Materia Medica
5
3
5
3
3
5
3
5
3
£32 11
Materia Medica may he deferred to the Third Year ,
6. Enter for and pass the Second Professional Examination.
Subjects of Examination.
1. Anatomy. — The Anatomy of the whole
Human Body.
Fee, £10 10s. 2. Histology.
3. Human Physiology) ;f t deferred.
{ 4. Materia Medica j
The Candidate must present himself at least in Anatomy and
Histology; if he pass in either of these subjects, he may, at the
discretion of the Examiners, get credit therefor. Physiology and
Materia Medica may, at the option of the Candidate, be postponed
to Examinations held during the third year.
fjgf" The Lectures on Physiology must be attended before
admission to any part of the Second Professional Examination.
\
7. Enter for and
attend Coursesforthe )
Third Professional
Examination.
Winter
six months
Hospital (18 monthsa) £25
Summer
three months
Dissections
Medicine
Surgery
Midwifery
Pathology
'Operative Surgery
Public Health and
Forensic Medicine
3
3
3
3
5
4
5
3
3
3
3
5
3 3
£51 9
8. Enter for and pass the Third Professional Examination.0
Subjects of Examination.
1. Medicine.
2. Surgery.
Fee, £9 9s. {3. Pathology.
4. Therapeutics.
5. Public Health and Forensic Medicine.
a In addition to that attended in the Second Year, with evidence of attend¬
ance in Fever Wards.
b This examination cannot be taken earlier than the end of the Fourth
Winter Session.
Medical Education and Examinations in Ireland. 301
A Candidate must present himself, in the first instance at least,
in Medicine, Surgery, Therapeutics, and Pathology. Should he
pass in any of these he may, at the discretion of the Examiners,
get credit therefor. Public Health and Forensic Medicine may be
postponed.
9. Enter for and attend
Courses for the Final Exami¬
nation.
<
Maternity Hospital,0 £6 6s.,
£8 8s., or ... £10 10
Ophthalmic Certificate ... 3 3
Vaccination a ... 1 1
Clinical Instruction in
Mental Diseases a ... 3 3
£17 17
10. Enter for and pass the Final Examination.
Subjects of Examination.
1. Medicine, including Medical Anatomy
and Mental Diseases.
2. Surgery, including Operative Sur¬
gery, Surgical Anatomy, Ophthal-
Fee, £6 6s. < mic and Aural Surgery.
3. Midwifery, including Diseases of
Women and New-born Children,
j and the Theory and Practice of
Vaccination.
Every Candidate must produce evidence that he has acted as
Medical Clinical Clerk for three months, and as Surgical Dresser
for three months.
Candidates are not admissible to the Final Examination earlier
than the end of the Fifth Year of Medical Study.
Candidates may enter for and pass separately in Medicine,
Surgery, and Midwifery.
Colonial Candidates who have taken out a portion of the Course,
or have passed Examinations in Australia and elsewhere, have
been accorded certain exemptions, which may be learned on appli¬
cation to the Secretary of the Committee of Management.
We are indebted to The Lancet , Sept. 2, 1899, for the following
Table, which we have revised and corrected in some minor
points : —
a May be taken in the Fourth Year.
302
Medical Education and Examinations in Ireland.
Tabular List of the Classes , Lecturers , and Fees at t (
Dublin
Dublin.
Dublin,
University
R. C. of Surgeons
Catholic Universit i
- - 1
Lectures, &c.
Lecturers
Lecturers
Fees
Lecturers
F
Histology and Physiology
• •
Prof. Scott
CO
Dr. Coppinger and
Dr. Coffey t
Anatomy, Descriptive
Dr. Cunningham
Prof. Fraser
Dr. Birmingham
and Surgical
ou
o
.
Practical Anatomy and
Dissections
Dr. Cunningham
Prof. Fraser
o
■4-3
• F-4
«
Dr. Birmingham,!
assisted by Drs.
Fagan and Dempsey
»
1:
Chemistry -
Dr. Reynolds
) Profs. Sir C. Cameron
4-3
o
a
1 Dr. Campbell,
j assisted by
Practical Chemistry
Dr. Reynolds
f and Lapper
£
( Dr. Frengley
t
Materia Medica and
Dr. W. G. Smith
Prof. Sir G. F. Duffey
to
IQ
lO
Dr. Quinlan*
Pharmacy
Botany and Zoology
Dr. Wright
Profs. Minchin and
a
Dr. Sigerson t and
Prof. Mackintosh
Cosgrave §
fCJ
Q
Dr. Blaney
t
"
Institutes of Medicine
Dr. Purser
Prof. A. H. White
•4-3
O
Dr. Me Ween ey
►
and Pathology
c3
plj
Natural Philosophy
• •
• •
CO
Prof. Stewart!
1
Hospital Practice
Sir P. Dun’s
or other
The various Dublin
Hospitals
»-o
UO
w
The various Dublin
Hospitals
c
j
Dublin Hospital
bh
«
l
<
J
Clinical Lectures
• •
• •
r—i
3
m
o »
Surgery -
Dr. E. H. Bennett
) Profs. Sir W. Stokes
u
<x>
04
Mr. P. J. Hayes and
i
«
c
Dr. E. H. Bennett
1" and W. Stoker
Mr. McArdle
Operative Surgery
t/5
<
<
Midwifery, &c.
Dr. A. V. Macan
Prof F.W. Kidd
1C
Si
Dr. A. J. Smith
p
Medicine -
Dr. Finny
Prof. J. W. Moore
4-3
c3
Sir C. J. Nixon
f,
4
Medical Jurisprudence -
Dr Bewley
Prof. Auchinleck
Mr. Roche
c
C
c
Comparative Anatomy -
Prof. Mackintosh
• •
o
t»
( V
ft
Dr. Sigerson and
Dr. Blaney f
l
4
i
<
Practical Pharmacy -
Dr. W. G. Smith
Prof. Sir G. F. Duffey
X
0>
«T
0)
Dr. Quinlan
<
<
t
Logic - -
The College Tutors
• •
CO
c3
5
• •
[ Medical Registrar:
c
C
Dr. Birmingham]
r
Physics -
Prof. FitzGerald
Prof. Lapper
c
•H
Prof. Stewart!
0
c
Pathology -
Mr. O’Sullivan
Prof. Arthur H. White
w
CO
CO
Dr. McWeeney
c<
c<
<4
Ophthalmology and
Royal Victoria
Profs. Jacob, Fitzgerald
o
o n
u
3
Dr. Werner
Otology
Hospital
and Story
o
O
Hygiene -
Dr. Bewley
Sir Charles Cameron
Mr. Roche
* In Summer.
t In Winter and in Summer
Medical Education and Examinations in Ireland.
303
iical Schools of Ireland for the Session 1899-1900.
Belfast
Queen’s College
Cork
Queen’s College
Galway
Queen’s College
Fees
Fees
Fees
Lecturers
(D
Lecturers
<D
-4-3 C/3
Lecturers
<13
-4J on
» U
m
Xfl
fru O
O
s6
£ s.
£ s.
£ s.
*. W. H. Thompson
3 0
)
3 0
Dr. Pye
3 0
Dr. J. Symington
2 0
j- Dr. J. J. Charles
• •
Dr. Pye
2 0
>r. Symington and
3 0
Dr. Charles and
3 0
Dr. Pye and
3 0
Demonstrators
Demonstrators
Demonstrators
Dr. Letts
2 0
Dr. Augustus E. Dixon
2 0
Dr. Senier
2 0
Dr. Lettsf
3 0
Dr. Augustus E. Dixon
3 0
Dr. Senier
3 0
Dr. W. Whitla
2 0
Dr. C. Y. Pearson
2 0
Dr. Colalian
2 0
R. 0. Cunningham}:
2 0
Professor Hartog
2 0
Dr. R. J. Anderson
2 0
each
• •
• •
• •
• •
Dr, Lynham
2 0
trof. W. B. Morton
2 0
Prof. William Bergin
2 0
Professor Anderson
2 0
lust Royal and other
• •
North and South
• «
Galway Hospital, Gal-
Sess.
Hospitals
Infirmaries
way Union Hospital, and
5 0
Galway Fever Hospital
• •
• •
• •
• •
Drs. Kinkead, Pye,
• •
Brereton, Colahan, and
Lynham
Dr. Sinclair
2 0
Dr. S. O’Sullivan
2 0
Dr. W. Brereton
2 0
Dr. Sinclair*
2 0
D;\ S. O’ Sullivan
2 0
• «
• •
Dr. J. W. Byers
2 0
Dr. Corby
2 0
Dr. Kinkead
2 0
Dr. Lindsay
2 0
Dr W. E. Ashley Cum-
2 0
Dr. Lynham
2 0
mins
Dr. Hodges
2 0
Dr. C. Yelverton Pearson
2 0
Dr. Senier >
Dr. Kinkead >
1 U
• 9
• •
• 4
• •
[. Modern Languages:
• •
Professor Steinberger]
r. V. G. L. Fielden
2 0
Dr. C. Yelverton Pearson
• •
• »
2 0
Professor J. Park
2 0
Professor Stokes
1 0
Professor French
2 0
r. J. Lorrain Smith
• •
2 0
Dr. Cotter
• •
2 0
Dr. M‘Kelvey
• •
2 0
r. W. A, M‘Keown
2 0
Dr. Sandford
• •
••
• •
■>r. E. A. Letts and
2 0
Dr. Donovan
• •
••
r. Henry Whitaker
} Zoology in Winter ; Botany in Summer. § Including Biology.
304 Medical Education and Examinations in Ireland .
MARKING.
(a) A numerical system of marks, ranging from 0 to 10, is now
in use.
(b.^ A uniform standard of 50 per cent. is the passing mark m
all subjects, and in all examinations.
(c.) In deciding as to whether a candidate has passed in any
subject or not, the marks in all the divisions! of the subject
written, oral, and practical — are considered together; provided,
however, that bad answering in the clinical portion shall not be
compensated for by excellence in the other portions of the subject.
EQUIVALENT EXAMINATIONS.
Candidates are referred for detailed information to the Official
Regulations published by the Colleges!.
MATRICULATION AS PUPIL OF THE ROYAL COLLEGE OF
SURGEONS.
All persons proceeding to* the study of Medicine may, if approved
by the Council, become matriculated pupils of the College on pay¬
ment of five guineas, and having done so, will enjoy the follow¬
ing privileges : —
1. They will, if matriculated before the preliminary exami¬
nation, be admitted on payment of <£1 lsi. (half fee).
2. They will be permitted to study in the Library and Museums
of the College. _ - .
3. Their fee for the First Professional Examination will be
reduced by <£5 5s.
DATES OF CONJOINT EXAMINATIONS.
Preliminary - March and September.
Professional - - - April, July, and October.
REGULATIONS FOR CANDIDATES FOR THE CONJOINT
DIPLOMA IN STATE MEDICINE.
%
The following regulations are compulsory on all Candidates
beginning the study of Sanitary Science after January 1st, 1894 ;
the date of commencement of study being fixed by the date of
the certificates.
Stated Examinations for the Diploma in State Medicine com-
Medical Education and Examinations in Ireland. 305
mence on the first Tuesday of the months of February, May, and
November, and occupy four days.
A special Examination for the Diploma, can be obtained — •
except in the months of August and September — on payment of
.£5 5s., in addition toi the ordinary Fees! mentioned below, and on
giving notice at least one fortnight before the date of the pro¬
posed Examination.
Every Candidate for the Diploma in State Medicine must be a
Registered Medical Practitioner. He must return his name to
die Secretary of the Committee of Management under the Con¬
joint Scheme, Royal College of Physicians, Dublin, three weeks)
before the Examination, and lodge with him a Testimonial of
Character from a Fellow of either of the Colleges!, or of the Royal
Colleges of Physicians or Surgeons of London or Edinburgh, to¬
gether with certificates of study as hereinafter set forth.
Candidates registered as Medical Practitioners or entitled to be
so registered after 1st January, 1890', must comply with certain
Resolutions passed by the General Medical Council on December
1st, 1893, in regard to Diplomas in State Medicine.
%* the Rules as to study shall not apply to Medical Practi¬
tioners registered, or entitled to be registered, on or before January
1st, 1890.
*** The Executive Committee [of the General Medical Council]
has power, in special cases, to- admit exceptions to the Rules
for the Registration of Diplomas in Sanitary Science, and report
the same to the General Council.
The Fee for the Examination isi Ten Guineas, which must be
lodged in the Ulster Bank, Dublin, to- the, credit of the Committee
of Management, at least two weeks beforei the elate fixed for the
Examination. Fees are not returned toi any Candidate! who with¬
draws from, or is rejected at, any Examination. The Fee for
re-examination is Five Guineas.
The Examination for the Diploma in State Medicine; comprises
tne following subjects: State Medicine and Hygiene, Chemistry,
Meteorology, and Climatology, Engineering, Morbid Anatomy,
Vital Statistics, Medical Jurisprudence, Law.
IY.
Apothecaries’ LIall in Ireland.
T he First, Second, and Third Professional Examinations are held
four times a year— viz., commencing the third Monday in January,
April, July, and October.
U
306 Medical Education and Examinations in Ireland.
The final Examinations are held in January and July.
The Fees payable for each Examination are as follows : —
First Professional
Second „
Third
Final Examination
Ladies who comply with the regulations will be admitted to
these examinations.
Candidates may be admitted to a Special Examination, under
special circumstances, which must be laid before the Examination
Committee. If the Candidate’s application be granted, an extra
fee of Ten Guineas over and above the full fee is required.
Candidates already on the Register will receive the Diploma
of the Hall, on passing an Examination in the subjects which are
not covered by their previous qualifications, and on paying a fee
of Ten Guineas. If Medicine or Surgery is required, Two Guineas
extra will be charged.
£5 5 0
5 5 0
5 5 0
6 6 0
COURSE OF STUDY FOR THE DIPLOMA.
Candidates who desire to obtain the Letters Testimonial of the
Apothecaries’ Hall in Ireland must, before proceeding to the
Final Examination, produce evidence of having been registered as
a Medical Student for 57 months ; also of having attended Courses
of Instruction as follows : —
Winter Courses of Six Months .
One Course each of the following : —
Anatomy (Lecture).
Chemistry — Theoretical.
V
Midwifery.
Practice of Medicine.
Physiology, or Institutes of Medicine.
Surgery.
Dissections, two courses of six months each.
Courses of Three Months.
One Course of each of the following : —
Materia Medica.
Medical Jurisprudence.
Chemistry — Practical.
Practical Physiology and Histology.
Operative Surgery.
Physics.
Medical Education and Examinations in Ireland . 307
Clinical Ophthalmology.
Biology.
Clinical Instruction in Mental Disease.
Pathology.
Vaccination.
Medico-Chirurgical Hospital, twenty-seven months, to be distri¬
buted at the Student’s own discretion over the last four years of
his study. The Candidate may substitute for nine months in this
Hospital Attendance six months as a Resident Pupil. He will be
required to present a certificate of having taken notes of at least
six Medical and six Surgical cases recorded under the supervision,
respectively, of a Physician and Surgeon of his Hospital.
Three months’ study of Fever — which may be included in his
twenty-seven months’ Hospital Attendance — in a Hospital con¬
taining Fever Wards, and having taken notes of five cases of
Fever — viz., either Typhus, Typhoid, Scarlet Fever, Small-pox or
Measles.
Six months’ Practical Midwifery and Diseases of Women during
the Winter or Summer of the third or the fourth year, at a recog¬
nised Lying-in Hospital, or Maternity.
Three months’ Practical Pharmacy, in a recognised Clinical
Hospital or a recognised School of Pharmacy, or a year in
the Compounding Department of a Licentiate Apothecary or a
Pharmaceutical Chemist.
Each Candidate, before receiving his Diploma, must produce
evidence that he has attained the age of twenty-one years.
EXAMINATIONS FOR THE DIPLOMA.
All information relative to the Examinations may be obtained
from the Registrar of the Apothecaries’ Hall, 40 Mary-street,
Dublin.
Dental Education and Examinations in Ireland.*1
The Royal College of Surgeons in Ireland grants Diplomas in
Dental Surgery under conditions of which the following is a
synopsis : —
The Candidate must be twenty-one years of age.
The Candidate must have passed three Examinations.
1. Preliminary (identical with the Medical Preliminary).
a Fuller particulars can be obtained by application to the Registrar,
Royal College of Surgeons, St. Stephen’s-green, Dublin.
308 Medical Education and Examinations in Ireland.
2. Primary Dental. Fee, £40* l 2 3 4 5 6 7 8 9 10 11 10s. (This Examination is
much the same as the Second Conjoint Professional.)
3. Final Dental Examination. Fee, £10 10s. Candidates
are examined in Dental Surgery and Pathology, and
in Mechanical Dentistry and Practical Metallurgy.
Candidates are required to do gold fillings, and con¬
struct mechanical work in the presence of the Examiners.
The Certificate required may be divided into General and Special.
1. The General Certificates required are about the same as
those required by the Medical Student for the Second
Conjoint Professional Examination.
The Special Certificates may be subdivided into — -
1. Dental Hospital. 2. Practical Mechanical Dentistry.
1. Dental Hospital. Two years’ attendance, with Lectures
in Dental Surgery and Pathology and in Mechanical
Dentistry and Orthodonty. Fee, £28 7s.
2. Practical Mechanical Dentistry. Three years’ instruc¬
tion from a Registered Dentist. The fee for this is
variable, but may be set down at from £50 to £150.
Large reductions in the' Special Certificate® required are' made
in the case® of qualified Medical Practitioners.
INDIAN MEDICAL SERVICE.
The Military Secretary, India Office, has sent for publication the
following list of the candidates for Her Majesty’s Indian Medical
Service who were successful at the competitive examination held
in London on July 28, 1899, and following days : —
Marks Marks
1 MacGilchrist, A. C. 3,151 12 Thornely, M. H. 2,400
2 Goodbody, C. M. 2,867 13 Stephen, L. P. 2,356
3 Megaw, J. W. D. 2,732 14 Murison, C. C. 2,335
4 Thurston, E. O. 2,619 15 Murphy, W. O’S. 2,261
5 Steen, R. 2,571 16 Beit, F. V. O. 2,172
6 Maclnnes, J. L. 2,565 17 Mackenzie, H. M. 2,139
7 Gilbert, L. 2,550 18 Long, W. C. 2,085
8 Browse, G. 2,542 19 Todd, L. B. 2,046
9 Matthews, E. A. C. 2,497 20 Corry, M. 1,945
10 Stokes, T. G. N. 2,415 21 Beamish, G. C. 1,943
11 Elwes, F.T. 2,410 22 Williams, H. A. 1,939
SANITARY AND METEOROLOGICAL NOTES.
Compiled b/ J. W. Moore, B.A., M.D. Uiiiv. Dubl. ;
P.R.C.P.I.; F. R. Met. Soc. ;
Diplomate in State Medicine and ex-Sch. Trin. Coll. Dubl.
Vital Statistics
For four Weeks ending Saturday , September 9, 1899.
The deaths registered in each of the four weeks in the twenty-
three principal Town Districts of Ireland, alphabetically arranged,
corresponded to the following annual rates per 1,000 : —
Towns,
Ac.
Week ending
Aver¬
age
Towns,
<fcc.
Week ending
Aver¬
age
Aug.
19
Aug.
26
Sept.
2
Sept.
9
Rate
for4
weeks
Aug.
19
Aug.
26
Sept.
2
Sept.
9
Rate
for 4
weeks
23 Town
250
247
257
28-3
25-9
Limerick
81
23*9
8-4
351
19*0
Districts
Armagh -
14-3
71
28-5
14-3
167
Lisburn
17-0
8-5
42-6
17*0
21-3
Ballymena
22-5
o-o
457
5-6
18-3
Londonderry
157
23-6
201
361
24-0
Belfast
21-8
26-5
247
237
24-0
Lurgan
137
4-6
18-2
137
12-6
Carrickfer-
29-2
5-8
117
17-5
167
Newry
81
28-2
81
121
141
gus
Clonmel -
19-5
97
73-0
4-9
26-8
Newtown-
ards
17-0
o-o
397
28-3
21*3
Cork
23-5
22-8
277
277
25*4
Portadown -
247
247
247
371
27*8
Drogheda -
26-6
3-8
H'4
22-8
161
Queenstown
57
23-0
287
17-2
187
Dublin
34-5
307
29-4
■367
32-8
Sligo
20-3
51
10-2
0-0
8-9
(Reg. Area)
Dundalk -
4-2
29-3
33-5
29-3
241
Tralee
5-6
o-o
16*8
o-o
5-6
Galway
34-0
151
37-8
7-6
23-6
Waterford -
21-9
21*9
13-9
517
271
Kilkenny -
33’0
47
18-9
14-2
177
I
W exford
271
13*5
181
181
19-2
In the week ending Saturday, September 9, 1899, the mortality
in thirty-three large English towns, including London (in which the
rate was 22*2), was equal to an average annual death-rate of 25:2
per 1,000 persons living. The average rate for eight principal
towns of Scotland was 22*6 per 1,000. In Glasgow the rate was
23'3. In Edinburgh it was 21 *2.
The average annual death-rate represented by the deaths regis¬
tered during the same week in the Dublin Registration Area and
310 Sanitary and Meteorological Notes.
in the twenty-two principal provincial Urban Districts of Ireland
was 28-3 per 1,000 of their aggregate population, which, for the
purpose of this return, is estimated at 1,053,188.
The deaths from the principal zymotic diseases in the twenty-
three districts were equal to an annual rate of 7*0 per 1,000, the
rates varying from 0-0 in nine of the districts to 18*6 in Porta-
down — the 8 deaths from all causes in that district including 3
from diarrhoea. Among the 159 deaths from all causes registered
in Belfast are 4 from whooping-cough, 8 from enteric fever, and
19 from diarrhoea. The 40 deaths in Cork include 1 from measles
and 15 from diarrhoea. There were 6 deaths from diarrhoea in
Londonderry, 3 in Limerick, 2 in Newry, and 2 in Wexford.
In the Dublin Registration Area the births registered during
the week amounted to 198 — 96 boys and 102 girls; and the deaths
to 251 — 140 males and 111 females.
The deaths, which are 93 over the average number for the
corresponding week of the last ten years, represent an annual rate
of mortality of 37*4 in every 1,000 of the population. Omitting
the deaths (numbering 5) of persons admitted into public institu¬
tions from localities outside the area, the rate was 36*7 per 1,000.
During the thirty-six weeks ending with Saturday, September 9,
the death-rate averaged 28*5, and was 1*2 over the mean rate for
the corresponding portions of the ten years 1889-1898.
The number of deaths from zymotic diseases registered was 83,
being 15 over the number registered in the preceding week, and
54 in excess of the average for the 36tli week of the last 10 years.
The 83 deaths comprise 17 from measles, 2 from scarlet fever
(scarlatina), 2 from influenza, 2 from whooping-cough, 1 from
diphtheria, 7 from enteric fever, 5 from simple cholera and choleraic
diarrhoea, 42 from diarrhoea (being 26 in excess of the average
number of deaths from that cause in the corresponding week of the
last ten years, and 6 over the number for the previous week), 1
from anthrax, and 1 from erysipelas. Fifty-nine of the 83 deaths
from zymotic diseases — including 15 from measles, 2 from scar¬
latina, and 39 from diarrhoeal diseases — occurred among children
under 5 years of age, those from diarrhoeal diseases comprising 25
infants under one year old.
The cases of measles admitted to hospital during the week
amounted to 43, being 4 over the number admitted in the pre¬
ceding week, but 23 under the admissions in the week ended
August 26. Forty measles patients were discharged, 6 died, and
127 remained under treatment on Saturday, being 3 under the
number in hospital at the close of the preceding week.
311
Sanitary and Meteorological Notes.
Seven cases of scarlatina were admitted to hospital, against 4
in the preceding week and 11 in the week ended August 26.
Eight patients were discharged during the week, one died, and 45
remained under treatment on Saturday. This number is exclusive
of 18 convalescents at Beneavin, Glasnevin, the Convalescent Home
of Cork-street Fever Hospital.
The number of cases of enteric fever admitted to hospital, which,
havino- risen from 41 in the week ended August 19 to 64 in the
following week, fell to 47 in the week ended September 2, rose to
61. Twenty-five patients were discharged during the week, 2 died,
and 214 remained under treatment on Saturday, being 34 over the
number in hospital at the close of the preceding week.
The admissions to hospital included 3 cases of typhus fever and
one of diphtheria : 3 cases of the former disease and 2 of the
latter remained under treatment on Saturday.
Thirty-one deaths from diseases of the respiratory system were
registered, being 13 over the average for the corresponding week of
the last ten years, and 18 over the number for the previous week.
They consist of 18 from bronchitis and 13 from pneumonia.
Meteorology
5?
A bstraet of Observations made in the City oj Dublin , Lat. 53° 20,
IV., Long. 6° 15' W., for the Month of August , 1899.
Mean Height of Barometer, - 30*070 inches.
Maximal Height of Barometer (on 1st, at 9 a.m.), 30*392
Minimal Height of Barometer (on 29th, at 7 p.m.). 29*595
Mean Dry-bulb Temperature, - 62*2°
Mean Wet-bulb Temperature, - - 59*5°.
Mean Dew-point Temperature. - 57*3°
Mean Elastic Force (Tension) of Aqueous Vapour, *469 inch.
Mean Humidity, - 84*6 per cent.
Highest Temperature in Shade (on 24th), - 77*8°.
Lowest Temperature in Shade (on 10th), - 49*1°.
Lowest Temperature on Grass (Radiation) (10th) 44*0°.
Mean Amount of Cloud, - 39*0 per cent.
Rainfall (on 10 days), - - 3*784 inches.
Greatest Daily Rainfall (on 5th), - - 2*227 inches
General Directions of Wind, - E., E.N.E.,
W.
Remarks.
August, 1899, was the hottest experienced for very many years.
In Dublin the mean temperature was 63*4°, or 3*7° above the
average and 0*4° above that of August, 1893, hitherto the record
312 Sanitary and Meteorological Notes.
August as to warmth. It was a month of paradoxes — the rainfall
was much in excess, the rainy days were much in defect; the
weather was dry, the air was damp ; easterly and westerly winds
were the most prevalent. In and near Dublin thunderstorms of
quite exceptional violence occurred between the 4th and 6th, the
thunder and lightning on the night of the 5th being to some
observers magnificent, to others appalling. The excessive rainfall
accompanying this storm is noteworthy — it amounted to 2-227
inches in Dublin (Fitz william-square). It was the fifth occasion
only since 1865 — that is, in 35 years — upon which 2 inches have
been measured in Dublin at 9 a.m. as the product of the previous
24 hours’ precipitation. The previous excessive falls were — August
13, 1874, 2-482 inches; October 27, 1880, 2-736 inches; May 28,
1892, 2-056 inches; and July 24, 1896, 2*020 inches. The
“splashes” of rain on the 3rd of the month (-300 inch), the 5th
(2-227 inches), and the 31st (*696 inch) contributed 85 percent, of
the entire precipitation, which was 3-784 inches. The measure¬
ment on the 5th alone equalled 59 per cent, of the total fall. The
amount of cloud was singularly small — only 39-0 per cent.; at 9
a.m. it was 47*4 per cent., at 9 p.m. it was as low as 30-5 per cent.
In Dublin the arithmetical mean temperature (63*4°) was
decidedly above the average (59*7°) ; the mean dry-bulb readings
at 9 a.m. and 9 p.m. were 62-2°. In the thirty-four years ending
with 1898, August was coldest in 1881 (M. T. — 57-0°), and
warmest in 1893 (M. T.=63-0°). In 1898 the M. T. was 61*4° ; in
1879 (“the cold year”) it was 57*7°. August, 1899, thus estab¬
lished a record for high temperature.
The mean height of the barometer was 30*070 inches, or 0-173
inch above the corrected average value for August — namely, 29*897
inches. The mercury marked 30-392 inches at 9 a.m. of the 1st,
and fell to 29-595 inches at 7 p.m. of the 29th. The observed
range of atmospheric pressure was, therefore, 0*797 inch.
The mean temperature deduced from daily readings of the dry-bulb
thermometer at 9 a.m. and 9 p.m. was 62*2°. It was 1-1° above
the value for July, 1899. Using the formula, Mean Temp.—
Min. + (max. — min. X *47), the mean temperature was 63*0°, or
3*7° above the average mean temperature for August, calculated in
the same way, in the twenty-five years, 1865-89, inclusive (59-3°).
The arithmetical mean of the maximal and minimal readings was
63-4°, compared with a twenty-five years’ average of 59*7°. This
is the highest value for August since the present series of observa¬
tions was commenced in 1865. On the 24th the thermometer in
the screen rose to 77*8° — wind, S.S.E. ; on the 10th the temperature
313
Sanitary and Meteorological Notes.
fell to 49*1° — wind, E. The minimum on the grass was 44-0°,
also on the 10th.
The rainfall was 3*784 inches, on 10 days. The average rainfall
for August in the twenty-five years, 1865-89, inclusive, was 2*825
inches, and the average number of rainy days was 15*5. The
rainfall, therefore, was considerably in excess of the average, while
the rainy days were much below it. In 1874 the rainfall in August
was very large — 4*946 inches on 18 days; in 1868, also, 4*745,
inches fell on, however, only 13 days ; but the heaviest downpour
in August occurred in 1889, when 5*747 inches were registered on
22 days. On the other hand, in 1884, only *777 inch was measured
on 8 days. In 1898, 3*456 inches fell on 18 days.
High winds were noted on 9 days, but never attained the force
of a gale in Dublin. Thunder occurred on the 5th, 6th, 25th and
27th. Lightning was seen on the 3rd, 6th, 11th and 27th.
Violent thunderstorms prevailed on the 4th, 5th and 6th. Tem¬
perature reached 70° in the screen on 18 days. Solar parhelia
were seen on the 24th. The atmosphere was foggy on the 3rd, 4th,
7th, 11th, 21st, 22nd and 28th.
The rainfall in Dublin during the eight months ending August
31st amounted to 18*200 inches on 117 days, compared with 16*516
inches on 124 days in 1898, 19*388 inches on 149 days in 1897,
14*464 inches on 120 days in 1896, 9*455 inches on 96 days
during the same period in 1887, and a twenty-five years’ average
of 17*558 inches on 128*1 days.
At Knockdolian, Greystones, Co. Wicklow, the rainfall in August
was 2*640 inches on 11 days, compared with 3*185 inches on 18
days in 1898, 6*195 inches on 27 days in 1897, and 1*245 inches
on 14 days in 1896. Of this quantity 1*610 inches fell on the
5th. The total fall since January 1 amounts to 25*630 inches on
120 days, compared with 17*830 inches on 112 days in 1898, 25*945
inches on 143 days in 1897, 14*327 inches on 91 days in 1896,
22*685 inches on 107 days in 1895,25*206 inches on 131 days in
1894, and 16*341 inches on 106 days in 1893.
At the National Hospital, Newcastle, Co. Wicklow, the rainfall
in August was 1*877 inches on 13 days, compared with 3*803
inches on 16 days in 1898, and 4*526 inches on 20 days in 1897,
*966 inch being measured on the 5th, and *334 inch on the 3rd.
Since January 1, 1899, the rainfall at this Second Order Station
has been 23*748 inches on 117 days compared with 20*101 inches
on 110 days in the first 8 months of 1898. The maximal tem¬
perature in the shade was 74*6° on the 1st, the minimum tem¬
perature was 47*0° on the 16th.
PEEISCOPE.
EXAMINATION OF CANDIDATES FOR THE ROYAL ARMY MEDICAL
CORPS AND HER MAJESTY’S INDIAN MEDICAL SERVICE.
The following papers were set for the recent Examinations : —
Medicine and Pathology. — Professor McCall Anderson. Friday,
28th July, 1899, from 10 a.m. to 1 p.m. N.B. — The replies to be
written with the ink provided, and not with a pencil or pale ink.
1. A man, aged 36, had for some months been below par, and was
losing flesh and colour, but continued at work, until one day, when
he rapidly became comatose. On recovering consciousness, it was
found that his right arm and leg were completely, while the lower
segment of the face on the same side was partially, paralysed, and
to every question he returned for answer either (i Yes ” or u No.”
His heart was not sound, but there were no murmurs, and dropsy
was absent. Pie had never had syphilis. Fill in the picture of all
the additional symptoms which might be present. G-ive the
diagnosis in full, and what would you find post-mortem in the event
of a fatal issue ? 2. Give an account of the indirect (pressure)
symptoms which may be encountered in cases of aneurysm of the
arch of the aorta. 3. Give a short sketch of the complications of
diabetes mellitus. 4. How can you satisfy yourself (a) that pus
is present in the urine, (h) that it comes from the pelvis of the
kidney, and (c) how would you treat the condition ?
Surgery. — Sir William MacCormac, Bart., K.C.Y.O. Friday,
28th July, 1899, from 2 p.m. to 5 p.m. All four questions to be
answered. 1. How is a dislocation backwards of the hip joint
produced? Give the diagnosis and treatment of the injury.
2. What are the different forms of cystic disease met with in the
female mamma? Give the pathology, symptoms, and treatment
of each variety. 3. For what conditions may iridectomy be re¬
quired ? Describe the operation, and give the after treatment of a
case. 4. State fully the considerations which would influence your
decision as to the treatment, either by amputation or by excision,
of a case of tuberculous disease of the knee-joint in a young adult.
Anatomy and Physiology. — Dr. Cunningham. Saturday, 29th
July, 1899, from 2 p.m. to 5 p.m. 1. Describe the fascia of the
psoas muscle, the fascia iliaca, and the fascia transversalis, laying
particular stress upon those connections which bear upon the
anatomy of psoas abscess, and of femoral and inguinal hernia.
2. Describe u Hunter’s Canal,” and state clearly the relative
position of the parts contained within it. 3. Give the form,
position, and relations of each suprarenal body, and mention what
you know of its function. 4. Describe the optic nerve, the optic
Periscope. 315
chiasma, and the optic tract, and state the central connections of
the fibres which form the optic tract.
Chemistry and Materia Meclica. — Dr. Norman Moore. Saturday,
29th July, 1899, from 10 a.m. to 1 p.m. 1. What is the composi¬
tion of chloroform ? How is it prepared ? 2. State the com¬
position, and explain, with formulae, the chemical preparation of
(1) sulphuric acid, (2) hydrochloric acid, (3) nitric acid, (4) carbolic
acid. 3. What rules regulate the strength of tinctures in the
latest edition of the British Pharmacopoeia? Give examples.
4. What is opium? What alkaloids does it contain ? What are
its official preparations, and what the strength of each? 5. What
are the therapeutic uses of mercury and of its salts ? What are
their official preparations and doses ?
Natural Sciences. — Dr, Norman Moore. Friday, 4th August,
1899, from 2 to 5 p.m. Candidates may answer not more than six
questions, and they must confine themselves to two branches of
science only. Geology and Physical Geography : — 1. IIow would
you recognise an extinct volcano ? What traces of volcanic action
are to be observed in the British Isles ? 2. What are the chief
fossils of the mountain limestone ? What beds lie immediately
above and what immediately below that rock in the British Isles ?
3. Describe the effects of (1) glacial action, (2) earthquakes.
Physics : — 1. Describe Attwood’s machine and explain its use.
2. State the facts which demonstrate that, with the exception of
tidal energy, all the work done in the world is due to the sun.
3. Explain the electrical phenomena illustrated and the apparatus
necessary in sending an ordinary telegraphic message. Botany : —
1. Give the characters of the following natural orders : (1) Primu-
laceae, (2) Iridacem, (3) Convolvulacem, (4) Linacem, (5) Poly-
gonacem. Describe the structure of an orchis, and explain the
method of fertilisation in that genus. 2. What is the botanical
nature of (1) ergot of rye, (2) potato disease, (3) smut of corn, (4)
lily disease? 3. Define the following terms: — (1) Umbel, (2)
spike, (3) capitulum, (4) raceme, (5) placenta, (6) albumen, (7)
bract, (8) petiole, (9) sepal, (10) cyme, and give an example of
each. Zoology : — 1. How would you recognise a poisonous snake?
Describe the structure of the skull and the anatomy of the poison
apparatus in any such snake. What difference of action is there
between the poison of the cobra and that of a viper? 2. Name
the entozoa which inhabit the human body, and describe fully the
structure and development of any one form. 3. Describe the
placentation of (1) the elephant, (2) the mare, (3) the cow, (4) the
cat ; and the dentition of (a) the sheep, (6) the rabbit, (c) the dog,
(d) the sloth.
|n Itlcmorhim.
JAMES CUMING, M.D., A.M., R.U.I.; F.R.C.P.!.;
PROFESSOR OF MEDICINE, QUEEN’S COLLEGE, BELFAST.
With much regret we chronicle the death of this distin¬
guished member of the medical profession on the night of
Sunday, August 27, 1899, in the sixty-seventh year of his age.
Pkofessok Cuming was a great physician and a courtly Irish
gentleman. We are indebted to the Belfast News-Letter of
Tuesday, August 29, 1899, for the following able sketch of his
life and work : — •
It is with deep regret that we have to record the death of Professor
James Cuming, M.A., M.D., F.R. C.P.I. , which occurred unexpectedly
at midnight on Sunday. Dr. Cuming, who occupied a prominent place
in the medical profession, and whose skill, not less than his integrity
and public spirit, has been familiar for many years to1 almost every
resident in the North of Ireland, was seized with a severe attack of
influenza more than twelve months ago, from which he never made
complete recovery. Indeed, in the summer of 1898 he was obliged to
relinquish his duties for some weeks, and in the succeeding winter,
finding the strain of College lectures too heavy for him, he was relieved
by Doctor Lindsay in this, one of the very numerous departments of
his work. Of vigorous temperament and exhaustless energy, he
continued, from the commencement of the present year almost up to
the hour of his death the performance of the multifarious duties asso¬
ciated with an immense practice, active membership of learned
societies, and devoted service of some of our worthiest local institutions,
with which he had been long associated. For some time past, however,
he was attended by Professor Whitla and Dr. Lindsay, who, it is
scarcely necessary to state, were unremitting in attention to their
eminent colleague. Dr. Cuming’s city residence was 33 Wellington-
place, Belfast, but the closing days of his life were spent at Green-
island, where, in company with liis sister, Miss Cuming, his
son, Mr. Francis Cuming, a member of the English Bar, and his
daughter, the Honourable Mrs. Russell, who is married to the eldest
son of Lord Russell of Killowen, he resided at Loughside. His death
was wholly unexpected — the previous day he had been attending to
professional duties in Belfast — and the news of it came as a painful
shock to his relatives, friends, colleagues, and the wide circle of his
acquaintance. Late on Sunday evening he was seized with a severe
attack of coughing, followed by much exhaustion, and shortly before
midnight he summoned liis son and daughter to his bedside. They
arrived immediately, only to find the end fast approaching, and within
a few minutes he breathed his last, death being due to heart failure.
The late Professor Cuming, son of the late Mr. Edward Cuming of
$tt flftemonam*
Markethill, County Armagh, was born early in 1833 in that town, and
was consequently in his 67th year. Having received his early tuition
at the Royal School in Armagh, he entered in the session of 1849-50
Queen’s College, Belfast, of which he was one of the earliest students.
Devoting his attention to both science and art — medicine being his
especial study — it was not long before he gained collegiate distinctions,
followed by a brilliant career in the late Queen’s University, in which he
became a Doctor of Medicine in 1855, and a Master of Arts in 1858.
He distinguished himself in most branches of science, and was senior
scholar in chemistry, his ardent interest in this pursuit being the
foundation of a close friendship with the late Professor Andrews,
then Vice-president of the College. Having completed his univer¬
sity course, he left Belfast, carrying with him the good wishes of
every fellow-student, for the Continent, where he studied under
Charcot in Paris, imbibing from this famous scientist his love for
the treatment of nervous diseases. With additional knowledge, ac¬
quired in Vienna and other centres of learning and research, he returned
to Belfast and began to practise in the city, where he married Miss
M'Loughlin, a member of one of the oldest Roman Catholic families in
Belfast, and at that time one of the great beauties of Ulster. In 1865
he was appointed to the chair of Theory and Practice of Medicine
in the Queen’s College, on the death of Professor Creary Ferguson,
for whom, during his illness, he had on several occasions lectured. The
same year he became staff physician to the Royal Hospital, an . nsh-
tution with which he was: identified up to the time of his death ;
latterly as senior physician and president of the medical staff. The
distinction was conferred upon him in 1876 of being elected to the
Fellowship of the Royal College of Physicians of Ireland. Though not a
voluminous writer, his contributions to medical literature are not
likely to be forgotten. Among the most important of these may be
numbered his “ Contributions to the Study of some Thoracic Diseases, ”
published in 1868, and his “Treatise on the Pathology of Delirium
Tremens, ” which was in print a year later. His private practice
rapidly extended, and during the last two decades he has been called in
to consult with other practitioners concerning thousands of critical cases,
with the result that his memory will be gratefully cherished in many
families who attribute the rescue of a loved one to his skilful advice. In
1882, on the dissolution of; the Queen’s University, the honorary degree of
Doctor of Science was conferred upon him, and two years later, when the
annual meeting of the British Medical Association was held in Belfast, he
had the especial honour of being elected president of that body. He filled
the chair with great dignity and ability, which found recognition in his
subsequent choice as a vice-president of the Association. As a mattei
of fact he held every post of honour in connection with the medical
profession, being president of the Ulster Medical Society on two
occasions, president of the North of Ireland Branch of the British
Medical Association, and Lord Chancellor’s Visitor in Lunacy (a post
to which he was appointed by Lord O’ Hagan). The study of mental
diseases was one which, together with that of the heart and neivous
troubles, he enthusiastically pursued, and his opinions were often sought
In fttmnuam.
on special occasions. He took the deepest interest in the work of the
Asylum Board, of which for a quarter of a century he was a member,
and barely a fortnight ago he presided over the monthly meeting of that
body, at which it was resolved to hold a special conference for the
consideration of the important subject of providing accommodation for
the harmless lunatics in the Workhouse. By a melancholy coincidence
the special meeting in question was to have been held in the Town
Hall at noon yesterday, and it was only at that time that most of the
members received the news of the sudden death of Dr. Cuming, who
latterly had directed their procedure as an efficient, experienced, and
painstaking chairman. To the late professor’s devotion to the Royal
Hospital during over a quarter of a century reference has already
been made, but it may be added that he acted as a representative of the
staff on the Royal Victoria Hospital committee, and quite recently,
when the plans of the new building were finally settled, he took the
deepest interest in them, and thoroughly supported the originality of
the architect’s design. For many years, too, lie was consulting physi¬
cian to the Ulster Eye, Ear, and Throat Hospital, a position which
he occupied with sound judgment and tact. His patients not only
found his remarkable professional skill devoted to the most critical
forms of illness, but that the physician was also the friend, taking
a most kindly interest in the everyday concerns of their life. Esteemed
greatly by them, he enjoyed perhaps the still higher regard of his
colleagues, occupying a unique position in the medical profession and
being consulted on all points of difference where sound judgment, not
always of a purely professional nature, became “requisite. He was a
man of the very highest culture and scholarship, possessing keen literary
tastes. An accomplished linguist, he spoke several modem languages,
and more especially French and German, with great fluency. His
example was of enormous value to the younger members of the pro¬
fession, as indicating the importance of all-round culture. He had a .
thorough knowledge of the ancient classics, as well as of modem works,
his moments of leisure being spent almost exclusively in the com¬
panionship of books, and up to the last he was completely conversant
with the best examples of latter-day authorship. Quite recently, at
the Literary and Scientific Society of Queen’s College, Belfast, he
read a most interesting paper on Horace — his favourite poet — whom,
together with Heine and Goethe, it was his wont to discuss brilliantly
before the members of the old Belfast Literary Society.
Professor Byers, a college colleague, whose father was born in the
same neighbourhood and attended the same school as the
late Hr. Cijming, called to see him at Wellington-place on
the Friday preceding his death. On that occasion Dr. Cuming men¬
tioned that he had decided to visit America in the Oceanic, in the
company of the Right Honourable W. J. and Mrs. Pirrie, by whom he
had been invited to make the passage, and of the Lord Chief Justice.
But he added in his quiet, thoughtful way the words which now
form such pathetic reading — “ If nothing happens between
this and the day of sailing. ” On Saturday, August 26th,
as already mentioned, Dr. Cuming left Greenisland, where
In fttcmoram.
lie lias been in country residence for twelve months or so, to visit
Strandtown and Windsor, but was seized with cardiac asthma the
same night. On Sunday he spent a restless day, .and between eleven
and twelve o'clock at night he had another alarming seizure, and
died in the presence of his son, daughter, and sister. The late Dr.
Cuming’s wife predeceased him five or six years ago, and the relatives
who most closely feel his loss are those already mentioned, togethei
with his brother, Mr. Edward Cuming, a member of the North-East
Bar of Ireland. In the medical and philanthropic world he will be
long and sincerely mourned ; his death lias removed by no means the
least distinguished and valued among the citizens of Belfast.
The death of Dr. Cuming is a grievous loss (writes an intimate friend
and colleague) to the medical profession and the public of the North
of Ireland. His was a unique personality, such as arises only now
and again in any locality or in any profession. He was much more
than an erudite and skilful physician, and an accomplished scholar.
He was a man of universal attainment to whom no branch of liberal
culture was unfamiliar, and he possessed a personality which exer¬
cised a remarkable influence over those with wdiom he was brought
into contact. His sagacity had almost passed into a proverb 'with his
medical brethren, and his advice and assistance were specially prized
in cases and circumstances of exceptional difficulty. He was, in truth,
as he was so often called, “the Nestor of his profession, ” a title which
has seldom been more justly bestowed: Wisdom, the fruit of wide
culture and large experience, was, indeed, his leading characteristic.
Seldom have there been found united so great a range of knowledge
and such various attainments with such complete absence of ostenta¬
tion and self-consciousness as in the case of the deceased physician.
Dr. Cuming seemed unconscious of his own greatness, and was always
ready to discuss any question of medicine, science, or general knowledge
on equal terms with any of his brethren. His intellectual acuteness,
breadth of view, and knowledge of affairs and men have seldom been
excelled and would have secured him eminence in any profession. As
a physician, his leading characteristics w'ere an all-embracing knowledge
of medical science and a degree of reticence and caution which some¬
times seemed excessive to those who failed to reflect that this was
founded upon a most exceptional familiarity with all the multifarious
possibilities of disease. Dr. Cuming refused to dogmatise because he
hng-yy^ jjg £g-yy men knew, how protean are the operations of nature,
how unfathomable are the possible ranges of natural law. To him
“modest doubt” was ever “the beacon of the wise.” His attitude
towards younger and cruder minds, prone to flatter themselves that
they could see further than he was able to do, was ever that of playful
banter and benignant toleration. Unlike the majority of mankind, he
always knew more than he professed to know. “I always understate
my case,” was a remark once made by him to the writer of these
recollections. Those who knew him best would unanimously agree
that, while the physician was great, the man was greater. Dr.
Cuming gave an impression of power and faculty which did not find
an entirely adequate field for their exercise in the profession of
lit iitcmort'am.
Medicine, and it is to be regretted that his reluctance to engage in
I authorship has deprived the world of the full fruits of his large
knowledge and exceptional experience. His literary taste was fine
and true, and he wrote a vigorous and polished style, but he has left
very few published works behind him. Dr. Cuming had read widely
in the classics and in the chief modern languages. Horace was a great
favourite with him, and it is not straining facts to say that in genial
wisdom, charming drollery, kindliness of disposition, and delightful
“urbanitas” he had much in common with the great humorist and
poet of the Augustan age. Among the moderns, Shakespeare, Goethe,
Wordsworth, Tennyson, and Browning were his chief delight. In philo¬
sophy he ranked Spinoza and Herbert Spencer very highly, and was
inclined to undervalue Plato and Kant. He put a high value upon
general culture and disapproved of the present-day tendency to make
medical education concern itself too exclusively with physical science.
To the outside world Dr. Cuming seemed chiefly the grave and
reserved physician, but those who enjoyed his intimate friendship
I found him a delightful companion, full of knowledge, wit, and wisdom,
playful and genial even when under the shadow of failing health, an
accomplished raconteur, and a charming conversationalist. As an
after-dinner speaker, he was often most happy, by turns grave and
gay, full of apt quotation and felicitous allusion, and with a wit
which sparkled, but never wounded. His was essentially a large and
tolerant nature, incapable of meanness or unkindness, loyal to friends,
magnanimous to opponents. It is not surprising that with such
qualities and endowments he should have achieved a position of
unique influence and distinction, or that he should have been for many
years the acknowledged head of the medical profession in the North
of Ireland. His memory will be long cherished by his colleagues, his
patients, and the larger world to which he was so conspicuous a figure,
but most of all by the inner circle which alone fully knew his worth
and which sorrowfully recognises that it will not look upon his like
again.
THE DUBLIN JOUKNAI
OF
MEDICAL SCIENCE.
NOVEMBER 1, 1899.
PART I.
ORIGINAL COMMUNICATIONS.
- - -
Art. XV. — Sarcoma of the Suprarenale and secondarily of
the Lungs? By J. Magee Finny, M.D. Dubl.; Past
President of the Royal College of Physicians of Ireland ;
King’s Professor of Practice of Medicine in the School of
Physic, Ireland ; Physician to Sir P. Dun’s Hospital.
The specimens I exhibit are the left lung and the supra-
renals, which are the seat of sarcoma, and, by the kindness
of Dr. O’Sullivan, Lecturer in Pathology, Trinity College,
Dublin, there are under the microscopes several sections ot
the diseased organs.
The patient from whom these specimens were obtained
was admitted to Sir Patrick Dun’s Hospital on 13th
October, 1898, and died 20th November, 1898.
The following notes of the case were compiled from
those taken by Mr. Gibbon Fitzgibbon, my clinical clerk,
to whom I am indebted for his careful and accurate daily
records : —
The patient was sixty-six years of age, a labourer in the gas
works, and complained of cough, copious expectoiaiion and debility.
He looked very haggard and emaciated, and his complexion was
notably darker than that of any other patient in the ward, or what
we are accustomed to see in those labourers exposed to the heat and
a Read before the Section of Pathology of the Royal Academy of Medi¬
cine in Ireland, Friday, February 24, 1899.
VOL. CVIII. — NO. 335, THIRD SERIES.
X
322 Sarcoma of the Suprarenale.
vapours at the gas works, who apply for medical aid at the
hospital.
The arteries on his forehead, and the radials, were tortuous and
atheromatous. The ascending aorta was dilated, and caused an
area of dulness and pulsation in the second and third right inter¬
costal spaces near the sternum. A double murmur was audible in
this area, but as it was limited to it, and the pulse was not collaps¬
ing, it was considered to be due to an atheromatous dilated vessel
rather than obstructive and regurgitant disease of the aortic
valves ; the cardiac area of dulness was not discernible owing to
the emphysematous condition of the border of the left lung, and
the cardiac impulse was indistinctly defined in its normal position.
There was no dexiocardia.
Examination of the lungs showed the right to be normal, except
for emphysema ; but the left side was dull on percussion over the
lower lobe behind from the fourth rib down, and this dulness did
not pass further forward than the mid-axillary line. The dulness
did not change on change of posture, and over this area there was
an absence of respiratory and vocal sounds, and of vocal fremitus.
The upper part of the thorax on the left side in front gave a
modified skodaic resonance. It was plain therefore that we had
to deal with a case of encysted pleurisy. One or two unusual features
were noted — (1) that the decubitus of the patient was on or
towards the right or healthy side ; and (2), that an area of acute
sensitiveness and tenderness to pressure existed over the fourth
and fifth ribs and intercostal spaces near the nipple.
On November 4th the pleura was explored in the scapular line
at the ninth interspace and a syringeful of bright red fluid was
withdrawn, which on examination was found to be blood-stained
serum, with some leucocytes in it, but these were healthy.
On November 7th a trochar and canula was inserted twice, but
no fluid was withdrawn, although with an exploring needle and
hypodermic syringe half an ounce of fluid was withdrawn similar
to that of the 4th.
As there was no special urgency to tap, and as the nature
of the fluid and. the constitutional cachexia made me
consider it a case of cancer of the pleura, no further
attempt to withdraw the fluid was made then or sub¬
sequently, and there were no changes noticed in the
physical signs, except that, a few days later, a distinct
friction sound was audible under the pectoral fold in front
of the mid-axillary dulness already referred to. The urine
323
By Dr. J. M. Finny.
was examined on several occasions and found free from
albumin. During the last week of his life he suffered from
sleeplessness, progressive weakness, and nocturnal sweat¬
ings. The sputum was examined for tubercle bacilli on
two occasions with a negative result.
The pulse was usually between 104 and 120. The res¬
piration was not increased, and the temperature rose
generally every second day to 101°— 10T6°, and fell to
subnormal or normal on the intermediate day.
The patient died of asthenia on 20th November, 1898.
The post-mortem was made by Dr. Littledale, our then
House Surgeon, and the contents of the thorax, the dia¬
phragm, and the kidneys were removed en masse , and
revealed a very interesting pathological study : —
The heart was greatly hypertrophied, without much, dilatation
of the cavities ; the mitral valve was healthy ; the aortic valves were
thickened, but not ulcerated, and capable of meeting and closing
the opening ; the coronaries were calcified, and the aorta presented
an excellent example of calcareous plates and rugosities, with very
great and general dilatation, producing, in fact, a cylindvoid
aneurysm.
The left pleura costalis was enormously thickened, and contained
a quantity of blood, which was encysted to the posterior half of that
side. The lower lobe of the left lung was a mass of soft, grumous,
bloody detritus, which when scooped out left a ragged cavity,
without any limiting membrane, and showed a sarcoma infiltrating
to more or less depth the rest of the middle part of the lobe.
Below the diaphragm, but unattached to it, the seat of the left
adrenal was occupied by a tumour the size of a foetal head, and
which lay above and upon the left renal arteries and veins, and
pressed into the left kidney. It was a mass of sarcoma rapidly
breaking down, and full of blood. When emptied of its contents
the sac was distinct from the kidney, while into its infiltrated walls
a small probe could be passed from the left lenal vein. A. similai
condition, but to a much smaller extent — not larger than a
pullet’s egg — was found in the right suprarenal body.
Thus the case was one in Avhich the left bloody pleurisy
played but a small part, except so far as supplying the only
physical feature recognisable during life, while there were
three distinct foci of sarcomatous disease — viz., the left
324 The Nordrach Treatment of Phthisis.
suprarenal, the right suprarenal, and the centre of the
lower lobe of the left lung.
From the rarity of sarcoma being a primary disease of
the lungs, and the frequency of the suprarenals being the
first part affected by this pathological neoplasm, it was not
improbable, as Dr. O’Sullivan suggested, that the disease
originated in the connective tissue or vessels of the left
adrenal, that by the open vein it passed through the left
renal vein into the circulation, and directly affected the right
adrenal, and that by embolic infarction it found its final
resting-place in the substance of the left lung. The most
careful examination failed to show any extension from the
adrenals to or through the diaphragm.
Dr. O’Sullivan has kindly made numerous and various
microscopical sections of the left kidney and of the lung.
These showed sarcoma of a mixed character, and, what
was most remarkable and strange, a number of giant
polynuclear or myeloid cells, containing as many as twelve
or fourteen nuclei, and resembling exactly those found in
sarcoma springing from the periosteum or ends of bone.
The case presented therefore the rare peculiarity — not
unknown in the life-history of sarcoma — of reproducing
cells of connective tissue type, which was not that of the
matrix from which it grew, inasmuch as there was in it
a complete absence of any bone disease.
Art. XVI. — The Nordrach Treatment of Phthisis in
Scotland. By David Lawson, M.A., M.D. (Ed.).
To say that popular notions are frequently fallacious is to
express a truism. No better example of a widely accredited
fallacy can be cited than the view commonly held, that
the further north one goes the lower does the tempera¬
ture become. No doubt it has been due to the tacit
acceptance of this belief that Scotland, ever in the van of
medical progress, has thus far hesitated to venture upon
a trial of the Nordrach treatment of phthisis in her own
land.
True it is that Dr. Caverhill, at the meeting of the
British Medical Association, held in Edinburgh in 1898,
325
* By Dr. David Lawson.
strongly urged the advisableness of the system receiving a
fair trial north of the Tweed. And it is equally true that
Dr. R. W. Philip has, at a great disadvantage and under
great difficulties, done good work in and around Edinburgh,
and has published the results of his efforts. But it is not
seriously contended that the Nordrach treatment in its
entirety has yet been attempted. It is now proposed to
make that attempt.
Some time ago the matter was fully and carefully con¬
sidered by a number of the leading consulting physicians
in Scotland, and as a result of their deliberations a site
has been acquired in what is by them, after an exhaustive
consideration of the climatic and surrounding conditions,
believed to be par excellence the most desirable locality
in Scotland for that purpose. Among those whose guidance
and support have rendered the trial possible are the
following prominent physicians : — Sir Thomas Grainger
Stewart (Professor of Practice of Medicine, Edinburgh
University), who hails it as a genuine effort to bring our
treatment of phthisis up to date, but whose health would
not permit him to take any active part in the initiation of
the scheme ; Sir William Gairdner (Professor of Practice
of Medicine, Glasgow University); Professor Finlay
(Professor of Practice of Medicine, Aberdeen) ; Professor
M‘Call Anderson, Drs. George A. Gibson, Muirhead,
Affleck, Robertson, Halliday Croom, Byrom Bramwell, &c.
Nordrack-on-Dee Sanatorium is being erected upon the
estate of Sir Thomas Burnet, to the westward of Banchory,
and 18 J miles from Aberdeen. It thus fulfils the desidera¬
tum of being far removed from any large centre of
population. Its air, free from every possible source of
contamination, is singularly pure and bracing. Surrounded
on all sides by pine woods, it does not lack for these
terebinthine vapours, nor for that shelter from strong
winds which is so highly desirable during the winter
months. Rich in ozone — over 2J- per cent. — the atmo¬
sphere may reasonably be expected to further those oxida¬
tion processes which make for health, and to assist the
constitution in its struggle against anaerobic foes.
The temperature of the air at this part of Deeside during
326 The Nordrach Treatment of Phthisis. ^
the winter months is truly surprising. I have before me
a table showing the temperature for each day during the
six weeks succeeding 1st December, 1390, taken at Green¬
wich and at Deeside respectively. The mean temperature
for that period at Deeside was 36° F., and at Greenwich
28 T° F. Thus the temperature of this northern district
possessed an advantage over that of the south of England
during the month of December, 1890, of nearly 8° F.
• The qualities of purity and warmth do not exhaust the
desirable properties which the air of this district possesses.
It is a dry air. The rainfall— 26 inches — is unexpectedly
low, lower indeed than that of the south, and the percentage
of bright sunshine— 30 per cent.— is relatively high. In the
latter respect N or drach-on-D e e claims a most suipusmg
superiority over our much-lauded South of England climate.
Kew observatory enjoys 29 per cent, and Greenwich but
26 per cent, of bright sunshine.
South-west winds prevail during nearly nine' months in
the year. These winds in previously passing over the
Grampian range of mountains become depleted of their
moisture. This no doubt accounts for the relatively low
rainfall, and for the proportionately high percentage of
sunshine which this district enjoys. These warm winds,
prevailing, as they do, for the most part during the winter
months of December, January, and February, account for
the by no means generally known fact that during winter
more warmth prevails in the north-east of Scotland than
in the south-east of England. This fact is of great value,
when it is remembered that patients are expected to live
in the open air all the year round.
Such are the considerations which determined us in our
choice of middle Deeside, and to regard it as the most
desirable district in Scotland in which to test the feasi¬
bility of carrying out the Nordrach treatment in our own
climate.
The Topography of the Facial Nerve.
327
Art. XVII. — The Topography of the Facial Nerve in its
relation to Mastoid Operations .a [Abstract.] By Robert
Dwyer Joyce, M.R.C.S.
In connection with this subject I have made a systematic
examination of 30 temporal bones with the object of ascer¬
taining the precise relations of the facial nerve to the
surface of the adult skull ; its depth, as well as that of the
external semicircular canal from the surface ; and the relation
of both these structures to the operations on the mastoid
region.
For the material upon which the examination was con¬
ducted, as well as for many valuable suggestions, I am
greatly indebted to Professor Birmingham, in whose labor¬
atory the work was carried out.
Method. — Each temporal bone was cut vertically from
before backwards, beginning in the angle between the petrous
and squamous portions, so as to expose the aqueduct of
Fallopius in its entire extent ; the external semicircular
canal was also cut across by the same section in every case.
Then I projected the facial canal on the surface by drilling
from the exposed canal outwards. In order to do this cor¬
rectly it was necessary to make the holes accurately at right
angles to the sagittal plane, and of course parallel to one
another. For this purpose I constructed the following
simple contrivance : — A wheel-drill was fastened down on a
sliding bed, so that the drill was capable of backward and
forward movement only. An end-board was then fastened
at right angles to the end of the base-board in which the
drill-bed moved. This end-board was so fastened that it
could be shifted about in a vertical plane perpendicular to
the line in which the drill worked. Each bone was now
fastened to the end-board in correct (physiological) position
by embedding it in dentist’s “modelling composition,” with
the exposed facial canal towards the drill. Now, the drill
always working in the same direction, and the bone capable
of adjustment while remaining in a plane at right angles to
the drill (i.e., sagittal, as the bone was in correct position), I
a Read before the Sixth International Otological Congress, London, August,
1899.
328
The Topography of the Facial Nerve.
was enabled to get a perfectly true projection of the facial
canal on the surface. Next I measured the distance of the
facial canal from three points on the surface of the bone
(see Fig.) — viz., A, a point immediately behind the external
auditory meatus on a horizontal line passing through its centre;
B, a point immediately behind the upper part of the meatus and
immediately below the level of its upper margin ; C, a point-
high up over the middle of the meatus on the posterior root
of the zygoma. The points A and B are taken as repre¬
senting the anterior lip of the bone wound when the mastoid
is opened below or above respectively. Also B is the point
from which, as Birmingham has shown, the antrum may in
every case be tapped, with least danger to both the lateral
sinus and the cranial cavity, by a small drill or trephine sent
straight in. The distance of the facial canal from C is of
importance in removing the outer wall of the attic from the
external auditory meatus.
Results. — The line of projection of the facial nerve lies on the
posterior and superior walls of the external auditory meatus,
about midway between the sulcus tympanicus and the outer
margin of the bony meatus (see Fig.). As regards the rela¬
tion of the facial nerve to the mastoid process, a straight
drill-hole 3 or 4 mm. behind the posterior wall of the meatus
and parallel to it will in every case strike the nerve if sent
in far enough. This holds true from the level of the floor
i
Bj Mr Robert Dwyer Joyce. 329
of the meatus to within 4 mm. of the roof. I have found
the distance of the facial nerve from the surface to vary
very considerably. From the point A the average distance
was 16*75 mm., the minimum being 13*25 mm. From the
point B the average distance was 18*5 mm., and the minimum
14*75 mm. From the point C the average was 19*4 mm.,
and the minimum 16*25 mm.
The average distance of the external semicircular canal
from B was 18*56 mm., and the minimum 13*75. The
average distance from C was 18*5 mm., the minimum being
16*25 mm.
Summary. — (1) The facial canal lies altogether in front
of the mastoid process, and a drill sent straight in from any
point on the surface of the latter cannot injure the nerve.
(2) Measured from the point B the facial canal was in
43*3 per cent, of cases more superficial than the external
semicircular canal ; in the same percentage of cases this was
just reversed ; and in the remaining 13*4 per cent, these
two structures were the same distance from the surface.
Thus the external semicircular canal cannot be taken as a
guide to the depth of the facial nerve.
(3) The average distance of the facial canal from the
point B is slightly less than that of the external semicircular
canal from the same point.
(4) In removing the outer wall of the attic it should be
remembered that the external semicircular canal is almost
always (91 per cent.) nearer the surface, at the point C,
than the facial nerve ; however, as it is 1*5 mm. higher than
the latter, it is almost out of danger ; besides, it has a thicker
covering of compact bone in this situation (attic) than the
nerve.
330 Localised Outbreaks of Typhoid Fever.
Art. XVIII. — Localised Outbreaks of Typhoid Fever appa¬
rently due to Infected Milk. By Sir Ohas. A. Cameron,
C.B.; M.D.; D.P.H. (Camb.); Hon. F.R.C.P.L;
F.R.C.S.I. ; &c.
A dairy establishment owning 18 milch cows is situated on
the northern side of the Phoenix Park, Dublin. In August
last the proprietor and his sister were ill with what was under-
stood to be some kind of fever. On the 27th of September
the proprietor was admitted into the Meath Hospital and
County of Dublin Infirmary, and treated for typhoid fever.
His sister had previously been admitted into another Dublin
hospital.
It would appear that a woman had been in attendance on
the patients who also had attended to the business of the
dairy. The milk from this dairy was used in the Depot of
the Royal Irish Constabulary, Phoenix Park, in the barracks
(Bessborough) of the Dublin Metropolitan Police, Phoenix
Park, in the Cabra Auxiliary Workhouse of the North
Dublin Union, in Morgan’s and Mercer’s Endowed Schools,
near the Phoenix Park, and in a few private houses.
Outbreak in the Constabulary Depot. — In August there
w7ere 600 Constabulary, 40 women, and 100 children in the
Depot. The milk supplied to the sergeants’ mess and
quarters came from what I shall designate the suspected dairy
above referred to. The acting-sergeants and constables
obtained their milk from another source.
In last Alienist cases of enteric fever began to occur
amongst the inmates of the Depot, and in that month and
the following one 20 of the Constabulary, 2 women, and 10
children were attacked by the disease. Five of the Con¬
stabulary succumbed to it, but none of the women or children
have died up to the present, and they are now believed to be
out of danger.
It was not till September that it was known that serious
sickness had occurred to the owner of the suspected dairy.
The milk which he supplied was submitted by Dr. Baird to
a bacteriologist, who did not detect the typhoid bacilli in it,
but found that it contained Bacilli coli communes , which are
to be found in sewage and filth generally.
It would appear that the milk supplied to the sergeants
By Sir C. A. Cameron.
331
from the suspected dairy was believed by the constables to be
superior to that which was furnished to them, and accordingly
several of the men purchased the milk from the suspected
dairy. The milk which did not come from this dairy was
examined bacteriologically, but no micro-organisms associated
with disease or sewage were detected in it.
Inquiries made by the Constabulary authorities elicited the
fact that it was only the persons who used the milk from the
infected dairy who contracted typhoid fever in August and
September.
Outbreak at JBessborough Police Barracks. — Twenty-one
policemen were stationed in these barracks. Between the 7 tli
and the 24th of September six of them developed typhoid fever,
which in the case of one of the patients terminated fatally.
All the patients had used milk from the suspected dairy.
Outbreak at Cobra Workhouse . — In this workhouse children
were lodged under the care of twelve nurses — all nuns. The
milk supplied to the nurses came from the suspected dairy,
whilst the children’s supply came from another source.
During September four of the nuns were stricken down
with typhoid fever, to which disease one of them succumbed
in October.
Outbreak at Morgan s and Mercer s Endowed Schools. —
These schools are next to each other. Morgan’s has accom¬
modation for forty boys and Mercer’s for thirty-six girls.
Fortunately only about one-third of the girls had returned
to the school before the outbreak commenced.
The cases of enteric fever in Morgan’s School comprised
three masters, eight pupils, and three maid servants. Three
pupils and two maids died.
In Mercer’s School but one case of typhoid fever occurred,
but without a fatal result.
Cases in Private Houses. — Two lieutenants of the Royal
Army Medical Corps, residing on the North Circular-road,
who used milk from the suspected dairy, and a captain in
the Army Pay Department, who also used the milk, are now
suffering from typhoid fever.
A girl residing in a house near the suspected dairy was
sent to that establishment with a message from her mother.
The child was given a tumbler of milk, which she drank.
She is now a typhoid fever patient in the Adelaide Hospital.
332
Localised Outbreaks of Typhoid Fever .
I am informed on good authority that two persons residing
on the North Circular-road, and who are ill with enteric
fever, were supplied with milk from the suspected dairy.
Two persons in Cowper-street and two persons in Weston-
terrace, who used milk from the suspected dairy, are suffer¬
ing from typhoid fever, but are considered out of danger.
It is a curious circumstance that in the dairy premises in
question there is no well or pump. It is difficult to under¬
stand how cleanliness could be properly observed under such
circumstances.
I have it on the authority of Mr. J. Collins, Chief In¬
spector of Dairies and Dairy Yards, that water for the use
of the dairy was sometimes taken from the “Poor Man’s
Well,” Blackhorse-lane. In this locality for some time past
typhoid fever has been somewhat prevalent. The water in
this well was examined last month, and found to be tolerably
good, but a later analysis which I have made gave unfavour¬
able results, as will be seen by the following
Colour, looked at through a tube
two feet long -
Odour at 100° F.
Suspended Particles
Turbidity (after standing) -
Sediment
Total Solid Matters contained in
one gallon (70,000 grains)
(in grains) -
Including —
Albuminoid Ammonia
Saline Ammonia
Nitrous Acid
Nitric Acid
Chlorine -
Sulphuric Acid
Equal to Calcium Sulphate -
Phosphoric Acid
Hardness -
Very slight yellow
Nothing peculiar
Numerous
None
Considerable
53-200
0-024
0-013
None
3*120
4-572
4*320
6*000
Trace
40*000
It contained a rather large number of micro-organisms,
including some Bacilli coli communes. The quantities of both
albuminoid and saline ammonia were excessive, and indicated
By Sir C. A. Cameron. 333
a decided, though not excessive, pollution. The well is not
protected from surface drainage.
I am informed that the water from a pump at Bessborough
Barracks was often taken to the dairy in the cans which had
brought milk to the barracks. The following is its composi¬
tion : —
Colour, looked at through a tube
two feet long -
Odour at 100° F.
Suspended Particles
Turbidity -
Sediment -
Total Solid Matters (one Imperial
gallon contained in grains)
Including —
Albuminoid Ammonia
Saline Ammonia
Nitrous Acid
Nitric Acid
Chlorine -
Sulphuric Acid
Equal to Calcium Sulphate -
Phosphoric Acid
Slight yellow
Nothing peculiar
Numerous
Very slight
Slight
38-500
0-012
0-030
None
Trace
4-671
Trace
Trace
Trace
The presence of so large a quantity of ammonia in this
water clearly indicated some, though not extensive, pollution,
and accordingly I recommended that the use of the water,
unless boiled, should be discontinued.
Prevalence of Typhoid Fever in the Autumn of 1899. — It
must be admitted that typhoid fever has been more than
usually prevalent in Dublin and its suburbs in the autumn
of 1899. During the decade ended in 1898 the mean number
of deaths ascribed to typhoid fever in the months of August
and September was 29 ; in the same months of the present
year the number was 50, or 21 above the mean number in
the corresponding period in the previous ten years. The in¬
crease is by no means sufficient to render it at all probable
that the outbreaks above described might have occurred
if the patients had not been supplied with milk from the
suspected dairy.
A dairy supplied with the milk of 18 cows is not a very ex-
334 Clinical Reports of the Rotunda Hospitals.
tensive establishment, yet at least 66 persons suffering from
enteric fever have been consumers of milk supplied by it.
It appears to me to be one of the most convincing cases of
the spread of typhoid fever by infected milk which has been
recorded. It is now nearly twenty years ago since I published
in this Journal the particulars of an outbreak of fever caused
by infected milk from a Dublin dairy ; 65 of the persons who
drank the milk suffered from typhoid fever, and 6 of them
died from that disease.
It is unfortunate that notifications of illness in the suspected
dairv were not made until long after its commencement. It
appears that several years ago the Notification of Infectious
Diseases Act was adopted by the Guardians of the North
Dublin Union, in which the suspected dairy is situated. As,
however, no circulars, notification forms, or directed enve¬
lopes, were sent to the medical practitioners of the district,
it seems to have been forgotten that notification was com¬
pulsory. The new North Dublin Rural District Council are
now taking steps to make it known that the medical men in
their district must notify cases of infectious disease.
Art. XIN. — Clinical Reports of the Rotunda Hospitals, for
One Year, November 1 si, 1897, to October olsf, 1898. By
R. D. Purefoy, F.R.C.S.I. (Master) ; and R. P. R.
Lyle and II . C. Lloyd, Assistants.
(Continued from page 172.)
CAESAREAN SECTION.
Case I. — M. C., aged thirty, 1st pregnancy; admitted on
October 4th from Extern Maternity, from which she was sent in
for pelvic contraction. She had been in labour for four and a half
hours. She was only 4 feet 4 inches in height, and was much
deformed. There was considerable prominence of the chest, marked
lordosis, curved femora, 9 inches long, and twisted, bayonet-shaped
tibiae. f
On vaginal examination the conjugate was found to be much
contracted, the promontory so high above the symphysis as to give
the impression that there was a displacement of one or two lumbar
vertebras. On measuring with Skutsch’s pelvimeter it was found
that the true conjugate was only 61 cm. (or 2 ^ ins.), and the
Clinical Reports of the Rotunda Hospitals. 335
transverse 9# cms. The os was the size of half a crown, and the
membranes unruptured. The head had not engaged.
The abdomen was opened, the uterus drawn forward and opened
by a longitudinal incision, and the child extracted alive with
some difficulty. The placenta and membranes were withdrawn,
and the uterine wound closed by means of interrupted silk sutures,
which passed through the entire thickness of the uterine wall. The
abdominal wali was closed by silkworm-gut sutures, including all
three layers.
The pulse, which was 100 on admission, commenced to rise
immediately after the operation, and on the first evening was
120, with temperature of 99*4° F. A vaginal douche was given
next day ; the temperature was still below 100° F. On the third
evening, the temperature rising to 102°, a uterine douche was given
with difficulty, owing to the prominence of the promontory, above
and at the back of which the uterus lay, and some debris was
washed away. The next day, as the thermometer registered
102*6° F., uterus was again douched and plugged with iodoform
gauze, and this was continued twice daily throughout. On the 10th
day she began to complain of cough, and the examination of the
chest revealed rhonclri on both sides. Poultices were applied, and
the signs on the right side disappeared, though crepitations were
heard at the left base ; breathing was frequent and expectoration
free. On the 18th day she had a slight shivering, temperature
ranging between 98*6° F., and 101° F., and pulse 130 to 156.
Next day there were bubbling rales at the left base, extending a
considerable way towards the apex and rhonchi on the right side ;
the heart was beating tumultuously at about 156 beats per minute.
The expectoration was black and very foul. From this the
temperature ran steadily up and reached 104*6° F. on the 20th day,
when she died, the pulse being 164.
The post-mortem showed that the stitches in the uterine wall
had sloughed out, and there was a collection of about §ii. of
pus encysted between the uterus and the abdominal wall, to which it
was adherent. The finger could be passed through the wound in the
uterus and out at the cervix, yet there was at no time any discharge
of pus through the uterus. There was no sign of peritonitis. The
liver was much enlarged and very friable. The base of the left
lung contained two large abscesses full of thin, foul-smelling pus.
The abdominal wound had healed perfectly.
Case II. — J. D., aged twenty-four, 1st pregnancy ; admitted June
11th. A history of a drinking bout followed by severe headache,
336 Clinical Reports of the Rotancla Hospitals.
preceding onset of labour pains at full time. There was then
vomiting and loss of speech, with a condition verging on coma.
On admission, the right pupil was dilated and insensible to light,
the left being contracted and reacting. There was nystagmus in
this eye. No paralysis of the limbs was evident. The temperature
was 101° F., and pulse 156, the action of the heart being very
violent. There were no labour pains, and after an enema contain¬
ing chloral and pot. brom., she became quiet, but gradually passed
into an unconscious condition, with laboured breathing, which
gradually ceased. The abdomen was opened as soon as the patient
was found to be dead and the child extracted, but no effort could
resuscitate it. It weighed 8 lbs. Post-mortem examination showed
acute suppurative meningitis. There was a quantity of pus over
the occipital lobes.
The percentage application of forceps in the Extern
Maternity was 1*67 per cent., and in the Intern 3*97 per
cent. This great difference is most probably due to the
fact that the proportion of primiparse to multipart is far
greater in the Intern Maternity than in the Extern.
In one case the forceps were applied to the second of twins,
as the head remained in the brim for five hours, and the
child commenced to show signs of distress. Delivery was
easy and the child alive.
In another case the patient had an epileptiform seizure as
she came into the second stage. She passed no urine during
the day, and the bladder wTas empty; an hour later she
had another seizure, when it was considered necessary to
apply the forceps. After delivery she was given half a
drachm of bromide of potassium and 15 grains of chloral
hydrate, after which she slept for nineteen hours. On
awakening the catheter was passed, and 36 ounces of
pale urine of low specific gravity, and containing no albumen,
were drawn off ; a few hours later 19 ounces were drawn off.
Convalescence was normal.
One patient — a 6-para, aged twenty-eight — was admitted
in a very excited state. She was considerably under the
influence of alcohol, and during the pains, which were fre¬
quent, she strained violently. On examination the os was
found fully dilated, head barely engaged in the brim and her
pulse 120; the foetal heart was irregular. She had a history
Clinical Reports of the Rotunda Hospitals. 337
of forceps on all lier previous confinements. Forceps were
applied, and the child, weighing lbs., delivered alive with
some difficulty. The pulse remained rapid and feeble for
three hours after delivery, and as she continued restless and
excitable, she was given £gr. of morphia hypodermically.
She became maniacal soon after delivery, but it passed off
on the ninth day, and she was discharged well on the eleventh.
The temperature fluctuated between 99° F. and 100° F., and
on one occasion reached 101° F.
Table No. YII.
Application of Forceps.
Indication
Dead
Children
Remarks on Dead Children
Delay in 2nd stage over
One child was macerated ; in two, though
four hours* -
35
4
no foetal heart was heard for some
Threatened death of
foetus
6
2
time previously, forceps had to be
applied on behalf of the mother.
Rise in maternal tem-
perature and pulse -
4
1
No foetal heart heard on admission.
Delay with pelvic con-
1
traction
1
Prolapse of funis
4
4
Three admitted with funis prolapsed.
Hyperemesis -
1
1
Eclampsia
2
1
Seven months’ foetus.
Convulsions (with
anuria)
1
'
Mania acuta
1
—
Hsematoma vulvse
1
—
Threatened rupture of
uterus
1
1
Total
57
14
* There were two occipito-posterlor positions.
Y
338 Clinical Reports of the Rotunda Hospitals.
Sub-table A.
Applications of Forceps.
I.-para.
48
VI. -para.
2
Il.-para.
2
VII. -para.
1
III. -para.
1
XIV. -para.
1
IV. -para.
2
Total -
57
Sub-table B.
Ages of Primiparce.
17-25
21
26-80
-
-
20
31-85
-
-
6
36-45
-
-
1
INDUCTION OF PREMATURE LABOUR AND DEFORMED
PELVIS.
There were five cases of deformed pelvis, in three of which
labour was induced.
Case I. — M. C., aged thirty, 5-para; four previous children, all
stillborn. Pelvis measured 3^- inches in the true conjugate, and
4J inches in the transverse diameter. Muller’s method was tried,
and, as the head would not descend, it was decided to induce labour
by Krauze’s method ; the membranes, however, ruptured in the
passing of the bougies. Next day, as labour did not commence, the
bougies were removed, bipolar version was performed, and a foot
brought down. Four and a half hours later the child, weighing
5 lbs., was born alive ; the head was delivered by Smellie’s method
the patient being in Walcher’s position.
Case II. — K. C., aged thirty-three. 10-para; 8 months pregnant ;
nine previous children were all stillborn. Pelvis measured
3'iu inches in the true conjugate. Krauze’s method was
tried twice unsuccessfully. On the third occasion three bougies
were passed, five laminaria tents were placed in the cervix,
and the vagina plugged with boiled cotton wool. Twenty-
four hours later these were removed, and a hot vaginal douche of
creolin solution was given. During the next day two more hot
douches were given, and the fundus frequently massaged, after which
the patient came into labour. The child, which was lying in the
Clinical Reports of the Rotunda Hospitals. 339
transverse diameter, was turned to a vertex by external version,
and some hours later the patient delivered herself of a living child
weighing 6 Jibs.
Case III. — K. C., aged thirty-five, 4-para. Had a history of
one child stillborn, one dying soon after instrumental delivery, and
a third delivered by forceps with difficulty, still living. The pelvis
measured 3J inches in the true conjugate. Labour was induced by
Krauze’s method, but the labour pains passed away when the os
was one-half dilated ; the membranes were then ruptured, and
labour pains commenced again. When she was in the second
stage she got maniacal, and could with difficulty be kept in bed.
She was anaesthetised, and delivered by the forceps of a living child
weighing 4Jlbs. Convalescence in these three cases was normal.
Case TV. — C. D., aged twenty, 1-para, contracted pelvis ;
measurement not recorded. Patient was delivered with the forceps.
She had a severe attack of secondary post-partum haemorrhage on
the fifth day, otherwise the convalescence was normal.
Case V. — Reported under “ Caesarean Section.”
HYDROCEPHALUS AND PARACENTESIS CAPITIS.
There were three cases of hydrocephalus, two of which
had to he tapped.
Case I. — K. O’K., aged twenty-one, 1-para ; presentation, vertex;
foetus putrid, weighing 9 lbs. ; delivery unaided. Membranes and
placenta also putrid ; vaginal and uterine douche.
Case II. — M. R., aged twenty-nine, 9-para ; presentation, breech;
foetus weighed 8 lbs. The aftercoming head was tapped, and wtas
extracted by Smellie’s method.
Case III. — B. N., aged forty-one, o-para ; presentation, vertex.
While the patient was lying quietly in bed, unconscious of labour
pains, the membranes ruptured and there was severe hsemorrhage.
On examination the os admitted two fingers, and the head, which
was hydrocephalic, was resting on the brim. It was tapped, a large
quantity of fluid coming awTay ; bipolar version was then performed,
and a foot brought down, the subsequent delivery being left to
nature. Foetus weighed 11 lbs. In every case convalescence was
normal.
CRANIOTOMY.
This operation was performed in three cases.
Case I. — K. M., aged thirty-eight, 10-para. Detailed under
“ Brow Presentations.”
340 Clinical Reports of the Rotunda Hospitals.
Case II. — E. D., aged thirty-nine, 10-para. Admitted in great
suffering from the country, where two unsuccessful attempts had
been made to deliver with the forceps the previous day. On
admission the vulva was much swollen, the head free above the
brim, large caput succedaneum, and no foetal heart audible.
Craniotomy was performed with Auvard’s instrument ; delivery
was easv and convalescence normal.
*/
Case III. — C. W., aged twenty-two, 4-para ; her previous
children were all born dead. On examination the head was found
balloting above the brim and the pelvis obviously contracted,
though not measured ; the membranes were unruptured, and the os
nearly fully dilated. On examining her again forty-five minutes
later the foetal heart could not be heard, the cord was prolapsed
and pulseless. Craniotomy was accordingly performed. Con¬
valescence was normal.
"VERSION.
Version was performed eleven times ; external cephalic
version was performed twice prior to rupture of the mem¬
branes — in both instances for oblique presentations. In one
of these cases the cord presented, but the child was dead, so
delivery was left to nature.
Internal podalic version was performed in three instances —
twice for prolapse of the arms, and once for placenta praevia
lateralis with face presentation. In every case the child wTas
born alive. Braxton-Hicks’ method of bi-polar version was'
performed four times — once in a case of generally contracted
pelvis, once for placenta prsevia, once for prolapse of the cord,
and once in a case of hydrocephalus which was tapped.
In the two latter cases the child was born dead.
In two cases of transverse presentation, where a hand and
foot presented, traction was made on the foot, and the head
pushed up. In one of these cases the patient had been in
labour forty hours prior to admission, and the membranes had
been ruptured several hours. The child was large, weighing
8 Jibs., and was extracted with considerable difficulty ; it
was born dead. The other child was alive.
In two instances only was there a rise of temperature, and
both occurred on the evening of the first day, after which
the temperature was normal, and continued so.
Clinical Reports of the Rotunda Hospitals. 341
PELVIC PRESENTATIONS.
Of the 62 cases of pelvic presentation 34 were full-time,
12 premature, and 16 non-viable. Twelve cases occurred in
twin pregnancies. Of the 34 full-time cases 27 infants
were alive and 7 dead. Of those cases in which the infant
was dead, one was a case of hydrocephalus, the after-coming
head having to be tapped; another was a case of impacted
breech, admitted from the country, where several unsuccess¬
ful attempts had been made to deliver her. A strong fillet
of iodoform gauze was passed round the groin of the infant,
and it was delivered by traction. In two others there was
a large retro-placental clot, the placenta and clot coming
away in each case immediately the child was born. Of the
12 premature cases 6 infants were alive and 6 macerated.
TRANSVERSE AND OBLIQUE PRESENTATIONS.
Seven cases presented themselves. In two external
cephalic version was performed prior to rupture of the
membranes, and a tight abdominal binder was applied. In one
of these cases there was a presentation of the cord, but no
foetal heart could be heard, or foetal movements felt, neither
was there any pulsation of the cord, and the child was born
dead.
In one case one arm, and in another case both arms were
prolapsed into the vagina. In both cases internal version
was performed under an anaesthetic, and the children were
delivered alive.
Another case of oblique presentation, where the breech
would not engage in the brim, was delivered by bringing
down a foot.
Another case is reported under “ Twins.”
In the seventh case a hand and foot presented; the head was
in the left iliac fossa. A foot was pulled down, the head pushed
up, and the child (which was large, being 8^ lbs. weight)
was extracted with considerable difficulty ; it was dead.
In every case convalescence was normal.
FACE PRESENTATIONS.
Of the six face presentations two were without special
interest, and terminated naturallv. In three others the child
342 Clinical Reports of the Rotunda Hospitals.
was anencephalic, two of which, were associated with hydram-
nios. The sixth was a case of lateral placenta prsevia, in
which version was performed, and the child delivered alive as
a breech presentation. Convalescence in every case was
normal.
BROW PRESENTATIONS.
There were three brow presentations. Two were horn as
vertex, occipito-posterior ; one of these was associated with
hydramnios, and in the eight month of pregnancy ; the foetus,
although it survived for three hours, was macerated. This
patient had a temperature six hours after delivery of 101° F.,
which rose to 102*6° F. next morning. A creolin uterine
douche was administered, and the temperature gradually fell
to normal, and continued so, the patient being discharged
well on the eighth day.
The third case of brow presentation was admitted with a
history of the membranes having ruptured twelve hours
previously. Meconium was coming away, os not fully dilated,
head free above the brim, and no foetal heart could be heard.
Six hours later the head was still above the brim, but the
cervix had retracted, owing principally to the formation of a
considerable caput succedaneum. Version being contra¬
indicated, owing to the condition of the uterus, the forceps
were applied twice, but without success; the head was then,
perforated, a large quantity of fluid escaping from it. Crani¬
otomy was performed, and delivery easily effected. It was a
left fronto-anterior position. There was a large hydroence-
plialocele springing through the occipital bone, extending
down the neck and back, and upwards on the scalp ; it was
about the size of a foetal head. Convalescence was normal.
There were 17 cases of prolapse of the cord ; they are
sufficiently described in the following table, with the exception
of three — C. W., K. O., and E. M‘C. — which are described
elsewhere. In the case of one of the children which lived
no pulsation could be felt in the cord before delivery.
Convalescence was normal in every case except in the case
of L. D. She had a temperature of 101*2° F. on the second
and third evenings ; a vaginal douche was given on each
evening, and the temperature fell to normal and continued so.
Clinical Reports of the Rotunda Hospitals. 343
Table No. VIII. — - Prolapse of Funis.
Name
Age
Para
Period of
Pregnancy
Presentation
Child
Remarks
A. Gr.
27
III.
Full time
2nd vertex
D.
No pulsation in cord ;
forceps ; asphyxia
pallida
M. C.
37
III.
54 months
Breech
A.
First of twins died
shortly afterwards
C. W.
22
IV.
Full time
Vertex
D.
Craniotomy, q.v.
K. 0.
30
IV.
7 months
Hand, foot and cord
A.
Second of twins, q.v.
B. T.
24
I.
Full time
1st vertex
D.
Foetus expressed
L. D.
22
I.
55
55
D.
Forceps, head on peri¬
neum
M.B.
34
X.
6 months
Footling
D.
Placenta prasvia mar-
ginalis
E.M‘C.
31
VIII.
Full time
Oblique
D.
External version, vide
“Oblique Presenta¬
tions ”
E. L.
23
I.
55
Footling
A.
Extraction by foot
M.M‘E.
33
VII.
5 5
1st vertex
A.
Expressed ; head on
perineum
B. C.
30
VII.
55
55
D.
Forceps ; membranes
ruptured before ad¬
mission
M. B.
28
IV.
55
55
D.
Forceps ; head just
through brim
C.M.
28
IV.
55
55
A.
Labour rapid; j
Schultzed
L. H.
21
II.
55
2nd vertex
D.
No pulsation; child
had a large cystic
swelling on the right
side of neck and
chest
S. C.
37
VIII.
55
5 5
D,
Macerated; mem¬
branes ruptured 13
days previously
S. B.
30
V.
55
55
D.
Bi-polar version, and
foot brought down
A, R.
19
I.
74 months
Breech
A.
Second of twins ;
membranes ruptured
HAND AND HEAD PRESENTATIONS.
On two occasions wras tlie arm prolapsed in full extension
in front of the head, once in the second of twins, and once
in a 7-para, the head being fixed in the brim in both instances,
when the hand presented through the vulva ; delivery was
left to nature and presented no difficulty. The child in
the former case weighed 5J lbs., in the latter 8-J lbs.
344 Clinical Reports of the Rotunda Hospitals .
INTERESTING CASES.
Case I. — M. It., aged twenty-eight, 4th pregnancy. This case
is of interest from the fact that the patient — a countrywoman who
was on her way to the hospital on foot — was confined at 4 45 a.m.
on the road about two miles away. Her husband was the only
person near her. The placenta came away in half an hour, after
which the husband carried baby and placenta, while the woman
walked into the institution, which she reached in a very exhausted
condition. The puerperium was uneventful, and she left on the
eighth day, mother and baby both well.
Case II. — A. K., aged twenty-eight, 3rd pregnancy. The con¬
finement was normal ; twenty-one hours later, when at stool, there
was a procidentia uteri. The uterus was replaced, and a uterine
douche administered. Three hours later patient took advantage of
the absence of the nurse to leave her bed and walk across the ward ;
the uterus again came down and was once more replaced. There
was no further trouble, and patient went through a normal conva¬
lescence, and went out well on the ninth day.
PREGNANCY AFTER HYSTEROPEXY.
Case III. — L. S., aged twenty-five, 2nd pregnancy. On this
patient an abdominal hysteropexy was performed in the hospital
two years previously. The first child was born dead, and was anence-
phalic. She had on this occasion excessive liquor amnii, and the
child, weighing 8^ lbs., was anencephalic and had a large meningo¬
cele. She was seen two months later ; the uterus was retroflexed.
It was replaced and a pessary inserted.
Case IV. — -L. F., aged twenty-nine, 3rd pregnancy. Underwent
Makenrodt’s operation some time before in the hospital; there was
nothing of note in her confinement or puerperium. She was seen
three months later ; the uterus was retroflexed ; it was replaced and
a pessary inserted.
MYOMATA IN PREGNANCY.
Case V. — A. M., aged thirty-three, 2nd pregnancy. The delivery
was normal ; there was a pedunculated fibro-myoma as large as
a tennis ball attached to the right side of the uterus by a thin
pedicle about two fingers deep. It was very freely movable, and
was noted four years previously when patient was in the hospital.
It decreased somewhat in size during the puerperium.
laik V. Case of Iiocidentia Uteri in an Infant occurring on the
(Second Day.
Clinical Reports of the Rotunda Hospitals. 345
Case VI. — A. W., aged twenty-seven, 1st pregnancy. Had also
a fibro-myoma on the right side of the uterus. It was as large as an
orange and was sessile ; she had secondary hemorrhage. There
was marked exophthalmic goitre, for which she underwent treat¬
ment elsewhere some time previously, and improved greatly. The
pulse continued very rapid during convalescence, and reached
144 on occasions, with temperature ranging about 100° F. The
pulse decreased rapidly in frequency when the patient sat up.
PROCIDENTIA UTERI IN AN INFANT.
Case VII. — The infant of M. K., aged twenty, primipara, was
lound on the second day to have a prolapse of the uterus and vaginal
walls. The whole mass was very readily replaceable, but no con¬
trivance proved adequate to keep the parts in place, and they were
forced out again directly the child cried. The baby died in a con¬
vulsion on the fourth day, and on opening the abdomen it was
found that the fundus uteri was just visible on a level with the
pelvic floor, all the ligaments being very lax. The child had also
a spina bifida, and double talipes calcaneus. Plate V.
IMPACTION OF SHOULDERS.
Case VIII. — L. W ., 9-para. The head of the child being
delivered, it was found impossible to extract the shoulders (which
had become impacted in the antero-posterior diameter) in the usual
manner. The body was pushed upwards between the pains, when
it was found possible to rotate the shoulders into the transverse
diameter, when delivery was effected by traction. The child, which
was unfortunately dead, weighed 104 lbs.
Sub-table A. — List of Concurrent Diseases.
Phlebitis
Plenritis
Mastitis
Influenza
Bronchitis
Pneumonia
Alania
Phthisis
- 2
- 2
- 16
- 8
- 3
Q
-
- 1
- 1
Total,
346 Clinical Reports of the Rotunda Hospitals.
Table No. IX. — Morbidity.
Temperature
>
©
6
©
Q
d
©
pH
March
April
May
©
a
3
July
Aug.
Sept.
4-S
O
O
Total
100-8° F. and under
6
4
7
7
0
6
7
7
8
7
9
4
77
101-2° F.
101-2° F. and under
2
5
5
2
5
3
5
4
3
6
2
-
42
102-2° F.
102-2° F. and under
3
5
4
2
2
1
2
2
1
2
3
3
30
104° F.
104° F. and under
—
1
1
—
2
1
1
—
-
-
1
-
7
105° F.
105° F. and over
—
—
—
1
—
—
—
1
2
Total monthly mor-
11
15
17
12
14
11
15
13
12
15
16
rr
4
158
bidity
i
1
From this table it will appear on first sight that the
morbidity has been extremely high during the year, hut not
one rise of temperature occurring on, or subsequent to, delivery
of, or above, 100*8° F. has been excluded from our list. On
careful examination of the charts we find that in only 42 cases
was there any cause to believe the rise was due to infection
of the genital canal; no less a number than 81 occurred
without any apparent cause, and disappeared without any
further treatment than an aperient, and none of these
exceeded the normal limits on more than one occasion.
Moreover, 35 rises of temperature included in our list were
due to a definite cause, without any evidence of infection of
j
the genital canal, and we have tabulated them separately.
All the cases of mastitis, with one exception, were of a
trifling nature, and yielded to mild treatment. This case
was admitted to the hospital with the right breast full of
suppurating sinuses ending in abscess cavities. The patient
was anaesthetised, the breast freely opened, curetted, and
plugged with iodoform gauze. The patient went out well.
It is very interesting to note that of the total number no
fewer than 70 patients were not interfered with before,
during, or after delivery, even to the extent of a vaginal
examination, also that in 20 other cases a vaginal examina¬
tion was the only interference.
Clinical Reports of the Rotunda Hospitals. 347
There were two cases of severe puerperal ulceration of the
vagina and cervix, both of which were douched daily and the
vagina plugged with iodoform gauze. In one case the
temperature (103*8° F.) fell by crisis to normal on the sixth
day, and continued so. In the other, the temperature, which
resembled closely that of a case of typhus fever, fell by crisis
to normal on the fourteenth day of the fever (or seventeen
days after the confinement) and continued so. At the
commencement of the second week she developed an abscess
on the inner side of her right ankle, with a superficial inflam¬
mation extending to the knee. The abscess was opened, and
about two ounces of pus came away; the inflammation
rapidly subsided; the joint was not involved, and there was
no further trouble from this source.
Antistreptococcic serum (10 c.cs.) was injected twice
daily for one week, but on no occasion was there the slightest
reaction, either transitory or permanent.
Ten days after the crisis (27th day) she developed peri¬
pheral toxic neuritis, with severe pains in all the joints of
the upper extremities and back of the neck, which we
attribute to the use of the serum. With this there was a
second rise of temperature lasting fourteen days. After
this the convalescence was uneventful, and she was dis¬
charged two months after admission in good health. Five
months later she was seen and was in good health.
Table No. X. — Mortality.
Name
Age
Admitted
Delivered
Died
Cause of Death
E. O’JD.
32
Dec.
20
Dec. 21
Dec.
23
Cardiac disease
E. K.
36
March
7
March 7
March
8
Chronic Bright’s
disease
A. M.
28
March
26
March 27
March
28
Hyperemesis gravi¬
darum, q.v.
K. B.
30
June
o
O
June 4
June
18
Acute mania
J. D.
24
June
11
June 11
June
11
Acute suppurative
meningitis
M. C.
30
Oct.
4
Oct. 4
Oct.
23
Pyaemia
348 Clinical Reports of the Rotunda Hospitals.
Case I. — E. O’D., admitted from the country with general
anasarca, severe dyspnoea and bronchitis, associated with mitral
disease and failing compensation. The urine was loaded with
albumen. She was delivered nine hours after admission. Con¬
siderable improvement took place in her condition under treatment
with expectorants, laxatives, and digitalis, until the evening of the
second day, when she had a sudden and severe attack of cardiac
dyspnoea, and survived only until the next day.
Case II. — E. K., also admitted with general anasarca and
laboured breathing. Face puffy, pulse irregular, urine albumi¬
nous, but no abnormal cardiac sounds. She gradually sank and
died next day. Autopsy showed that the kidneys were granular
and contracted. There was cyanotic atrophy of the liver and
oedema of lungs.
Case IV. — K. B. During the puerperium this patient showed
signs of eccentricity. On the fourteenth day she developed puerperal
mania and became very violent. Next day she fell into a sleep, the
breathing became stertorous, and she died suddenly. No autopsy
could be obtained.
Case V. — J. D. Reported under “ Cmsarean Section.”
Case VI.— M. C. See “ Caesarean Section.”
THE RIGHT TO PERFORM AN AUTOPSY.
Mr. Arthur N. Taylor, LL.B., is contributing to the New
York Medical Journal a series of special articles on the law in its
relations to physicians. On the subject of the right to perform
an autopsy, Mr. Taylor says, under date August 19, 1899 : — u The
matter maybe summed up as follows: An autopsy performed with
the consent of the relative who is entitled to the custody of the
dead body can never be questioned if properly performed. Such
an operation, when performed under direction of law, is never
subject to legal punishment, yet the existence of the two cases last
examined should be a suthcient reason to convince the cautious
practitioner of the advisability of always securing such consent
when possible. Where consent is withheld, and the physician feels
that a conscientious performance of the duty before him requires
that a post-mortem examination be made, he should, in furtherance
of his own safety, turn the case over to the coroner, or at least act
under the direction of that officer.”
PART II.
REVIEWS AND BIBLIOGRAPHICAL NOTICES.
- -
The Pathology of the Emotions ; Physiological ancl Clinical
Studies. By Ch. FYre, Physician at the Bicetre.
Rendered into English by Robert Park, M.D. London :
The University Press, Limited, Watford, London. 1899.
Large octavo. Pp. vii— 525-xiv.
When to that worshipful company of players of which Snout
the bellows-mender, and Snug, the joiner, and Starveling,
the tailor, were such eminent ornaments, there appeared
the immortal weaver with an ass’s head in place of his
familiar physiognomy, the carpenter-manager, Quince, in
his dismay and despair has no words but these: — “Bless
thee, Bottom ! bless thee ! thou art translated. ”
Everyone who knows anything of modern psychiatry
knows and admires the work of Christophe Fere. His
width of culture and his versatility are as remarkable as
his keen scientific spirit. Therefore, when this work was
placed in our hands we rejoiced, for though we would have
preferred to see some other portions of his voluminous
w ii tings, some acount of his exquisite embryological ex-
periments, or his treatise on epilepsy, or la F amille Neuro-
/pathique, or his dissertation on the family care of the insane
(a subject which he has so persistently and so successfullv
kept before his countrymen), or a selection of his occasional
writings, hi ought before the English reader rather than
I^a Pathologie des Pm otions, which we regard as perhaps
the least valuable portion of his work. Yet even this book if
it were rendered into English would be instructive and
valuable to those wdio are not sufficiently familiar with
French to read the original without loss of time.
It struck us that the work before us was rather late in
appearing, and when we looked up our copy of the French
and found that the Paris edition was published in 1892 we
felt a little surprise. Our surprise diminished wdien we
350
Reviews and Bibliographical Notices.
had dipped into Dr. Park’s version, and as we proceeded
honest indignation took the place of surprise.
This translation is one of those works which seem to
be executed in anticipation of securing early sale when
Volapuk comes into general use. It cannot be fairly said
to be written in any tongue current in the modern world.
However, we would not like to mislead our readers, and,
perhaps, we may be wrong. Tt may be that Watford,
which seems to have developed a university, has some claim
like that other twin of learning, Oxford, to be a special
exponent of the English tongue, and, therefore, we of the
“ Silent Sister ” should be dumb on this point.
We cannot but wish, however, that the Watford Univer¬
sity curriculum included a few lessons in elementary E rench.
It ought to be easy to obtain a teacher or two from the
neighbouring village of Stratford atte Bowe.
The translator cannot object to our taking as a sample of
his work the following passage from the preface, which
Dr. Park has ear-marked by the unpleasant trick, apparently
common through the book, of inserting some French words
of the original between brackets. “ Without entirely neglec¬
ting the facts which pertain to history, ” poor Dr. Fere is
made to say, “I have systematically set in relief ( repousse )
those which are scattered ( repandus ) in literary works whose
authors have not proposed for themselves the motive of a
biological study, but a description capable of interesting
their readers. I have1 myself dealt almost exclusively with
facts drawn from medical works; I believe that this pre¬
caution is almost indispensable ; it appears to me that it
would be wrong to permit oneself to accept as scientific
documents, facts reported by literary authors.”
There is a thing which theologians call wilful and in¬
corrigible ignorance. In the above passage, not even the
contents and the meaning of the whole, as plain as the nose
on a man’s face, can prevent our translator from glorying in
his discovery that repousser has but one meaning and that is
to set in relief !
Enumerating the forms of nervous enuresis our translator
mentioned “the incontinence of those who believe (think?)
to urinate some part.” We believe (think?) to tingle some
Fknf; — Park — The Pathology of the Emotions. 351
part of our epidermis under the birch of our worthy old
schoolmaster if we had ventured to present him with such
a piece of translation.
The following is a gem: — “But it is not only the cutaneous
sensibility and the cephalic senses which are capable of
being affected. The genital sense itself can also be. I
observed for several years a patient, aged 38 years, belonging
to the class of degenerates, after Morel, by signs, physical
and mental (among which are impulsions, meriting a special
study), and who, all his life has been incapable of coitus,
and even of having an erection otherwise than in full day,
or in a chamber lighted a giorno ; he did not, however,
spare the means of supplying the physiological excitation
of light.”
It merits a special study why men translate a language
which they do not understand into another which they can¬
not write, or what reasons can induce anybody to insult
the intelligence of readers by producing a giorno an exercise
that any child would be ashamed of.
It is generally a reproach to a critic not to have read the
entire of the book he reviews, but w^e must admit that our
respect for Fere, and our indignation at the crime that has
been committing upon him have prevented us from fulfilling
our duty. We cannot say that we have fully measured
I)r. 1 aik s atrocities. W e can only ,say that every page
at which we have glanced contains passages like the above.
Skipping some hundreds of pages we light upon the folio w-
mg . A smgulai emotion which he came to experience”
incapable of awakening, even in a vigorous young' man
(which e\ en was not the case), any aesthetic sentiments” — ■
“ several times he had, not without astonishment repeated the
expei ience, and the advice which he made me was provoked
by the following circumstances.” We boldly defy our
readers to understand this, “he pretended to be able to
lecognise continents. It is not .said of the Tuscan artist
viewing through optic glass the spotty globe of the moon, as
the careless reader might suppose, and poor Fere’s meaning
should thus be rendered in English, “he claimed to be able to
distinguish those who were chaste.” We are told that the
Duke of Anjou wiped his face with the chemise a lady “
came
352 Reviews and Bibliographical Notices.
to leave,” this being quite a customary rendering of the idiom
venir de.
We are told that “Hippocrates speaks of one Kicanor
who effaced himself at the sound of a flute.” Perhaps he
does, for we are not familiar with the Goan, hut Hr. Fere
does not ; he only says that Nicanor fainted at the sound of
of a flute.
“ Eramus said to a madman, ( I am not the fruit of an
ennuyed conjugal effort?’” But we protest against such
English being addressed to sane folk.
Emotional people are very ridiculous, but why call one of
them an “emote” P Emeu would be equally expressive and
would be English of a sort. Cassowary or cameleopard
might serve and would be sonorous as well. The conduct of
the “emote” is as eccentric as his designation — “Besides his
mother came to die, he played with a part of his fortune,
and gave way to his passion. ”
Hammond’s advice to a victim, of homicidal impulse is
praised — “ He counselled him to recall his sequestration in
an asvlum. ” Here we pause to wonder whether it has
struck Dr. Park that even a Frenchman generally has some
meaning in his language. It is obvious that the translator
of passages like these can have taken no meaning out of
the words which he renders into this ridiculous jargon.
We cannot pretend to have put before our readers one-five-
hundred-and- twenty-fifth part of the absurdities with which
Hr. Park’s performance overflows, and yet we fear they are
“ennuyed.” It is the business of a reviewer to point out
to readers the works which are worth their reading and
those which are not, and we warn all whom it may concern
that this “traduction” falls in the latter category. If we have
been too severe in our comments we conceive that like him
of old, we “ do well to be angry, ” seeing what a monstrous
outrage has been done to an unoffending foreigner who
might have “recalled” a hospitable “sequestration” to our
shores.
Hr. Park, perhaps, is out of court, but his readers may
complain that badly as he has served poor Fere the Uni¬
versity Press, W atf ord, has added its contributions to the
mess. “Beard has quite properly insisted upon the causes
Shaw — Golden Rules of Psychiatry . 35 3
of terror to wliicli one is exposed in experimentation upon
living men/’ &c. This is a misprint for error. The experi¬
ments which have been performed upon Dr. Fere, a living
man, by Dr. Park and his printer would surely be a cause of
terror to the two latter if the first named worthy gentleman
were as bellicose as French writers to the lay press appear
often to be.
Of one thing we are sure. Dr. Park has affixed to this
work a modest preface of his own, beginning thus : — “ A
work of importance of Dr. Ch. Fere’s La Pathologie des
Emotions can dispense with the translator’s preface, but
to put myself into “ rapport” with the reader, I venture
to explain that I am not only the medium whereby the
thoughts and experiments and case records of the great
French physician have been done into English ; but T
homologate his conclusions. ” We are confident that the
specimens of the “English” into1 which the book is “done”’
that we have laid before our readers will not aid to bring
them into “ rapport” with Dr. Park, and we are certain
that Dr. Fere (to whom we offer our respectful sympathy)
will no more “ homologate ” this “ translation ” than Bottom,
the weaver, homologated the ass’s head when he too was
“translated” !
Golden Rules of Psychiatry. By James Shaw, M.D.
“Golden Pules” Series, Ao. Y. Bristol: Wright & Co,
16mo. Pp. 74.
The series to which this little book belongs describes itself
as of waiscoat-pocket size. We, therefore, cannot look for
a wealth of detail or beauty of style. The most that we
can demand is that clearness be not sacrificed to brevity, and
that a due proportion be maintained even in condensing.
The opuscule before us deserves praise under both these
heads. Diagnosis, prognosis, treatment, and certification
are, on the whole, very judiciously dealt with. The work is of
course intended for the general practitioner. As with all such
compendiums, some previous knowledge is implied to enable
the reader to duly assimilate Dr. Shaw’s excellent precepts ;
but now that all students are required to obtain some
z
354
Reviews and Bibliographical Notices.
instruction in mental disease, these rules will recall vividly
to the mind matters that might otherwise be overlooked.
The preliminary rules as to the examination of patients
may prove useful even to specialists, and if asylum com¬
mittees were to supply copies to their assistant medical
officers, it might sometimes prevent that jumble of faulty
and deficient memoranda, made with an eye to the com¬
missioners’ visit rather than with any view to medical
requirements, which pass for records of cases in so many
asylums.
A System of Medicine by many W riters. Edited by Thomas
Clifford Allbittt, M.A., M.D., LL.D., D.Sc,, F.R.C.P.,
F.R.S., F.L.S., F.S.A. ; Regius Professor of Physic in the
University of Cambridge ; Fellow of Gonville and Caius
College ; Hon. Fellow Royal College of Physicians of Ire¬
land. 4 olume T II. London : Macmillan & Co. 1899.
8vo. Pp. 937.
Ti-ie completion of this great work comes on apace. This
is the seventh volume and but one more is to succeed it.
The original design contemplated a series of only six vol¬
umes. Rut Dr. Allbutt tells us in his preface that estimates
based on the proportionate parts of the previous English
treatises on Medicine, even of the more recent of them,
"proved erroneous in the present phase of extraordinary
movement and expansion in our art, and in the sciences
ancillary to it. ”
One chief reason for the expansion of the work is that
the Editor, in his discretion, decided that the sections on
such special subjects as diseases of the larynx, tropical
diseases, mental diseases, and diseases of the skin, should be
as full and complete as experts in these several departments
would require. The enlargement of the work in the direc¬
tion indicated will make the reader independent of special
text-books on the special departments of medicine just
named.
I olume VII. is entirely given up to Diseases of the
Nervous System. It will be remembered that this great
subject was commenced in the sixth volume. It occupies
Allbutt — A System of Medicine. 355
the whole of the seventh volume, as we have stated, and it
is to he finished in the eighth and concluding volume.
The scheme, according to which nervous affections are
discussed in the present volume, is as follows: — Diffuse and
limited diseases of the spinal cord, diseases of the brain,
and finally a group of other diseases having a less definite
localisation and a more obscure pathology.
To the last section Dr. Risien Russell is the principal
contributor, and needless to say he has done his work right
well. His articles are on chorea, the tics, “ paramyoclonus
multiplex, ” saltatory spasm, head-nodding, and eclampsia
nutans.
The only title among these which probably requires ex¬
planation is that which we have enclosed within quotation,
marks. It is unfortunately also called “Friedreich’s disease, ”
but it must not be confounded with hereditary ataxy,
described by Professor Friedreich, of Heidelburg, in 1861.
The affection, for which Dr. Risien Russell selects the name
“ Paramyoclonus multiplex, ” was isolated from the chaos of
motor neuroses by Professor Friedriech in 1881. It is a
motor neurosis characterised by sudden shock-like clonic
contractions, usually of corresponding muscles on the two
sides of the body ; the spasms may be not only symmetrical,
but also isochronous. The affection rejoices in nine syno¬
nyms. Besides the two already given, we have myoclonus,
multiple myoclonus, myoclonus epilepticus, myokimie,
myospasia simplex, spinal epilepsy, and convulsive tremor.
Dr. Russell says that “spinal epilepsy” is a designation to
be avoided in describing this affection, as that appellation
has long been identified with the clonic spasms which
occur in the parts below a destructive lesion of the spinal
cord.
Dr. Frederick Taylor is the author of the article on
myelitis. In discussing the a3tiology of the acute form of
this disease,, lie observes under the heading “cold” — “the
modern belief in an almost universal bacteriological patho¬
logy would lead us to suppose that the cold acts by depres¬
sing the vitality of the spinal cord, and thus rendering it
prone to succumb to bacteria or toxins.” He reports on
the authority of Rosenthal and Thiroloix, a remarkable
356
Reviews and Bibliographical Notices.
case which, they regard as demonstrating this connection.
(Bull. Soc. Anat., April, 189T, page 376).
The caisson disease and haematomyelia are the other
diffuse spinal affections described in the first part of the
volume. The authors are respectively, Dr. Andrew H.
Smith, of New York, and Dr. Fred. E. Batten, casualty-
physician to St. Bartholomew’s Hospital.
Limited diseases of the spinal cord are arranged under
the headings sclerosis and nuclear diseases.. The writers
are Sir T. Grainger Stewart, Dr. Beevor, Dr. Allen Starr,
Dr. Itisien Bussell, Dr. Ormerod, and Dr. Mott, and the
Editor, who contributes a short article on senile paraplegia.
Among the authors on diseases of the brain are the
familiar names of Eerrier, Bastian, and Byrom Bramwell,
The section opens with an able treatise on the experimental
pathology of the cerebral circulation by Dr. Leonard Hill,
lecturer on physiology at the London Hospital Medical
School. 'No Irish author has taken part in the writing of
this volume of the System of Medicine, and this is a matter
for regret, not only on grounds of policy, but perhaps even
for the sake of the literary and scientific character of the
work.
The Schott Methods of the Treatment of Chronic Diseases
of the Heart with an Account of the Nauheim Baths ,
and of the Therapeutic Exercises. Illustrated by AY.
Bezly Thorne, M.D., M.R.C.P. Third Edition.
London : J. & A. Churchill. 1899. 8vo. Pp. 132.
Since we reviewed the first edition of this book in the
Journal for June, 1895 (Yol. XCIX., page 485), it has
considerably developed both in size and in importance.
In the first place this third edition is illustrated by four
plates of radiographs, and a fifth plate containing tracings
on paper fixed to the fluorescent screen.
Secondly, there are two entirely new chapters — one on
the conditions which should govern the application of the
Schott methods, and the other on conditions not primarily
cardiac to which the methods are applicable, such as lithasmia,
the weak heart of influenza, anasmia, asthma, distension of
the stomach, coldness of the extremities, and atheroma.
Hare — Dercum — Medical Complications. 357
Thirdly, the old material has been rearranged, and a careful
revision of the whole work has been effected.
We can still recommend the book as the best extant guide
to the Schott treatment, as practised at Nauheim, and now
everywhere.
The Medical Complications , Accidents , and Sequelce of T yphoid
or Enteric Fever. By Hobart Amort Hare, M.D., B.Sc.
With a special chapter on the Mental Disturbances follow¬
ing Typhoid Fever , by F. X. Dercum, M.D. ; Clinical
Professor of Diseases of the Nervous System in the
Jefferson Medical College. London : Henry Kimpton.
1899. 8vo. Pp. 286.
What Dr. W. W. Keen did last year for the Surgical
Complications and Sequelae of Typhoid Fever, Dr. Amory
Hare has done this year for the Medical Complications,
Accidents, and Sequela? of that disease. And so, with much
propriety, Dr. Hare dedicates his essay to his “ honored
colleague, W. W. Keen, M.D., LL.D., Professor of the
Principles of Surgery and of Clinical Surgery in the Jeffer¬
son Medical College of Philadelphia.”
The author observes that cases are not infrequently met
with in which the manifestations wandered so far from the
classical descriptions of the disease under consideration as to
be puzzling and obscure. Sometimes also the malady has
been so altered in its course by intercurrent affections as to
be unusual, and to call forth all the diagnostic knowledge
and therapeutic skill of the physician. His essay deals with
these aberrant forms of typhoid fever.
After a chapter devoted to general considerations, in
which Dr. Hare remarks that the frequency, severity, and
mortality of typhoid fever are distinctly on the wane — an
encouraging statement, which, however true, unfortunately
does not apply to Dublin — the author describes the varieties
of onset of the disease. The next chapter deals with the
aberrant symptoms, states or complications of the well-
developed stage of the disease. Then follow chapters on the
complications of the period of convalescence, the conditions
358
Reviews and Bibliographical JSlotices.
which ape typhoid fever, the duration of the malady, and
the immunity to second attacks which it confers.
Dr. Dercum’s essay — for such it is — on the mental com-
plications of typhoid fever forms the seventh and concluding
chapter in the book. According to the author post-typhoid
insanities may make their appearance in one or other
of the following forms: — (1.) Acute delirium. (2.) Con-
fusional insanity, stuporous insanity. (3.) Cerebral asthenia,
pseudo-dementia, pseudo-paresis. (4.) Insanity with syste¬
matised delusions resembling paranoia. (5.) True melan¬
cholia or true mania.
In concluding a very readable account of the mental states
in typhoid fever, Dr. Dercum alludes to the remarkable fact
that, in quite a large number of cases of insanity, an attack
of typhoid fever is followed by recovery of mental health,
irrespective of the special form of insanity. In other cases
long-continued improvement ensues. “ The interesting fact
of recovery of insanity after typhoid fever is comparable to
the effects of other infectious processes, such as erysipelas,
and also to the results occasionally following trauma and
surgical operations on the insane.
In his work, Dr. Amory Hare has given to the litera¬
ture of typhoid fever a valuable contribution, and has added
to the reputation of the great American School of Medicine.
Text-book of Obstetrics . By Barton Cooke Hirst, M.D. ;
Professor of Obstetrics, University of Pennsylvania.
With 653 Illustrations. Philadelphia : The Bebman
Publishing Co. 1899. 8vo. Pp. 820.
We do not know whether the author or the publishers of
this book are to be the more congratulated ; the former for
having written a work which sets a standard of excellence
for future -writers, the latter for the artistic manner in which
it is presented to the public.
Amongst the numerous good plates and illustrations in
which the book abounds we notice many old friends which
have already appeared in former works emanating from the
same firm.
As is usual in obstetric text-books, this one commences with
359
Hirst — Text-book of Obstetrics.
a description of pelvic anatomy and embryology. Beyond
the fact of these sections being excellently illustrated, there
is nothing particular to note about them.
The development of the ovum as next described leaves
little to be desired, and the subject is brought well up to
date.
Chapter Y. deals with foetal diseases, great prominence
being given to syphilis in this connection. The importance
of this hereditary taint cannot be exaggerated, and yet the
author is one of the few text-book writers who has dealt
adequately with the subject.
We wish to particularly call attention to Plate III., which
beautifully portrays the evidence of epiphyseal syphilitic
inflammation. This inflammation is a certain, though rarely
looked-for, indication of the disease. On the other hand,
Fig. IY. can hardly be said to be a happy illustration of the
complaint.
The kidney of pregnancy is contrasted in a tabulated
form with that of chronic nephritis on p. 228. This, we
imagine, will delight the hearts of students reading for any
of the higher obstetrical examinations.
Abortions are still classified, we observe, in the time-
honoured manner — namely, threatened and inevitable ; and,
following the lead of others, appropriate treatment is advised
for each stage. We would not be concerned to notice this
almost universal classification were we not aware that in
practice it has exercised a pernicious influence. Those
moulding their treatment on this classification must fre-
quently face the crux as to whether a threatened or an
inevitable abortion is at the moment being dealt with.
This question is frequently hard to settle, while to make a
mistake in the diagnosis might well lead to disastrous conse¬
quences, for the lines of treatment pursued under each
condition differs widely the one from the other.
How much more simple than this is it to follow the rule
laid down in the teaching of the Rotunda Hospital, and
consider all cases as of the threatening variety until either
the ovum is expelled or circumstances arise which endanger
the mother’s life. These circumstances will call for active
treatment quite irrespective of other possibilities. More-
860
Reviews and Bibliographical Notices.
over, we do not hold that to tampon the vagina is the safest
and readiest means of emptying the uterus.
Pages 347-8-9 give full directions to both mother and
nurse as to their parts in the management of the lying-in state.
When dealing with either accidental haemorrhage or with
placenta prsevia, the Dublin methods wholly differ from
those advised by the author ; and we would especially warn
our readers against efforts directed towards the dilatation of
the cervix with the fingers in the latter complication. The
cervix is often rotten to a remarkable degree in placenta
prasvia, and tears like wet paper under the exorcise of small
force, with the result that severe, and sometimes uncontrol¬
lable haemorrhage follows. We can call to mind one fatal
result from this accident, while literature abounds with
similar cases.
Puerperal sepsis may be picked out as one of the many
instructive articles in this book. There is much compara¬
tively new work recorded here, while those interested in
serum therapy can, with advantage, study the subject in this
book.
A chapter on children, the injuries to which they are
liable during parturition as well as some of the more common
complaints of the new-born, brings this valuable work to a
conclusion.
The Practice of Obstetrics. By American Authors.
Edited by Chas. Jewett, M.D. With 441 Engravings
and 22 full-paged Coloured Plates. London : Henry
Kimpton, Publishers. One Volume. 1899. 8vo. Pp. 763.
The above heading indicates to some extent that the hand¬
some volume before us is one of no ordinary merit. Dr.
Jewett deserves much praise not alone for his choice of
contributors but also for the care he has shown in apportion¬
ing each their section in so judicious a manner.
The work covers the whole subject of Obstetrics, and is
wonderfullv free from the usual faults so often observed in
books compiled from the pens of many authors. It can be
read without the fear of encountering needless repetitions or
tedious elaboration, not infrequently encountered in the
Jellett — Short Practice of Midwifery . 361
writings of those to whom uncongenial sections have been
allotted.
Of the contributors all have done their work well, and it
would be invidious to select any one in particular for praise,
while to review the writings of each one of the nineteen
would be a task beyond the limits of our allotted space.
There is no doubt that this work will find much favour
and be eagerly studied by both the student and the practising
physician, while the library of the specialist cannot be said
' to be complete without it.
A Short Practice of Midwifery. By Henry Jellett,
M.D. Dublin; F.B.C.P.I. ; late Assistant-Master, Botunda
Hospital. London : J. & A. Churchill. 2nd Edition.
1899. Pp. 381.
The appearance of a second edition of this excellent work in
so short a space of time since its original publication, is
sufficient proof that our former estimate of its usefulness has
been fulfilled.
Dr. Jellett has been fortunate in obtaining much help
from Dr. A. V. Macan in this his second edition, and to this
he bears willing testimony in his Preface.
The work has been improved in many respects. The
subjects dealt with are better arranged. The faults of style
are eliminated, while the errors, almost inseparable from first
editions, are now conspicuous by their absence.
We strongly recommend this book, in particular, to those
who have been debarred by circumstances from obtaining
some portion of their obstetric training in the Botunda
Hospital.
Glasgow Hospital Reports. Edited for the Committee by
G. S. Middleton, M.D., and H. Butherfurd, M.D.
Volume I. With 65 illustrations. Glasgow: J. Mac-
Lehose & Sons. 1898.
In May, 1896, a number of Glasgow medical men, mostly
members of the staffs of the various hospitals, decided to
establish an annual volume of hospital reports. Circum-
362 JRevieivs and Bibliographical Notices.
stances delayed the appearance of the first volume, hut it is
intended to issue it regularly every year in future.
We can warmly congratulate the Editors and Committee
upon the excellence of their “Reports.” The book strikes us as
being about the best of the works of its kind that we have
seen. Many of the articles in it are not merely records of
cases, but careful monographs on various subjects which
show evidence of original work and laborious investigations.
Dr. Robertson contributes a paper on “ Percussion and
Auscultatory Percussion of the Skull in Diagnosis and
Treatment.” He finds that by percussing the skull with the
point of the finger with a degree of force incapable of causing
pain elsewhere, pain may be caused when the percussion is
practised over an area of disease, whether the disease exists
in the inner table of the skull, in the membranes, or in the
brain, tie also calls attention to the note elicited by per¬
cussing the skull, and heard through a stethoscope applied
over the frontal suture. This note is modified by excess of
liquid in the skull, and by other conditions which modify
the conduction of vibrations along the bones.
Dr. Newman is the author of a carefully written and well
illustrated paper on “Malformations of the Kidney.” He
classifies them under three heads : — 1. “ Displacements with¬
out Mobility;” 2. “Malformations;” and 3. “Variations
in Pelvis, Ureters, and Blood-vessels.” There are many
sub-divisions of these heads. Altogether the paper is an
excellent one.
One of the best articles in the book is that on “ Urinary
Asepsis,” by Dr. Nicolh It is divided into two parts. In the
first he investigates the possibility of sterilising the various
forms of bougies and catheters in use. As regards bougies,
they are comparatively easy to render aseptic ; ordinary care¬
ful washing, followed by careful drying with a sterilised
towel, will suffice, if only the surface of the instrument is
free from cracks or chips. On the other hand, catheters —
except those of metal and of red rubber, which can be boiled —
are very difficult of disinfection. He gives the results of a
laborious series of investigations, which will well repay per¬
usal. The second part relates to the presence or absence in
the urethra of bacteria, but as the investigation is not yet
Kelynack — The Pathologist’ s Handbook. 363
completed Dr. Nicoll reserves his conclusions for a further
communication.
Dr. Steven has an important contribution to the “ Pathology
of the Coronary Arteries of the Heart.” His statistics show
that disease of these vessels is a frequent factor in the causa¬
tion of sudden death and of angina pectoris, hut that, on the
other hand, they are often seriously diseased without causing
either of these phenomena.
There are other papers which are well worth reading.
We warmly congratulate the Glasgow Hospital Staffs on
these Reports.
The Pathologist' s Handbook. By T. N. Kelynack, M.D.,
M.R.C.P. ; Pathologist to the Manchester Royal Infirmary,
&c. London : J. & A. Churchill. 1899. 8vo. Pp. 186.
In writing a concise manual on post-mortem technique Dr.
Kelynack has certainly endeavoured to supply students with
a much-needed handbook, and has, moreover, undertaken
one of the most difficult tasks an author can set himself to —
namely, condensing a big subject into a small space. The
result of his labours is rather disappointing, because by
introducing a quantity of useless and irrelevant pictures he
has been compelled to treat in a few words some of the
leading points of post-mortem examination. We shall con¬
sider the various chapters in order, as far as possible.
The first two chapters are more or less introductory, and
contain one very excellent piece of advice on the washing and
disinfecting of one’s hands, sadly neglected by some patho¬
logists, who seem to feel a pride in filthy hands and untidy
dress.
The third chapter is a description of post-mortem instru¬
ments, with illustrations from Weiss’ catalogue — twenty-
eight pages wasted, when we consider that nearly four whole
pages are used up in depicting ordinary scalpels and magni¬
fying lenses, with which every student is quite familiar.
The fourth chapter, on external examination of the body
and its surroundings, is good, especially from a medico-legal
standpoint ; but in the last paragraph there is a very elemen¬
tary mistake made in the confusion of the terms upost -
364
Reviews and Bibliographical Notices.
mortem staining” and u post-mortem Avidity,” which the
author uses as synonymous.
The fifth chapter gives a general outline of the examina¬
tion of the thorax and abdomen. He first opens the abdomen
and directs that the recti be detached from the os pubis, and,
if necessary, divided again higher up, omitting to mention
that this is done merely to give more room. “ The thorax is
now to be opened, and a wider view given of the abdominal
cavity.” He has as yet made no examination of the abdomen,
and the moment the 4 4 operculum ” is removed and diaphragm
cut through the relations of the abdominal organs are com¬
pletely changed, a point Virchow lays such stress on, to say
nothing of an empyema flooding the whole cavity. Two
whole pages are again wasted, one with an anatomical plate
and another with 44 Transpositions of the Viscera ” ! — space
that can ill be spared, and which might well have been used to
describe properly, if briefly, the method of inspecting the
abdomen and thorax.
The sixth chapter deals with the detailed examination of
the thoracic viscera. The author gives here a good and
simple method of opening the heart as an alternative for
Virchow’s, but introduces an element of difficulty into the
latter by failing to point out Virchow’s guiding incision into
the right ventricle, which gives the plane for all the others,
and is a perfectly simple method. The pictures here again,
as indeed throughout the entire book, are, for the most
part, worthless — first, because they try to illustrate special
pathological features ; and secondly, because they fail hope¬
lessly in the attempt. Who, for instance, could ever tell
that Fig. 55 was melanotic sarcoma of the heart, or that
Fig. 109 was a cirrhotic liver ? The advice to remove
organs en masse for later dissection is not good ; it is often
a necessity, as circumstances will not permit the dissection
of parts in situ, which is, of course, far better. A good
point in examining phthisical lungs in haemoptysis cases is
the method of injecting the pulmonary vessels with water.
The direction for avoiding the cutting of the pulmonary valve
is another good point.
The next chapter, on examining the abdominal viscera,
starts with removal of the intestines, but no mention is made
Gould — Year-book of Medicine and Surgery. 365
of the most important point to consider in doing this — viz.,
holding the knife-blade at right angles to the gut. The
method of examining the male genito-urinary tract is a very
good one, but far too briefly described. When stomach and
duodenum are opened in situ , as is usual, everything else
except the liver should be removed first, as it is impossible to
prevent soiling.
The examination of the brain and cord would be one of
the best chapters in the book if some useful diagrams were
substituted for the anatomical plates, which are absolutely
out of place here.
The chapter on special examination gives useful advice on
examining bones. The rest of the chapter gives too scanty a
description of medico-legal examination to be of any value
to anybody.
The next chapter is forensic medicine not pathology.
The final chapter contains some very useful advice as to
the “ Restitution of the Body,” but might very well have
been supplemented with a somewhat further account of
modern methods for preserving specimens.
The American Year-book of Medicine and Surgery: being a
Yearly Digest of Scientific Progress and Authoritative
Opinion in all branches of Medicine and Surgery , drawn
from Journals, Monographs, and Text-books of the leading
American and Foreign Authors and Investigators. Collected
and arranged, with critical editorial comments, [under
the general editorial charge of Geokge M. Gould, M.D.
Illustrated. London : The Rebman Publishing Co., Ltd.
1899.
This huge year-book consists of 1,100 pages of large octavo
size. It is well printed in large, clear type, so that it is
easy to read — no small advantage in a medical book.
The twenty-nine sectional editors are gentlemen of re¬
cognised standing in their several specialties, and .bear
names that command respect. As Dr. Gould states: —
“ The editorial staff continues the onerous duty of ^previous
years with that expertness of intelligence in gleaning[and
ripeness of judgment in deciding as to values which canjonly
366
Reviews and Bibliographical Notices.
be gained by experience and knowledge, and which are
prime essentials.” Only by these qualities can the practitioner
be certain that the collection shall not omit or exaggerate
the importance of any contribution, and, most needful of all,
that it shall not be a mere undigested gathering of “ all and
sundry,” leaving the physician, too busy for much reading,
undecided and dazed, as if by a multitude of clamorous
voices.
The able staff that Dr. Gould has gathered round him in
the work have accomplished their task well, and year after
year the book grows in favour with the profession as a trust¬
worthy book of reference.
The Year-book of Treatment for 1899: a Critical Reviezo
for Practitioners of Medicine and Surgery. Illustrated.
London, Paris, New York, and Melbourne : Cassell & Co.,
Limited.
For fifteen years this concise year-book has held its own in
popular favour. For this success it is largely indebted to
the careful editing that secures for the practitioner all that
is desirable and excludes all padding. Each section of the
manual is not alone a good summary of the progress of
medicine in its own province, but it is also a criticism on the
same by an acknowledged authority.
The present number contains an article on the open-air
treatment of phthisis by Dr. Burton-Fanning, who has had
practical experience of the method at Cromer.
On the Study of the Hand for Indications of Local and
General Disease. By Edward Blake, M.D. London :
Henry J. Glaisher.
Dr. Blake, in this little monograph of forty pages, has
gathered together an immense mass of well-arranged facts,
and gives the profession a very useful little pamphlet.
He commences with a description of the temperature,
dryness, moisture, and tremor of the hand, and passes on
to consider the colour and texture. The nails, their form,
colour, distortion, and disease follows, and in the succeeding
Mackintosh — Skia graphic Atlas of Fractures. 367
vhapteis lie deals witli the diseases of the hand — parasites,
eruptions, papillomata, and soforth.
The pamphlet is a good example of how much a careful
observer and well-trained physician may learn by examining
oven a small part of the body of a patient.
Skiagraphic Atlas of Fractures and Dislocations. With
Notes on Treatment for the use of Students. By Donald
J. Mackintosh, M.B. ; Medical Superintendent, Western
Infirmary, Glasgow. London: H. K Lewis. 1899.
This atlas contains eighty plates, of which some twenty are
not properly described under the term “ Skiagraphic Atlas
of Fractures and Dislocations.” The book is splendidly
brought out, and looks at first sight as if it would be too
dear to take its place as a student’s manual, as its title and
preface both suggest. We find, however, that its price is
very moderate (12s. 6d.), and our wonder is how it can be
sold so cheaply. The skiagraphs of the fractures of the
limbs aie very clear and beautiful, but we cannot say this of
the representations of lesions of the hips and pelvis. It
seems that, even with most skilful workmanship, the thick
and restless structures of the living trunk are but little
accessible to the X-rays. The “ brief descriptive notes ” are
brief indeed, not more than four hundred and sixteen lines
in all. Although the author must have had plenty of oppor¬
tunities for obtaining the histories of the accidents which
produced the fractures photographed, he has in verv few
cases given any note to help the student to associate the
type of fracture with the character and direction of the
force which produces it. In Plates XIV. and XY. a very
remarkable deformity of the radius is shown — a fracture
united with great angular deformity. The note which
accompanies it is the following:—1 “ Greenstick fracture of
the radius (anterior view). The patient was eight years of
age, and had received an injury to the forearm four years
previously, but no deformity was observed till three months
after the injury. Movements of pronation and supination
were impaired. Treatment : Osteotomy and straightening
the bone. Partial resection may be required.”
368 Reviews and Bibliographical Notices.
We have quoted the whole note to allow our readers to
judge of its value. W e would ask whether the late discovery
of marked deformity justifies the diagnosis of greenstick
fracture ? We think the author would have published a
more useful book if he had omitted the letterpress.
We notice a new word introduced into the English
language in these brief notes : — “ Nothing can be done here
to remedy the shortening of the limb, but the deformity
might be lessened by chiselling or sawing off the prominent
end of the upper tibial fragment, and, having rawed the
lower fragment, wiring the bone/’
RECENT WORKS ON NURSING.
1. Nursing : its Theory and Practice. Being a complete
Text-book of Medical, Surgical, and Monthly Nursing.
By Peecy G. Lewis, M.D., M.R.C.S., L.S.A., A.K.C.
(Folkestone). Thirteenth Thousand. Enlarged and
Revised throughout. London : The Scientific Press.
1899. 8vo. Pp. 427.
2. A Handbook for Nurses . By J. K. Watson, M.D.
Edin. London: The Scientific Press. 1899. 8vo.
Pp. 413.
1. W"e may preface our remarks by congratulating nurses
upon the marked advance made in the text-books intended for
their use. Those now before us enter into detail and the
“ reason why ” in a satisfactory manner which will be
appreciated by the nurse who often spends ill-spared hours
seeking information she yearns for from mighty tomes too
scientific and classical for practical purposes, as far as she is
concerned. Here all she needs, or probably seeks for, is
condensed and arranged for easy reference. Of Dr. Lewis’s
book we cannot speak too highly; it is up to date in every
particular, including mental nursing, Nauheim treatment,
and massage, and is more than double the size of the first
edition, published in 1890.
2. Dr. Watson’s handbook should be on every nurse’s shelf
for the practical instruction it affords in cases both medical
and surgical, given in fullest detail of symptoms, treatment,
and application.
Smith— Wasting Diseases of Infants . 369
In both these works a more even balance of responsi¬
bility between doctor and nurse is advocated than we have
hitherto met with — a step in the right direction, from
which both professions will benefit. Deeper insight and
acknowledgment will lead to more intelligent obedience, and
get more enthusiastic work from the true and helpful woman,
who alone should aspire to become a nurse.
The Wasting Diseases of Infants and Children. By
Eustace Smith, M.D., F.R.C.P. ; Physician to His
Majesty the King of the Belgians ; Senior Physician to
the East London Children’s Hospital, and to the City
of London Hospital for Diseases of the Chest. Sixth
Edition. London : J. & A. Churchill. 1899.
The issue of the sixth edition of this well-known work will
be hailed with satisfaction. No English physician is so
well entitled to write on this subject as Dr. Eustace Smith.
Dealing with, perhaps, his favourite subject, Dr. Smith
heiein embodies the results of his life-long experiences
amongst sick children. After an introduction of some
fifteen pages the reader is presented with separate complete
essays on the following diseases: — 1. “Infantile Atrophy,”
or Marasmus; 2. “Chronic Diarrhoea;” 3. “Chronic
Vomiting;” 4. “Rickets;” 5. “Inherited Syphilis;”
6. “Mucous Disease ; ” 7. “Worms;” 8. “Tuberculosis;”
the volume concluding with a chapter on “ The Diet of
Children in Health and Disease.”
This is eminently a book for physicians, being beyond the
scope of most students, and for clinical study in an out¬
patient department or children’s ward. No volume will
lie found to treat better, if as well, the subjects tabulated
above. It costs only six shillings.
There is a learned and beautiful description of “ rickets ”
in Chapter IV. Dr. Smith very properly points out that
lickets is not merely a disease of the bones, but one which
affects the tissues of the body very widely : — “ The disease
occurs amongst the children of the rich as well as amongst
the poor, for wealth cannot buy judgment, and education is
no guarantee against foolish indulgence. We know that a
2 A
370 Reviews and Bibliographical Notices.
cliild may be in reality starving although fed every day upon
the richest food, for he is nourished, not in proportion to the
nutritive properties of the food he swallows, but in propor¬
tion to his ability to digest what is given to him. If, there¬
fore, he be supplied with food which is unsuited to his age*,
the result is the same whether he live in a palace or a
cottage.”
“ Rickets does not produce malnutrition, but malnutrition
produces rickets.” 44 By judicious treatment it may be
stayed at any point of its career, and the treatment re¬
quired is merely food — food wdiich nourishes, and drugs
which are not so much medicines as food under another
name.”
The other essays are equally interesting.
This volume is another proof of what has been before in¬
sisted upon in this Journal — viz., that children die from
medical diseases, that surgery has little or no part in the
prevention of infantile mortality, and that hospitals for sick
children should be mainly devoted to medical work. Rickets
is an entirely preventable disease, and, if taken in time, is
cured without difficulty ; by the time it reaches the surgeon
irreparable damage has been done.
We most highly commend the distinguished author on
the appearance of this scholarly treatise upon some of the
most difficult clinical problems in medicine, and recommend
earnest investigators to consult its pages on the above in¬
tricate diseases of children.
The Guide to South Africa . For the use of Tourists,
Sportsmen, Invalids, and Settlers. With Coloured Maps,
Plans, and Diagrams. Edited annually by A. Samler
Brown and G. Gordon Brown, for the Castle Mail
Packets Company, Limited, 3 & 4 F enchurch-street,
London, E.C. 1899-1900 Edition. Seventh Edition.
London : Sampson Low, Marston & Company, Limited ;
Cape Town, Port Elizabeth, and Johannesburg: J. C.
Juta & Co. 1899.
The seventh edition of this useful and popular handbook,
issued in September, 1899, has been entirely revised. All
Brown — Guide to South Africa. 371
data available at the end of July have been incorporated with
the text, and the necessary alterations have been made in
the very complete series of coloured maps.
The work does not pretend to be merely a “ Guide ” in
the ordinary sense of the word, but adds to the information
usually given in a traveller’s vacle mecum a mass of con¬
densed and statistical matter bearing on South Africa
generally. This cannot iail to prove both interesting and
instructive at a time when the fate of what may be called
the South African Empire hangs in the balance. In con¬
nection with the present crisis we have repeatedly had
occasion to consult this work, and never in vain or without
profit. It is marvellously cheap, costing only half a crown.
ROYAL COLLEGE OF SURGEONS, EDINBURGH.
At the annual meeting of the College, on October 18th, 1899, Dr.
James Dunsmure was unanimously elected President for the
ensuing year, and the following gentlemen, having passed the
requisite examinations, were duly elected Fellows of the College : _ _
Francis Horatio Amner, L.R.C.S.E., Tongkah, Siam ; Nathaniel
Thomas Brewis, F.R.C.P.E., Edinburgh ; Arthur Mayers Connell,
M.R.C.S. Eng., Sheffield; George Aubrey Jelly, M.R.C.S. Eng.,
Sunderland; Robert Holbourne William Johnston, L.R.C.S.E.,
Maidstone; John Norman Macleod, M.B., C.M., Glasg., Indian
Medical Service ; Robert Henry Parry, L.R.C.S.E., Glasgow ;
Henry Carden Pearson, M.B., C.M., Edin., Darlington ; John
Connel Ramsay, L.R.C.S.E., Peebles ; Donald Ferdinand Schokman,
L.R.C.S.E., Colombo, Ceylon; John William Struthers, M.B.,
Ch.B. Edin., Edinburgh ; and Andrew Hutton Watt, M.B., C.M.
Edin., Edinburgh.
HYSTERIA IN A CAT.
i
A nine-months’ old kitten, very fond of play, was one day bitten in
the back by a dog. Thereafter it dragged its hind legs, and did
not move its tail, just as if the cord had been crushed. Later it
fell from the first story of the house. It was instantly cured and
used its legs and tail as well as ever. It is evident that the shock
of the fall produced a psychic effect sufficiently powerful to over¬
come the idea of paralysis. That the trouble was only a hysterical
paralysis was further shown by the preservation during the whole
time of the functions of bladder and intestines. — Medical News ,
June 3, 1899.
PART III.
MEDICAL MISCELLANY.
- -
Reports , Transactions , and Scientific Intelligence.
The Achievement of the Mens Medical By John William Moore,
M.D., Dubl., P.R.C.P.I. ; Physician to the Meath Hospital and
County Dublin Infirmary.
INTRODUCTORY.
The whirling years assign to me once more the honourable task
of opening the Clinical Session at the Meath Hospital and County
Dublin Infirmary.
Exactly twenty-four years have passed since it was my privilege,
then a neophyte of six months’ standing on the Medical Staff, to
trace the medical history of the Meath Hospital from its opening
on March 2, 1753, to the resignation on April 1, 1875, of William
Stokes, a man
“ Of very reverend reputation, sir,
Of credit infinite, highly beloved,
Second to none that lives here in the city.”
— Comedy of Errors, v. 1.
HOSPITAL IMPROVEMENTS.
Were that great and good physician now to revisit this scene of
his earthly labours for forty-nine years, he would much rejoice to
find that the lessons he taught as to the prevention, not less than
the cure, of disease, have borne ripe fruit in the hospital he served
so faithfully and loved so well.
We can point with pride to the isolation hospital which has been
erected on our grounds within the last few years for the treatment
of infectious fevers ; to the modern operation theatre, which has
already proved an invaluable boon ; to the admirable drainage
system of the hospital buildings ; and to the remodelled and enlarged
laundry, with its splendid machinery, now utilised to heat the
theatre and to supply hot water to all parts of the hospital.
Although any statement relative to the Operation Theatre would
a An Address introductory to the Session of 1899-1900, delivered at the
Meath Hospital and County Dublin Infirmary on Monday, October 9, 1899.
373
Achievement of the Mens Medica.
come more appropriately from the lips of one of my surgical
colleagues, I cannot but allude to the work done in it since its
opening on October 1, 1898. The Report of the Hospital for
the year ended March 31, 1899, states that the new theatre has
been built on a higher level than the old one, and is in direct
communication with the surgical landing, so that patients are now
simply wheeled from the wards into the theatre, and back again
to the wards on the completion of the operation. In the theatre
itself the aim has been to combine simplicity with perfection of
detail in carrying out as thoroughly as possible all the requirements
of modern aseptic surgery. Arrangements have been perfected
for a constant supply of boiling and cold sterilised water ; and
heating is effected by means of steam radiators, so that the severest
abdominal operations can be performed at a temperature of 70° F.,
even in mid-winter. The floor consists of marble mosaic, and the
walls are built of specially prepared cement, so that the whole area
can be thoroughly washed and disinfected both before and after
use. No porous or dirt-retaining fittings have been used, and the
dust from the students’ boots, clothes, &c., is prevented from
reaching the field of operation by glass screens running round the
galleries. Since its opening, now twelve months ago, operations
have been performed in the theatre day after day, without a single
mishap or a single instance of septic infection. This fact alone
shows the perfection of detail with which the arrangements were
planned, and the conscientious care with which they have been
carried out by the Surgical and Nursing Staffs.
In connection with the Surgical Department of the hospital also,
a new male accident ward, containing twelve beds, has been erected
on the site of the old operating theatre. This spacious and
cheerful ward has been fitted with separate bath-room, lavatory
and closets. It is lofty and admirably ventilated and lighted ; it
it has been supplied with every requisite for the benefit and
comfort of the patients. Provision has been made in the old ward
for the isolation of patients affected by septic conditions, or offensive
cases likely to contaminate a ward.
Of the accommodation for infectious cases, I need say but little.
The “West Wing ” is doing noble work during the present season
in the matter of the treatment of the epidemics which have visited
Dublin this autumn — measles and typhoid fever. In our Epidemic
Wing we are able to accommodate some 40 patients with safety to
themselves and to the public health. From what has been stated,
it is clear that no expense or pains have been spared to make the
f
374 Introductory Address.
Meath Hospital a fully-equipped School of Clinical Medicine and
Surgery in the modern sense.
THE LOCAL GOVERNMENT ACT, 1898.
The past year has, in another direction, been a noteworthy one
in the history of the hospital. Founded in 1753, the Meath
Hospital was, in 1774, constituted the County Dublin Infirmary
by Act of Parliament, and received from the Grand Jury accord¬
ingly a presentment of £100 per annum. This brought the hospital
under the operation of the Local Government Act, 1898. Section
15 of this measure provides that “every County Infirmary shall
be managed by a Joint Committee, appointed triennially, consisting
of such number of Members of the Corporation of the Governors
and Governesses of the Infirmary appointed by the corporation, and
of such number of members of the County Council, as the Local
Government Board from time to time fix in the case of each
infirmary.” Letters have been received from the Secretary of the
Local Government Board, stating that that Board had fixed the
number of members of the Joint Committee for the manage¬
ment of this Infirmary for the next three years at twenty-three —
viz., one representative of the Corporation of the City of Dublin,
three representatives to be appointed by the County Council of
Dublin, and nineteen representatives to be appointed by the
Governors and Governesses of the Infirmary.
The new Joint Committee will doubtless work with a single eye
to the best interests of the institution which has thus been entrusted
to its care. Its representative character should entitle it to public
confidence. But, if it is objected that the Corporation and the
County Council are not sufficiently represented, the remedy is
simple — let those bodies double their contributions, and at the next
triennial election their representation will be proportionately
increased.
PROPOSED NEW LUNG FOR THE HOSPITAL.
There are still, in my opinion, two directions in which generous
donors might benefit the hospital. One is in the matter of the
purchase of a waste piece of ground to the westward of the
hospital extending from Willi ams’s-place to the rear of Lower
Clanbrassil-street. If it were once the property of the “ Governors
and Governesses,” together with the intervening row of cottages in
Williams’s-place, we should have secured as fine an open space or
“ lung” on the west, as that which already exists on the east, side
of the hospital.
Achievement of the Mens Medica.
375
A NURSING HOME.
Perhaps a still more pressing need is the erection of a Nursing
Home in the vicinity of the hospital, and the establishment of a
Training School for Nurses under the immediate control and
management of our own Committee. A properly managed and
efficient Nursing School and Home would in a comparatively short
time prove a source of profit, and be a benefit to the institution.
Far be it from me to underrate or decry the invaluable services
rendered to the sick and suffering treated in our wards by the Bed
Cross Sisters and Probationers, with Sister Ellinor Lyons at their
head. But the existing system leaves much to be desired in regard
to finance, control, and repute as a School of Sick Nursing. I
trust that the closing year of the Nineteenth Century — the year of
our Lord, 1900 — will witness the realisation of the two schemes
of improvement I have ventured to suggest. In the proposed
Nursing Home provision should be made for a Lecture Theatre, of
which the hospital is sorely in want. A suitable site would be the
plot of ground west of the hospital, to which reference has just
been made.
THE NOBLENESS OF MEDICINE.
Gentlemen, members of the Medical and Surgical Class of the
Meath Hospital, to you especially shall my brief words on this
occasion be addressed.
Many of you are to-day standing upon the threshold of your life-
work — and a very solemn life-work it is. “ Medicine,” said the
late Sir Andrew Clark in one of his many addresses to students,
is “the metropolis of the Kingdom of Knowledge/’ “You have
chosen,” said he, “ one of the noblest, the most important, and the
most interesting of professions, but also the most arduous and
the most self-denying, involving the largest sacrifices and the
fewest rewards. He who is not prepared to find in its cultivation
and exercise his chief recompense, has mistaken his calling, and
should retrace his steps.”
The issues at stake in the practice of the Medical Profession are
indeed momentous. To the physician are for the time being, in a
measure, committed the balances of life and death ; the joys and
sorrows of humanity pass daily in a pageant before his eyes ; to
him are entrusted secrets, the revealing of which might blast a
reputation or snap the thread of life. He is the confidant of man¬
hood, the trusted champion of womanhood, the friend of little
children. His part it is to tell of approaching death when his skill
has failed to save life — oh ! let him act this tragic part with tender-
376
Introduc tory A ddress .
ness and loving sympathy, lest his words should wound like barbed
arrows, rather than soothe like the “ balm of Gilead.” When the
prophet of old sought to describe the desperate state of his nation,
he uttered the plaintive words — “ Is there no balm in Gilead ? Is
there no physician there? Why then is not the health of the
daughter of my people recovered ? ”
/
THE ct MENS MEDICA.”
Such being the dignity and the responsibility of our profession,
surely we should approach its portals with bated breath and
reverent mien. I do not urge that the physician should be an
ascetic. The very solemnity of our work forbids this, and counsels
recreation as a foil to the stern realities of our daily life. The
best physician is the man who, daily witnessing the havoc wrought
around him by the hand of Death, from his experience forms the
habit of acting with a constant view to death, and develops the
earnest desire to shield from its stroke the sick entrusted to his
care. “Perception of distress in others,” writes Bishop Butler in
The Analogy of Religion , “ is a natural excitement passively to pity,
and actively to relieve it ; but let a man set himself to attend,
inquire out, and relieve distressed persons, and he cannot but grow
less and less sensibly affected with the various miseries of life, with
which he must become acquainted ; when yet, at the same time,
benevolence, considered not as a passion, but as a practical principle
of action, will strengthen, and whilst he passively compassionates
the distressed less, he will acquire a greater aptitude actively to
assist and befriend them.”
This is the “ Mens Medica,” which endows the true physician
with the God-like power of healing. His compassion, observation,
experience, reason, and learning are all enlisted in a self-denying
and supreme effort to combat disease and to ward off death.
Fellow-students of the Hospital Class, it needs no words of mine
to show you that the “ Mens Medica,” of which I speak, is a
possession not to be lightly won, but to be highly prized. It is, as
it were, the Golden Fleece which you, the Argonauts, must win
through many trials and temptations, through many perils by land
and sea. My task, in the few moments allotted to me on this Red
Letter Day of a new Session, is to point how best this prize may
be achieved.
CLINICAL CASE-TAKING.
With much concern the physicians of the hospital have observed
that for some years back — especially since the institution of a fifth
377
Achievement of the Mens Medica.
year of medical study— students have been inclined to pay less
attention to their clinical work than was hitherto their custom.
They still “ walk ” the hospitals, but their attitude has become less
actively attentive than of old. When it was not compulsory to
“ take cases,” cases were taken as they should be taken — that is, the
patients were visited twice a day, and every symptom and turn of
their illness were noted. Now, I do not for one moment wish to
belittle the teaching in our Schools of Medicine. A liberal
general education and a sound knowledge of the ancillary sciences
are essential elements in the 'evolution of the physician or the
surgeon. But the paramount use of these aids to a professional
training is to enable the medical student rightly to observe and
study disease — and this crowning work of medical education can
be pursued only at the bedside of the sick — there alone can u the
ways of the sick ” be learned. In my first Address, delivered in
1875, I quoted Robert James Graves on this point. With your per¬
mission, I shall quote him again. In his first introductory lecture
after his appointment as Physician to this hospital in 1821, he
wrote : — u From the very commencement the student ought to
witness the progress and the effects of sickness, and ought to
persevere in the daily observation of disease during the whole
period of his studies.” He continues A great number of
students seem little, if at all, impressed with the difficulty of
becoming good practitioners ; and not a few appear to be wholly
destitute of any prospective anticipation of the heavy, the awful
responsibility they must incur when, embarking in practice, the
lives of their fellow-creatures are committed to their charge. It is
by persons of this description that the earnest attention and
permanent decorum which ought to pervade a class employed in
visiting the sick are so frequently interrupted. Young men of the
character to which I allude attend, or, as it is quaintly enough
termed, walk the hospitals very regularly, but they make their
appearance among us rather as critics than as learners — they come,
not to listen, but to speak — they consider the hospital a place of
amusement rather than of instruction. Students should aim not
at seeing many diseases every day ; no, their object should be
constantly to study a few cases with diligence and attention ; they
should anxiously cultivate the habit of making accurate observations.
This cannot be done at once ; this habit can be only gradually
acquired. It is never the result of ability alone; it never fails to
reward the labours of patient industry. You should also endeavour
to render your observations not only accurate, but complete ; you
'378 Introductory Address.
should follow, when it is possible, every case from its commence¬
ment to its termination, for the latter often affords the best
explanation of previous symptoms, and the best commentary on the
treatment.”
In some degree, the languid case-taking of the present day is
due to the active training of nurses and probationers which goes
on in our wards. Our neat Clinical Charts are filled in by the
probationers who are trained to take observations on the tempera¬
ture, the pulse rate, and the rate of breathing. But this should
not interfere with the case-taker’s records — quite the reverse, for a
second series of observations would control the first. Speaking
with more than thirty years’ experience as both student and
practitioner, I assert with all the emphasis at my command that
the student who neglects his clinical work, or carries it out in a
half-hearted and perfunctory manner, will bitterly regret his lost
opportunities in after-life. Sooner or later, with much searching
of heart and with many a misgiving, weighed down by a full sense
of undivided responsibility, he will have to strive after that ripe
experience which was within his grasp while yet a student, when
he could share all responsibility with his teachers, and was sheltered
beneath the aegis of their position.
The apologist of the medical student will urge that so many new
subjects have been added to the curriculum and examinations that
he has no time for hospital practice. To this apology there is a
threefold answer — (1) A fifth year has also been added to the
curriculum; (2) the additional subjects are necessary if he is to be
an “up-to date” physician and surgeon; (3) their study renders
hospital work at once easy and fascinating.
THE ADVANCE OF MEDICINE.
Medicine and Surgery have advanced within the past quarter of
a century by leaps and bounds. Almost precisely twenty years
ago, on November 3, 1879, it was my lot to deliver the Address
introductory to the session in this hospital, and I chose as my
subject “ The Microcosm of Disease.” The term “Bacteriology”
was not then in use, but it was what I meant. Look how rapid
and how conducive to the welfare of mankind has been the
march of knowledge in regard to the bacterial origin of disease.
Think of the triumphs of modern aseptic Surgery, more glorious
because more beneficent than any triumphs the world ever saw
before.
Nor has Medicine lagged behind. Day by day we are learning
more of the intimate nature of contagion in relation to the infective
379
Achievement of the Mens Medica .
diseases ; our diagnostic powers have been reinforced by microscopic
investigation of stained bacteria, by observation of the altered
behaviour of ’"certain pathogenic micro-organisms in the presence
of infected blood — witness the Widal test for typhoid or enteric
fever ; and one fell disease at least has been robbed of its terrors
by the serum or antitoxin treatment — namely, diphtheria.
THE FEVER PROCESS.
The nature of the fever process is now far better understood than
it was even a few years ago, and we have learned that “ fever,” or
elevation of bodily temperature above the standard of health, or
“normal,” serves a useful purpose, provided that it is properly
controlled. There is, in fact, what the Germans aptly call “ das
Heil-Fieber” — “the fever which brings back health.” At the
close of an able Address on “ Antipyresis ” before the Tenth
International Medical Congress at Berlin, in 1890, Professor
Arnaldo Cantani, of Naples, used the memorable words — “ Das
Fieber, das in so vielen Krankheiten der beste Verbiindete des
Arztes ist ” — “ the fever, which in so many diseases is the best
ally of the physician.” Fever, in a word, purges the system. In
an excellent article on Typhoid Fever, written in the present year,
Drs. Affleck and Ker, of Edinburgh, say — “ The ordinary fever
of a typhoid case runs such a fixed and definite course that it is
hard to believe that the pyrexia is not Nature’s cure for the disease.”
In this mixed assembly of laymen and members — actual or pre¬
sumptive — of the medical profession, I would raise a warning voice
against the pernicious doctrine that in fevers the temperature must be
reduced as quickly as possible to what is popularly called “ normal.”
It cannot be too often or too emphatically and authoritatively
declared that such a procedure is very likely to destroy life. The
so-called antipyretic medicines, or heat-reducers, should never be
used by unskilled hands. The employment of such remedies, even
by the skilled physician, calls for the utmost caution and the most
anxious consideration. The danger lies in an interference with
the production of body-heat, while the escape of heat from the
system is increased. In this way collapse is likely to be induced.
For many years I have taught that the only safe antipyretic, or
assuager of fever-heat, is water, and especially cold water. It
helps the escape of heat from the body in many ways, while it does
not interfere with heat production — rather, indeed, does the use of
cold water internally and externally encourage the evolution of
heat in the body.
380
Introductory Address.
ALCOHOLIC STIMULANTS IN DISEASE.
Another popular error, rife among medical students also, is that
alcoholic stimulants are a sheet-anchor in serious disease. Such a
notion may be fraught with grave consequences — immediate and
remote. A patient, already suffering from the effects of a specific
poison, may be doubly poisoned by alcohol, itself an intoxicant,
or poison. And— a still greater disaster — a habit of alcoholism
may be engendered through the careless administration of alcoholic
stimulants. Children and women, as a rule, bear stimulants badly,
and in their case especially their use should be but temporary. In
so-called u nervousness,” nervous depression and sleeplessness, stimu¬
lants are much more likely to do harm than to do good. If they are
given at all, it should be under the watchful supervision of the
physician, the effect of each dose being carefully noted and weighed.
The question of the administration in fever of these powerful
drugs — for such they are — is an anxious one. The chief indica¬
tions for their use are derived from the state of the pulse, the heart,
the tongue, and the brain ; and from the presence of complications,
particularly of the “ typhoid state,” or that state which betokens
profound depression of the nervous and muscular systems. Stimu¬
lants are most urgently required during the night and in the early
morning, when the life-tide is at the ebb and the vital powers are
wont to flag. In the forenoon they are much less needed. A
comparatively safe way of exhibiting stimulants is in combination
with food, in the form of eggflip, wine-whey, sillabub, and so on.
DIET OF THE SICK.
This leads me to remark that, if you wish to be a good physician,
it is necessary that you should also be a good cook. At all events
you should be a good theoretical cook, effect being given to your
theory by a good practical cook. There is scarcely a disease in which
diet does not play a more important part than mere medicines. Again,
there are no two patients whom precisely the same dietary will suit.
We might say : Quot homines , tot epulce. The skill of the physician
will at times be severely tested in the attempt to draw up a suitable
bill of fare for a fastidious patient. We should always remember
that “what is one man’s food is another man’s poison.” Dr. T.
King Chambers, in his excellent “ Manual of Diet in Health and
Disease” (published in 1875), reminds us that when the tailor
in Laputa sternly refused to take the usual measurements, and
insisted on constructing Captain Gulliver’s coat, waistcoat, and
breeches on abstract principles, the customer vowed it was the
Achievement of the Mens Medica. 381
worst suit of clothes he ever had in his life. Dr. Chambers adds :
“We should certainly fail in the same way if we did not take the
measure of numberless contingencies in the daily life, and number¬
less peculiarities in the persons of those who consult us about their
diet and regimen.”
PULMONARY TUBERCULOSIS.
The hospital treatment of consumption — by which is commonly
understood pulmonary tuberculosis — is an anxious question, and
one that is difficult of solution. Year by year the conviction grows
stronger that in treating this fell disease in the wards of a general
hospital we are committing a grave hygienic error.
In an Address on the “ Prevention and Cure of Tuberculosis,”
delivered before the Section of Medicine at the Carlisle meeting of
the British Medical Association in 1896, I pointed out that,
theoretically, the air of an hospital ward, however clean and
well-ventilated that ward may be, is unsuited for a consumptive.
In it his surroundings are calculated to depress. The dietary may
not coax his appetite. And then to look at the question from the
point of view of the other patients, the presence of the consumptive
may be no more than tolerated. He keeps them awake at night
with his hacking and racking cough ; he resents open windows, yet
may pollute the air in the ward to an extreme degree. If his
expectoration is not destroyed or disinfected, he may even infect his
fellow-sufferers with his own disease.9. He occupies month after
month a bed which otherwise would accommodate many generations
of patients labouring under less chronic and more curable maladies.
Lastly, the hospital treatment of tuberculosis breaks down because of
its utter inadequacy to cope with so universal and so tedious a disease.
In a week every bed in every hospital in the United Kingdom
might be tilled with consumptives, and even then thousands upon
thousands of cases would be left without hospital accommodation,
so widespread is the plague of phthisis.
The Hospital Treatment of Tuberculosis should resolve itself
into providing of —
1 . Consumption Hospitals , or Sanatoria, in which the disease
could be treated in its earlier and more hopeful stages.
2. Special Consumption Wards in General Hospitals, into
which tuberculosis, and that disease alone, should be
received.
a Geo. Allan Heron. The Relation of Dust in Hospitals to Tuberculous
Infection. Lancet, Jan. 6, 1894.
382 Introductory Address.
3. Refuges for those far advanced in, or dying of, consump¬
tion. The German name for such an institution is very
expressive — “ Friedensheim,” or “Home of Peace.”
The providing of special wards in, or adjacent to, our general
hospitals would meet to a certain extent some of the objections I
have advanced to the treatment of consumption in hospitals. In
such wards consumptives in a more advanced stage of the disease
could be treated, the separate principle being carried out wherever
possible, a ward in any case being planned to contain never more
than 3 or 4 patients, and provision being made for inhalations of
ozonised oxygen, as suggested and carried out by Dr. Ransome.
In Dublin there are two large institutions of a sadly pathetic
nature — one is the Royal Hospital for Incurables ; the other, Our
Lady’s Hospice for the Dying. The former stands on its own
grounds, which are very extensive, in the Pembroke Township,
a healthy suburb of Dublin. It was founded in 1740, but has
been greatly enlarged within recent years. It contains 212 beds,
many of which are occupied by cancer cases, and patients suffering
under incurable visceral diseases (of the heart, liver, kidneys, &c.).
There are also numerous cases of advanced or incurable tuber¬
culosis.
Our Lady’s Hospice for the Dying stands on extensive grounds
at Harold’s Cross, in the Rathmines Township, another large
outlet of Dublin. This institution affords accommodation for 112
patients, and is designed only for those whose illness is likely to
terminate fatally within a limited period. The bulk of the cases
received into the wards are the victims of tuberculosis, and espe¬
cially of consumption.
MEDICAL ETIQUETTE.
I do not wish to weary you with a long Address, but there is one
fact which, if once pressed home, may save you and others from
many a heart-burning in your professional life. A physician or a
surgeon has no vested right or property in a patient. To put it in
another way, the public have the most absolute right to choose
their own medical attendants, and to change them as often as they
please. Therefore, do not pick a quarrel with a professional
brother on the ground that he has superseded you, and do not judge
him harshly, or at all, until you have heard both sides of the
question.
Do not misunderstand me. While the public must be left free¬
handed in this matter, a serious responsibility rests upon every
383’
Achievement of the Mens Medica.
member of our profession who does not act towards his professional
brethren with consummate tact, consideration, and forbearance.
-Never take advantage of a brother. If you are called in to visit a
patient hitherto under his care, acquaint him of the fact with the
least possible delay. Come to an honourable understanding with
him. Do unto him as you would he should do unto you. If he
then takes umbrage, the fault lies at his door, not at yours. Such is
u Medical Etiquette.” William Stokes concluded one of his eloquent
Addresses on our conduct towards other men with the words of
Hamlet — “ Use them after your own honour and dignity ; the less
they deserve the more merit is in your bounty.”
CONCLUSION.
It only remains for me to bid those of you who are now for the first
time entering our wards for clinical study, cetiu tnilo police
a hundred thousand ivelcomes — and to grasp once more in hearty
friendship the hands of those who have in past sessions worked
side by side with us in the harvest-field of this hospital.
In the Song of the Old Woman of Beare , Digdi, the aged woman
of Bearhaven — who for a hundred years had worn the veil which
Cummine blessed upon her head — contrasts, in language of indescrib¬
able pathos and beauty, the privations and sufferings of her old age
with the pleasures of her youth, when she had been the delight of
kings. She draws her imagery from the flood-tide and ebb-tide of
the wide Atlantic, on whose shore she had lived and loved and
suffered —
“The wave of the great sea talks aloud,
Winter has arisen.”
Be it yours rather, after a youth spent in noble toil and loving
service to the sick and suffering, to enjoy in your old age the
pleasures born of a well-spent life, and on the flood-tide of the
Master’s love to be wafted into the quiet haven, where- —
“ Beyond these voices there is Peace.”
LITERARY INTELLIGENCE.
Dr. Jellett, the author of a u Short Practice of Midwifery,”
which has already reached a second edition, is, we learn, at work
upon a companion volume on Gynaecology. The work, which will
be of an eminently practical character, will be illustrated freely-
The publishers are to be Messrs. J. & A. Churchill, of 7 Great
Marlborough-street.
ROYAL ACADEMY OF MEDICINE IN IRELAND.
President — Edward H. Bennett, M.D., F.R.C.S.I.
General Secretary — John B. Story, M^.B., F.R.C.S.I.
SECTION OF SURGERY.
President — R. L. Swan, President of the Royal College of
Surgeons in Ireland.
Sectional Secretary— John Lentaigne, F.R.C.S.I.
Friday, May 12, 1899.
The President in the Chair.
Gastro- Enter ostomy.
Mr. C. B. Ball read a paper on this subject. The form of
operation recommended was the posterior route through an opening
made in the transverse meso-colon, as advocated by von Hacker
and Courvoisier. The first loop of jejunum arising from the
duodenum was selected, and divided completely across, as recom¬
mended by Wolfler, the incision being continued for about an inch
and a half into the mesentery ; the mesenteric wound was topsewn
with fine catgut, and the distal end emplanted into the stomach
by means of the author’s pattern of decalcified bone ring for
intestinal anastomosis, the proximal end having previously been
implanted laterally into the jejunum with a second ring at a point
about three inches below the portion joined to the stomach. I he
advantages of an ample and direct lead from the stomach to the
intestine, together with the entrance of bile and other duodenal
contents into the bowel at a point some inches away from the
stomach, in the opinion of the author more than counterbalanced
the disadvantage of a double anastomosis, and the treatment of a
considerable mesenteric wound. Two cases were related. In the
first the stricture of the pylorus was manifestly malignant, with con¬
siderable involvement of the omenta and glands. The patient
recovered well, and two months after operation had increased two
stone in weight; he subsequently developed secondary cancer of the
liver, of which he died six months after operation. In the second
case the tumour was more extensive, and appeared to be malignant.
385
Section of Surgery.
The operation was carried out in the same way, except that the
duodenal end of the jejunum was attached to the stomach, and the
distal end laterally implanted into the proximal. At the time of
writing, eight months after operation, the patient was in absolutely
good health in every respect, so that it is possible that the diagnosis
of malignancy was mistaken.
Mr. P. J. Fagan remarked on the rapidity of Murphy’s button
over simple suture.
Mr. M'Ardle took exception to the term gastro-enterostomy,
as a gastro-enterostomy lower down was not surgery at all, and
he thought that they should confine themselves to the term
gastro-jejunostomy. Herniation might occur in anterior gastro-
jejunostomy, and, therefore, the operation should be exterminated.
In a case of anterior gastro-jejunostomy performed by himself
persistent churning up of bile in the stomach occurred, and every
morning the patient vomited three or four ounces of acid bile, which
was very distressing. He liked the operation of posterior gastro¬
jejunostomy, which was simple. From 1890 till the present he had
done eight operations, all for benign stricture, successfully, and all
the patients were still alive. Fie was against continuous suture as
done by Lauenstein, and believed that a high mortality attended the
application of any method of continuous suture in posterior gastro¬
jejunostomy. He was glad to see that Mr. Ball used the purse¬
string suture advocated by Murphy in lateral junction of the
bowel. He disliked a bobbin such as Mr. Ball’s, as it left un¬
controlled a piece of inverted bowel wall, and was liable to cause
stricture. About two per cent, of Murphy’s button on the market
were real, the rest were made for tradesmen’s profits.
Mr. E. H. Taylor had seen Mr. Ball perform his operation,
and he was greatly impressed with the ease with which it was
carried out. He believed that the bone rings were preferable to
simple suture. He did not approve of Murphy’s button, as the
chances of its becoming impacted were very great, and also the
difficulty of the button, of the size he would like to use, passing the
ileo-csecal valve, were very great. He held that any operation
which fixes the intestine either behind the posterior wall of the
stomach, or the anterior wall where the loop is not divided, is not
a good operation.
Dr. A. R. Parsons had recently had three patients on whom the
operation was performed. The first was a woman between fifty
and sixty years of age, who had been operated on successfully for
sub-phrenic abscess, and three months later came to hospital with
2 B
386 Royal Academy of Medicine in Ireland .
extreme dilatation of the stomach, with persistent vomiting and
emaciation. He felt a very large tumour in the right hypochondriac
region, and diagnosticated it as non-malignant. Mr. Croly performed
the operation on her by Murphy’s button. As far as the operation
went nothing could have been more successful. Death followed in
two days. Post-mortem showed nothing to account for death. The
second case was that of a woman between thirty and forty years of
age. She suffered from persistent vomiting, and became emaciated
very rapidly. A tumour was palpated in the neighbourhood of the
pylorus. Examination of the gastric contents showed it to be
malignant obstruction of the pylorus. Mr. Johnston performed a
posterior gastro-enterostomy. Patient remained perfectly well for
three months afterwards, but the disease spreading, vomiting again
occurred, and death followed six months after the operation. The
third case was that of a man thirty years old. Examination of the
gastric contents proved him to be suffering from malignant stricture
of the pylorus. Mr. Johnston performed a posterior gastro-enteros¬
tomy, and recovery was good. He thought that anterior gastro¬
enterostomy was a bad operation. He was greatly struck by the
extreme simplicity by which the anastomosis could be done by Mr.
Ball’s bobbin. He thought it might be better to plug the bobbin
with some kind of a sterilised cork, instead of plugging with gauze,
to insure prevention of extravasation during operation. Had an
examination of the gastric contents been made in Mr. Ball’s cases ?
Mr. Croly thought that it was more the method of operating
than the button that was of importance.
Mr. G. J. Johnston said that he had used Mr. Ball’s bobbin in
both cases. He believed in the posterior operation, and not in the
anterior. He thought that the direction of the currents of the
contents of the stomach and intestine should be the same in both.
In his second operation, he used lateral sutures as an addition to
prevent kinking.
Mr. Ball, in reply to Dr. Parsons, said that free HC1 was
absent in the first case ; he forgot whether it was absent in the
second case. His experience of anterior gastro-enterostomy
had been very unsatisfactory. He did not understand how Mr.
MtArdle had done a gastro-jej unostomy through the gastro-colic
omentum. Mr. M‘Ardle’s record of eight consecutive cases for
eight years was very remarkable. He had not altered the shape of
his button, and the purse- string suture was first used by Mr. Greig
Smith, and was the only form applicable to a lateral anastomosis.
He believed that Murphy’s button would soon be obsolete. Dr.
387
Section of Anatomy and Physiology.
Parsons’ suggestion about a cork in the button was very good, but
he had always found gauze to answer the purpose. In the second
case on which he operated, on introducing the fingers into the
stomach, the pyloric orifice represented a virgin os uteri, so that
scarcely any contents of the stomach were finding their way into
the duodenum at the time of the operation. He thought that
reo;urg;itation of the duodenal contents into the stomach was
likely to occur in posterior gastro-enterostomy so long as a loop of
intestine was simply lateralised to the stomach.
The Section then adjourned.
SECTION OF ANATOMY AND PHYSIOLOGY.
President — D. J. Coffey, M.B.
Sectional Secretary- — A. Birmingham, M.D.
Friday, June 2, 1899.
The President in the Chair.
Distribution of the Glands in the Human (Esophagus.
The President (Professor Coffey) said that the oesophagus, after
fixation and hardening, was divided into twelve segments of equal
length, aud then sectioned. The glands appeared isolated ; they
were large enough to be distinctly visible to the naked eye, and
lay imbedded in a fairly close-textured fibrous submucosa. Each
one was formed of a close cluster of alveoli, lying a short distance
below a well-defined continuous and rather broad band of muscularis
mucosae. Sometimes a detached strip of this muscular layer
extended below the gland. In the transverse sections, of which a
complete set had not yet been made, the glands occurred in inter¬
rupted vertical rows. The whole arrangement contrasted remark¬
ably with the thick almost unbroken stratum of glands which
occupied the whole submucosa in the dog. The number of glands
in any one vertical section through the whole length of the tube was
about thirteen as a rule. They were placed in the successive segments,
in the following order from above down— -three in the upper four
segments, four in the next two, the succeeding two segments were
devoid of glands, then followed four glands, and lastly, two in the
remaining segments. The examination of the junction of the tube
with the stomach was as yet unfinished. The upper half of the
mucous membrane was therefore better supplied with glands than
388 Royal Academy of Medicine in Ireland.
the lower half. Other features of the histological structure investi¬
gated showed that the unstriped muscle in the circular coat ex¬
tended almost to the upper extremity of the tube.
The Histology of the Human Vermiform Appendix.
The President said that the general arrangement and structure
of the layers of the tube corresponds with that of the large inte stine.
The muscular layers are, however, pretty thick for a tube of such
dimensions, the external or longitudinal being complete, and con¬
taining almost as many rows of cells as the circular layer. Most
interest attaches to the submucous coat. It is almost wholly
occupied by lymphoid nodules arranged in a thick ring. Each one
is conical in form, base outwards, and surrounded by a capsule
lined with endothelial cells, which thus constitute a lymph sinus
drained by the lymphatics. The solitary follicles, which in the
intestine lie mainly in the mucosa, are here crushed out into the
submucosa altogether. This determines a condensation of the
proper areolar constituents of this layer into a band of dense
fibrous tissue, lying outside the nodules and separating them from
the muscular wall. One or two thick bands, however, remain in
the radial direction, and run inwards from the muscular to the
mucous coat. The lymphoid nodules vary much in size, and a few
large ones appear to be projected inwards from the ring, invading
the mucous coat and reaching to the epithelial surface. These
differ in shape from the submucous nodules, being pyriform, with
the broad end inwards. They might be described as a sort of
second ring pushed inwards from the crowded outer set. The want
of uniformity in the size of the nodules is apparently associated
with the irregularity of the lumen of the tube. The glands of the
mucous coat are of the normal character and are fairly numerous .
The muscularis mucosae is thin and badly defined, it is broken into
strips and lies immediately internal to the apices of the conical
lymphoid nodules.
Professor Purser said that the finding of unstriped muscular
tissue so high up in the oesophagus was very interesting, and a new
fact to him. He had often in examining pathological .specimens
been struck with the absence of glands in the oesophagus, but that
may have been owing to the pathological condition. The distribu¬
tion of lymphoid tissue in the vermiform appendix was very in¬
teresting ; in the rabbit it was the rule that two or three layers
of adenoid tissue were present lying over each other.
Professor Birmingham said that a striking picture of the
389
Section of Anatomy and Physiology.
structure of the appendix was given in Testut’s Anatomy, but it
represented the muscularis mucosae as lying outside the lymphoid
structures. Evidently the true muscularis mucosae, which is very
faint, was overlooked.
The Form and Position of the Thoracic and Abdominal Organs in the
Lemur.
Dr. C. J. Patten read a paper on this subject. The com¬
munication was illustrated with lantern slides, and dealt more
especially with the relations of the viscera to the vertebral column
in the lemur as compared with some other animals. The value of
the method of preserving and hardening the viscera with formalin
was indicated, and the form which most of the solid organs assumed
was brought out.
The President remarked that the methods of classifying verte¬
brate types came to little more than dentition, and some few
features about bones, with most meagre facts about viscera.
Regarding lemurs, which are so doubtful in position, it was very
useful to show exactly the relations of their organs, and Dr. Patten’s
work was very carefully done in this respect.
Professor D. J. Cunningham said that Dr. Patten’s work was
most carefully done. It was another evidence of the value of
formalin. It was very unsafe to found any classification on one or
two characters. The animal must be investigated from top to toe,
and recently, even the muscles which had been thrown into dis¬
regard for a long time, are being utilised for this purpose. He was
doubtful if the study of formalin forms would help much in this
particular direction, but he thought that the work would probably
help them to get some idea of the forces which were at work in
determining the form of solid organs. This might be done by the
study of the comparative anatomy, but still more by the study of
the foetus. Some organs grew out in the direction of least resist¬
ance, and their shape was thus determined. Other organs, such
as the liver, offered more difficulty in the way of coming to a
conclusion.
Professor Fraser did not wholly agree with Professor
Cunningham’s remarks about the manner in which organs were
shaped. Some organs had plenty of room at their disposal, but yet
took a very definite shape, and he could not see how mechanical
causes came into play in every case.
Serial Sections of the Adult Human Body made ivithout Freezing.
Professor Fraser exhibited serial sections of the entire head
390 Royal Academy of Medicine in Ireland.
and neck, several from the thoracic region, and the entire lower
limb, from a subject which he had cut in the transverse vertical
direction, and serially at intervals of about one inch, from the
crown of the head to the soles of the feet.
The subject had been injected from the femoral artery with a
modified formalin solution under a pressure of about eight feet ; it
had then remained exposed to the air without covering in the
preparation room, when it was removed to the dissecting room,
and cut serially at the intervals stated above with an ordinary
amputating knife, and a small saw without a back, the latter being
applied to the bone wherever that became necessary.
The sections were perfect, both as regards the hardening and
the colour of the various tissues. Care had to be taken when
cutting in the abdominal region not to allow the coils of the small
intestine free in the particular section to fall out ; they had to be
secured by a stitch to neighbouring fixed coils, or to the adjacent
abdominal wall. The hardened blood, which was always found
in the veins, in the heart, and in certain of the arteries, in subjects
prepared as above, was removed under the water tap, and left the
vessels standing out in bold relief in the various sections.
These serial sections could be used with great freedom. They
could be handed round the class, and examined by each member ;
they could be left exposed to the air for days ; they could be left
under water also for days, or they could be finally mounted in a
preservative fluid.
It was desirable to have an alternative method of making useful
and instructive serial sections of the adult to that which had
hitherto been employed, which was the ordinary mixtures of ice
and salt, or snow and salt, in the absence of proper refrigerating
chambers, which were not, as a rule, attached to anatomical
departments in Great Britain or Ireland. The meeting could say
whether the sections now exhibited would not bear favourable
comparison with any that had ever been made by the method of
freezing.
The President said that the sections were of great value for
teaching purposes, and showed the natural appearances very well.
Professor Birmingham complimented Professor Eraser on the
beauty and usefulness of the specimens.
Formalin Specimen of the Abdomen.
Professor Birmingham exhibited a formalin specimen of the
abdomen, prepared to show the lines of reflection of the peritoneum.
The Section then adjourned.
SANITARY AND METEOROLOGICAL NOTES.
Compiled by J. W. Moore, B.A., M.D. Univ. Dubl. ;
P.R.C.P.I. ; F. R. Met. Soc. ;
Diplomate in State Medicine and ex-Sch. Triti. Coll. Dnbl.
Vital Statistics
For four Weeks ending Saturday , October 7, 1899.
The deaths registered in each of the four weeks in the twenty-
three principal Town Districts of Ireland, alphabetically arranged,
corresponded to the following annual rates per 1,000 : —
Towns,
&c.
Week ending
Aver¬
age
Towns,
<&c.
Week ending
Aver¬
age
Sept.
16
Sept.
23
Sept.
30
Oct.
7
Rate
for 4
weeks
Sept.
16
Sept.
23
Sept.
30
Oct.
7
Rate
fori
weeks
23 Town
266
24-0
27-0
247
25-8
Limerick
19*6
19*6
40*7
9*8
22*4
Districts
34*1
21*3
Armagh -
21-4
21-4
35-6
28*5
26*7
Lisburn
21*3
21-3
8*5
Ballymena
22-5
16-9
5-6
16-9
155
Londonderry
23-6
28*3
18*8
22*0
23*2
Belfast
23-5
22-8
21-9
26-1
23-6
Lurgan
18*2
18*2
4*6
27*4
17*1
Carrickfer-
23-4
5-8
29-2
o-o
14*6
ISTewry
8*1
20*1
8*1
24*1
15*1
gus
17*0
21*3
Clonmel -
24-3
9-7
29-2
4-9
17*0
Newtown-
ards
34*0
11*3
22*7
Cork
18-0
28’4
36-0
22*8
26*3
Portadown -
12*4
18*6
37*1
18*6
21*7
Drogheda -
15-2
3-8
34-2
22-8
19-0
Queenstown
11*5
11*5
0*0
11*5
8*6
Dublin
34-3
28-9
31*6
28*8
30*9
Sligo
71*1
15*2
25*4
0*0
27*9
(Reg. Area)
11*2
61*6
30*8
Dundalk -
20-9
335
12*6
20*9
22-0
Tralee
22*4
28*0
Galway
1.5*1
18-9
37*8
7*6
19-9
Waterford -
31*8
17*9
45*8
15*9
27*9
Kilkenny -
28-3
I
9-4
33*0
4-7
18*9
Wexford
18*1
9*0
13*5
31*6
18*1
In the week ending Saturday, October 7, 1899, the mortality
in thirty-three large English towns, including London (in which the
rate was 17-9), was equal to an average annual death-rate of 18*8
per 1,000 persons living. The average rate for eight principal
towns of Scotland was 17*5 per 1,000. In Glasgow the rate was
17-6. In Edinburgh it was 18*6. *
The average annual death-rate represented by the deaths regis-
tered during the same week in the Dublin Registration Area and
392
Sanitary and Meteorological Notes .
in the twenty-two principal provincial Urban Districts of Ireland
was 24*7 per 1,000 of their aggregate population, which, for the
purpose of this return, is estimated at 1,053,188.
The deaths from the principal zymotic diseases in the twenty-
three districts were equal to an annual rate of 5T per 1,000, the
rates varying from 0*0 in twelve of the districts to 12*4 in Porta-
down — the 3 deaths from all causes in that district including one
from enteric fever and one from diarrhoea. Among the 175 deaths
from all causes registered in Belfast are one from measles, one
from scarlatina, 4 from whooping-cough, one from simple con¬
tinued fever, 14 from enteric fever, and 9 from diarrhoea. Amon«*
the 33 deaths in Cork are one from measles and 5 from diarrhoea.
The 8 deaths in Lisburn comprise 2 from measles.
In the Dublin Registration Area the births registered during
the week amounted to 190 — 95 boys and 95 girls; and the deaths
to 196 — 97 males and 99 females.
The deaths, which are 47 over the average number for the
corresponding week of the last ten years, represent an annual rate
of mortality of 29*2 in every 1,000 of the population. Omitting
the deaths (numbering 3) of persons admitted into public institu¬
tions from localities outside the area, the rate was 28*8 per 1,000.
During the forty weeks ending with Saturday, October 7, the death-
rate averaged 28*9, and was 2*0 over the mean rate for the cor¬
responding portions of the ten years 1889-1898.
The number of deaths from zymotic diseases registered was 56,
being 33 over the average for the corresponding week of the last
ten years, but 18 under the number for the previous week. Th'e
56 deaths consist of 32 from measles — being 4 over the number
from that cause in the preceding week, and forming the highest
number registered in any week since the commencement of the
present epidemic — one from influenza, 2 from whooping-cough,
4 from enteric fever, one from cholera infantum, and 16 from
diarrhoea. Forty-seven of the 56 deaths from zymotic diseases—
including 30 deaths from measles and 14 from diarrhoea — occurred
among children under 5 years of age, those from diarrhoea com¬
prising 12, and those from measles 6, deaths of infants under one
year old.
The weekly number of cases of measles admitted to hospital,
which had fallen from 62 in the week ended September 23 to 53
in the following week, rose to 99. Eighty-nine patients were
discharged, 10 died, and 149 remained under treatment on Saturday,
being equal to the number in hospital at the close of the preceding
week.
393
Sanitary and Meteorological Notes.
The number of cases of scarlatina admitted to hospital was 10,
being one under the admissions in the preceding week, but 2 over the
number admitted in the week ended September 23. Seven patients
were discharged, and 39 remained under treatment on Saturday,
being 3 over the number in hospital on that day week. This
number is exclusive of 24 convalescents at Beneavin, Glasnevin,
the Convalescent Home of Cork-street Fever Hospital.
Sixty-three cases of enteric fever were admitted to hospital,
being 2 over the admissions in the preceding week, but 6 under the
number admitted in the week ended September 23. Fifty patients
were discharged, 3 died, and 313 remained under treatment on
Saturday, being 10 over the number in hospital at the close of the
preceding week.
The admissions to hospital included 2 cases of diphtheria ; 9
cases of this disease remained under treatment on Saturday.
Thirty-one deaths from diseases of the respiratory system were
registered, being 10 over the average for the corresponding week of
the last ten years, and one over the number for the previous week,
iney consist of 1G from bronchitis and 13 from pneumonia.
Meteorology.
Abstract of Observations made in the City of Dublin , Lat. 53° 20'
V., Long . 6° 15' IF., for the Month of September , 1899.
Mean Height of Barometer, - 29-859 inches.
Maximal Height of Barometer (on 9th, at 9 a.m.), 30*273 „
Minimal Height of Barometer (on 30th, at 3 p.m.), 29-258 „
Mean Dry-bulb Temperature, - - 54*9°.
Mean Wet-bulb Temperature, - - 52*1°.
Mean Dew-point Temperature. - - 49*5°.
Mean Elastic Force (Tension) of Aqueous Vapour, *360 inch.
Mean Humidity, - 82*9 percent.
Highest Temperature in Shade (on 4th), - 71*8°.
Lowest Temperature in Shade (on 28th), - 39 -0°.
Lowest Temperature on Grass (Radiation) (29th) 32*5°.
Mean Amount of Cloud, - 51*0 per cent.
Rainfall (on 21 days), - - - 2*748 inches.
Greatest Daily Rainfall (on 30th), - - 1*042 inches.
General Directions of Wind, - N.W., W.,
S.W.
394 Sanitary and Meteorological Motes.
Remarks.
September, 1899, was a month of sharp contrasts as regards
temperature— at first it was decidedly warm, afterwards it became
still more decidedly cold, so that a minimum of 29° was registered
in the screen at Parsonstown on the night of the 29th-30th.
The net result was to give a mean temperature for the whole
month slightly above the average. For the rest, the month was
unsettled and very squally, and showery blustering westerly and
north-westerly winds prevailing almost constantly from the 1 5th
to the 26th inclusive. At the close night frosts occurred inland,
and downpours of rain were generally accompanied by much
thunder and lightning. Hail also fell in many places. ^
In Dublin the arithmetical mean temperature (56*2°) was
slightly above the average (55*8°) ; the mean dry-bulb readings
at 9 a.m. and 9 p.m. were 54-9°. In the thirty-four years ending
with 1898, September was coldest in 1886 and in 1882 (M. P —
53*0°), and warmest in 1865 (M. T.=61*4°) and in 1898 (M. T —
60*2°).
The mean height of the barometer was 29*859 inches, or 0*051
inch below the corrected average value for September— namely,
29*910 inches. The mercury rose to 30*273 inches at 9 a.m. oi
the 9th, and fell to 29*855 "inches at 3 p.m. of the 30th. The
observed range of atmospheric pressure was, therefore, 1*015 inches.
The mean temperature deduced from daily readings of the dry-bulb
thermometer at 9 a.m. and 9 p.m. was 54*9°, or 7*3C below the
value for August, 1899. Using the formula, Mean Temp.=Mm .
+ {max.— min. X *476), the mean temperature was 55*9°, or 0*4°
above the average mean temperature for September, calculated m
the same way, in the twenty-five years, 1865-89, inclusive (55*5°).
The arithmetical mean of the maximal and minimal readings was
56*2°, compared with a twenty-five years’ average of 55*8 . On
the 4th the thermometer in the screen rose to 71*8° — wind, S.. ; on
the 28th the temperature fell to 39*0°— wind, W. The minimum
on the grass was 32*5° on the 29th.
The rainfall was 2*748 inches, distributed over 21 days. ^ The
average rainfall for September in the twenty-five years, 186o-89,
inclusive, was 2*176 inches, and the average number of rainy days
was 14*7. In 1871 the rainfall was very large— 4*048 inches on,
however, only 13 days; in 1896 no less than 5*073 inches fell on
23 days, establishing a record rainfall for September. On the
other hand, in 1865, only *056 inch was measured on but 3 days.
High winds were noted on 13 days, and attained the force of a
Sanitary and Meteorological Notes. 395
gale on six occasions in Dublin — the 18th, 19th, 21st, 22nd, 24th,
and 26th. The atmosphere was foggy on the 7th, 29th, and 30th.
Solar halos were seen on the 6th and 21st. A thunderstorm
occurred on the 30th. Thunder was heard on the 29th. Light¬
ning was seen on the 5th and 29th.
The rainfall in Dublin during the nine months ending September
30th amounted to 20-948 inches on 138 days, compared with 10-968
inches on 112 days during the same period in 1887, 17*9 68 inches
on 137 days in 1898, and a twenty-five years’ average of 19-734
inches on 142*8 days.
At ivnockdolian, Greystones, Co. Wicklow, the rainfall was 2 "8 10
inches distributed over 19 days. Of this quantity 1*030 inches
fell on the 30th. At that station the rainfall since January, 1899,
has been 28*440 inches on 139 days, compared with 25‘896 inches
on 137 days in 1894, 23*665 inches on 117 days in 1895, and
21-912 inches on 115 days in 1896, 29*570 inches on 158 days
in 1897, and 19*688 inches on 124 days in 1898.
At Cloneevin, Killiney, Co. Dublin, the rainfall in August was
3*61 inches on 13 days (the maximal fall in 24 hours being
1*95 inches on the 5th), compared with a fourteen years’ average
of 2*995 inches on 17*1 days. In September 3*04 inches fell at
Cloneevin on 20 days. The maximal fall in 24 hours was 1*02
inches on the 30th. On the average of fourteen years the
September rainfall at this station has been 1*790 inches on 12*28
days. Since January 1, 1899, 23*75 inches of rain have fallen at
Cloneevin on 139 davs. The rainfall in the first nine months of
the year at Cloneevin was 22-92 inches on 150 days in 1894,
21*58 inches on 129 days in 1895, 20*50 inches on 129 days in
1896, 22-91 inches on 158 days in 1897, and 18*19 inches on 136
days in 1898.
At the National Hospital for Consumption, Newcastle, Co.
Wicklow, rain fell in measurable quantity on 12 days to the total
amount of 2*411 inches, compared with 3*166 inches on 11 days
in the same month of 1897, and 1*991 inches on 13 days in 1898.
The maximal fall in 24 hours was *813 inch on the 30th. Since
January 1, 1899, the rainfall at this Second Order Station has
been 26*159 inches on 129 days. The highest temperature in the
screen was 71*7° on the 5th, the lowest was 37*9° on the 29th.
At Recess, Co. Galway, the rainfall was 4*673 inches on 26
days, 1*061 inches being measured on the 21st.
PERISCOPE.
REMOVAL OF THE STOMACH.
The woman from whom Schlatter removed the whole stomach for
carcinoma lived not quite fourteen months after the operation, and
died of multiple cancerous lymphatic nodules, and the resultant
cachexia. There was no trouble during this period in keeping up
the nutrition of the patient. The autopsy showed that there was
no attempt either on the part of the duodenum, or of the oesophagus,
to dilate and form a pouch, as was observed by Czerny after removal
of the whole stomach in a dog. The food taken passed directly from
the oesophagus into the intestine, and that intestinal digestion was
sufficient to supply her wants, was shown not only by the long
continuance of life, but by the fact that for a considerable period
after the operation she gained in weight. — Medical News , June 3,
1899.
FATAL WASP STING.
F. PI. Cooke, M.R.C.S., L.R.C.P. (Brit. Med. Jour., Yol. II., 1898,
p. 1429) reports the case of a strong, healthy girl, aged 24, who
was stung by a wasp in the hand. A few minutes afterwards her
face was very red. She complained of feeling numb all over, and
of losing her sight; she then fainted. (These symptoms of
numbness and blindness had also occurred on a previous occasion
when she was stung.) Her face turned suddenly pallid and she
expired in about twenty-five minutes.
[Death from sting of a wasp is reported in the Lancet (1883) ;
by Carpenter (1865), Casari (1853). An early number of the
u Methodist Magazine” has a case of a bee-sting of the tongue
causing suffocation. Dammann (1845) gives a case of delirium
ferox following on the sting of a bee. Ewens (1860), Finkel
(1861) report cases. Similar cases have been reported by Hanbury
(I860), Horing (1862), Lassen (1879), de Lepine (1875), Michel
(1861), Nivison (1857), Norton (1855), Odell (1873), Plotzlicher
(1872), Richoud (1827), Schemm (1860), Tonoli (1883).]
OBLITERATION of the cavity of the uterus from the use of
STEAM.
Otto von Weiss, ( Centr . Bl. f. GyneJcol ., June 18). — A Avoman,
aged 19, suffered from abundant metrorrhagia, for which steam
was applied to the mucous membrane of the uterus during scarcely
397
Periscope.
45 seconds. Five months afterwards no trace of the external os
could be found. During an unsuccessful attempt to restore per¬
meability of the uterus the cervical canal was found partly pre¬
served, but the uterine cavity had entirely disappeared.
kopltk’s “new diagnostic sign of measles.”
This is not a new thing, but, like so many “discoveries” nowadays
it has been “anticipated” by somebody else. In the year 1880 a
Danish practitioner, A. Flindt, published in Sundhedshollegiets
Aarsberetning the following description: — “Second day of pyrexia:
On the anterior surface of the soft palate, and on the adjoining
half of the hard palate, a mottled rash appears ; this eruption
acquires a peculiar appearance through numerous small, bluish-
white, punctiform, almost vesicular-looking specks, which are
situated in the centre of the small red spots, and, like these spots,
form irregular groups. One can see and feel how prominent these
small miliary vesicles are. The conjunctiva of the lids show
similar miliary ‘ formations.’ Third day of pyrexia : Similar
groups of vesiculated spots appear on the buccal mucosa, especially
in that part of the buccal mucous membrane which lies opposite
the interstice between the upper and lower molar teeth. ‘After this
buccal eruption the measles rash appears in the skin. . . S0
far Flindt, who not only saw and described in almost identical terms
that “new diagnostic sign” eighteen years before its re-discovery
across the Atlantic, but, what is still more interesting, also noticed
the prominent specks in the conjunctiva of the eyelids, and he also
“ felt ” them in the mucous membrane of the mouth. Not only
books, but also early diagnostic signs, have their fates. The disin¬
terment of Dr. Flindt’s remarkable discovery is due to the learning
and cosmopolitan reading of Professor Dr. Jiirgensen, who published
the first German translation of this quotation from the Danish in
his famous book on “Acute Exanthemata” (Nothnagel’s “ System
of Special Pathology and Therapeutics”).— Treatment, July 13
1899.
ERYSIPELATOUS PNEUMONIA.
A case is reported by Artaud and Barjou ( Gazette des liopitaux ,
1898, No. 102 ; Centralblatt fiir inner e Medicin, August 27, 1899;.
The patient, who was recovering from facial erysipelas, was
attacked with dyspnoea disproportionate to the physical signs, and
with spasmodic cough. There were no pneumococci in the sputa,
but they contained the Streptococcus erysipelatos , as was shown by
their producing typical erysipelas when inoculated on a rabbit’s
ear. — New York Med. Jour., September 23, 1899.
NEW PREPARATIONS AND SCIENTIFIC INVENTIONS.
The New “ Tabloids ” of Cascara Sagrada.
Messrs. Burroughs, Wellcome & Co. have recently issued two
new u tabloid ” preparations of cascara sagrada. In the past it
has been the custom of the firm in question to issue “ tabloid
cascara sagrada containing 2 grains of dry extract, but as the
susceptibility of patients to the action of . the drug varies some¬
what, they have been requested to prepare it containing 1 and o
grains of dry extract. By the issue of these three different strengths
it is hoped that the administration of cascara sagrada extract on a
definitely regulated plan will be simplified.
It is suggested that one of the 3 grain strength may be taken
once, twice, or even thrice daily for habitual constipation until the
habit of regular action of the bowels is established, when the dose
should be gradually reduced to one of 1 grain strength taken once
daily. It is then usually possible to do without a laxative after a
short period.
These “ tabloid ” products are issued, both plain and sugar-
coated, in bottles containing 25 or 100 in each.
“ Soloid ” Microscopic Stains.
The tendency to decompose which solutions of the aniline dyes
exhibit has always been a source of trouble in microscopic work.
To obviate this drawback, Messrs. Burroughs, Wellcome & Co.
have devised a number of u soloid ” microscopic stains. By means
of these, fresh solutions of the various stains may be prepared in
small quantities when required. Such “ soloids ” of gentian violet,
methylene blue, eosin, Bismarck brown, and fuchsin have been
submitted to us. These various stains can be bought foi foui
shillings and sixpence per dozen tubes of six each.
A saturated watery solution of fuchsin, methylene blue, gentian
violet, or Bismarck brown is obtained by powdering one “ soloid ”
product in 7 c.c. (two drachms) of distilled water, and then shaking
well. Five to ten per cent, dilutions with distilled water of these
saturated solutions are well adapted for ordinary staining purposes.
Thus one drachm of saturated solution made up to two drachms
with distilled water, gives 1 in 17, or a 6 per cent, solution.
A saturated alcoholic solution of methylene blue, gentian violet,
or Bismarck brown may be obtained by treating in the same way
one “ soloid” product with a similar quantity of absolute alcohol
instead of distilled water. A saturated alcoholic solution of fuchsin
New Preparations arid Scientific Inventions. 399
Is obtained by treating two 44 soloid ” preparations with 3*5 c.c.
(one draelim) of absolute alcohol.
To obtain a solution of eosin suitable for general staining one
“ soloid” product should be dissolved in 12*25 c.c. (three drachms)
of 50 per cent, absolute alcohol in distilled water. This gives
approximately a 0*5 per cent, solution.
Peace's Food for Infants and Invalids.
Messrs. Josiah R. Neave & Company, of Fordingbridge, via Salis¬
bury, have submitted to us samples of their well-known and most
valuable food. It can hardly claim to be a 44 New Preparation,”
as it has been for many years one of the most popular infants’ and
invalids’ foods in the market.
Neave’s Food is particularly rich in proteids and phosphates,
as well as in potash.. It contains, therefore, a large proportion
of both flesh-forming and bone-forming ingredients, and so is
invaluable in cases of wasting from acute or chronic disease and
in constitutional delicacy of any kind. Its use from infancy is a
preventive of rickets and also of premature decay of the teeth.
Finally, it is both palatable and easy of digestion at all ages. Its
reasonable cost brings it within the reach even of those whose
income is of very modest proportions.
The Aseptic Surgical Dressing Co.
We have received from the above company samples of their sterilised
dressings and bandages, the manufacture of which they have under¬
taken in order to meet the great spread of aseptic surgery. 44 The
dressings, first carefully sterilised, are packed in specially prepared
6 cartons,’ so constructed that, while they allow superheated steam
to pass rapidly through their pores, they offer an effectual barrier
to all micro-organisms. After the 4 cartons ’ are securely sealed
they are placed in a specially adapted 4 autoclave,’ where they are
again subjected to the action of superheated steam. Thus the
dressings and their coverings undergo a second sterilisation. ” As
the sterilisation of the products is guaranteed bacteriologically, it
seems as if we had here an ideal emergency dressing case. The
44 carton ” sent to us contained lint, three bandages, absorbent wool,
safety pins, gauze (plain and iodoform), waterproof tissue, and
three sizes of drainage tube. All seem of excellent quality. They
are specially recommended by the firm to the 44 general medical
practitioner” who does not possess facilities for sterilising his own
dressings. Unless the general practitioner has been soundly trained
in the schools of bacteriology and of aseptic surgery, we would
400 New Preparations and Scientific Inventions .
strongly advise him not to dabble in sterilised dressings, but to
stick to older methods with which he is more familiar. Asepsis in
untrained or careless hands can only lead to deplorable and prevent¬
able results.
Indicators for Chemical Tests.
In conducting chemical tests, and especially in volumetric deter¬
minations, it is frequently necessary to make use of some substance
which is capable of indicating the end of a reaction, such as the
exact point of neutralisation of an acid or an alkali, &c. Since
many of these so-called indicators are more or less unstable in
solution, especially when exposed to light, their preparation as
“ Soloid ” products in a compressed and permanent form by the
firm of Messrs. Burroughs, Wellcome & Co., of London and
Sydney, has been highly appreciated. By this means small amounts
of a solution of any indicator, of the proper quality and strength,
may be quickly prepared as required.
The following represent the indicators more frequently used : — •
« Soloid ” Indigo Carmine. — One, dissolved in 10 c.c. of solvent,
forms a suitable strength.
“ Soloid ” Lacmoid. — One, dissolved in 10 c.c. of solvent, forms
a suitable strength. This is much more delicate in reaction than
litmus, and it may be used in all cases where the latter is suitable
as an indicator. In contact with acids it becomes red, and when
thus slightly reddened it is again rendered blue by alkalies.
« Soloid ” Methyl Orange. — One is crushed and dissolved in water
to make 10 c.c. of solution. The solution acquires a yellow colour
in contact with alkali hydrates, carbonates, and bicarbonates. It
is not affected by carbonic acid, but the mineral acids change its
colour to crimson.
« Soloid ” Phenolphthalein . — One is dissolved in diluted (50
per cent.) alcohol to make 10 c.c. of solution. This is coloured
deep purplish-red by alkali hydrates or carbonates, and acids
render the reddened solution colourless. It is not suitable as an
indicator for ammonia or bicarbonates.
« Soloid ” Eosolic Acid. — One is dissolved in 1 c.c. of diluted
(50 per cent.) alcohol, and enough water added to make 10 c.c. of
solution.
« Soloid ” Starch. — One is added to about 100 c.c. of water, the
liquid boiled for a few minutes, and when cold the clear liquid is
poured off for use. It is used as a test for the presence or absence
of free iodine, and in volumetric processes based on a determination
of this element.
THE DUBLIN JOURNAL
OF
MEDICAL SCIENCE.
[DECEMBER 1, 1899.
PART I.
ORIGINAL COMMUNICATIONS.
Art. XX. — 1 enerectl Diseases a,ncl their Therapeutics .a By
Robert Lafayette Swan, President of the Royal
College of Surgeons in Ireland ; Surgeon to Steevens’
Hospital, Dublin.
It may not be thought out of place at this time, when the
subject of the prevention and treatment of syphilis in the
Army and Navy has been recently under discussion, to make
a few observations on this subject, so important to the
community at large, as well as to our soldiers and sailors.
I shall not enter on the question of the prevention of
syphilis by legislative means. Almost all persons who
are competent to form opinions unbiassed by side issues
have offered those opinions to successive Governments in
this country.
The classification of venereal diseases into gonorrhoea,
the chancroid or soft sore, and the Hunterian chancre, or
true syphilis, is, I believe, unalterable. They have nothing
in common, unless the locality. Gonorrhoea is a local dis¬
ease attacking the mucous membrane, and specific in the
fact of its having a special microbe. It is true that there
are occasional instances of systemic infection, evidenced by
a Being the substance of a Presidential Address delivered before the
Section of Surgery in the Eoyal Academy of Medicine in Ireland, on
Friday, November 10, 1899.
VOL. CVIII. — NO. 336, THIRD SERIES. 2 C
402 Venereal Diseases and their Therapeutics.
so-called gonorrhoeal rheumatism, by internal ophthalmic
lesions, not produced by contagion, and by eruptions on the
skin. In those exceptional instances there may be an
infective process. In the chancroid, likewise, a circum¬
scribed infective process may occur, as in the production of
the ordinary chancroidal bubo. True syphilis has its
importance and essence in its being always an infective
disease, the organisms passing into the general circulation,
and existing and multiplying in favourable situations.
How is it, then, that a lesion presenting at first all the
features of a soft sore may in time alter its character, and
be followed by some or all the sequelae of true syphilis %
Many surgeons of distinction consider the poisons of chan¬
croid and true syphilis to be identical. I believe the
patient in all such cases to have received a double inocula¬
tion ; that the chancroid has furnished a favourable culture-
medium for the syphilitic microbe, and perhaps even
hastened its period of incubation, which under average
circumstances is from three to four weeks.
Let us examine the usual progress of a soft sore. It
commences as a papule, which at the end of the second or
third day (depending on the delicacy of the skin involved)
becomes a pustule. This soon bursts, and at the end of
the first week a deep, suppurating sore is found, which in¬
creases in circumference and depth, and secretes pus
abundantly. In the soft sore are found all the phenomena
of inflammation, but no induration or thickening of its base.
There is a tendency to a progressive destructive involve¬
ment of surrounding tissues. The pus is inoculable on the
patient himself — on either the mucous membrane or skin ;
so that from want of cleanliness or care the sore is often
multiple. Chancroids may be treated as are other unhealthy
wounds. I have myself a routine, based upon the applica¬
tion of germicidal or antiseptic agents. Other surgeons
have their methods. The chancroid sometimes tardily
takes on, at length, healing action, and gets well like any
other ulcer, and is followed by no constitutional effects.
Frequeatly, as before stated, the lymphatics in the inguinal
region become enlarged, and after a time suppurate, leaving
perhaps troublesome sinuses, which lead to an indurated
403
By Mr. B. L. Swan.
mass of inflamed tissue. In passing, I may say that I have
found the best practice, in the case of chancroidal bubo in
any stage, is to cut down on the swollen tissues, remove
them with a sharp curette, thoroughly cleanse the parts,
and sew up the skin wound. It usually heals at once, and
no further trouble is experienced.
Not rarely, however, as time goes on, the sore assumes a
new appearance, the surface ceases to secrete pus, it
becomes glazed, and the base hard and cartilaginous. Still
later the throat becomes ulcerated, skin eruptions appear,
and the existence of true syphilis is disclosed. Here, then,
is the argument of those who maintain the identity of the
poisons. It is, I believe, as I have stated before, a double
inoculation, and the change and evolution of the simple
chancroid is explained by the latency of the microbe of
true syphilis and its more extended period of incubation.
Sometimes a soft sore, from intense inflammatory action,
produces a rapid and destructive tissue necrosis, known as
phagedeena. This event appears to show an intermission
and recrudescence in type, like other diseases which vary
in the intensity of their local inflammatory lesions — for
example, we see scarlatina maligna and measles of a
virulent form. When I was House Surgeon at Steevens’
Hospital, thirty years ago, phagedsena was one of the com¬
monest occurrences ; for many years it was infrequent,
lately it has not been uncommon. It was supposed that it
occurred invariably in persons of broken-down constitutions.
This is not so ; I have seen it in many persons of good
general health and vitality. I believe that the true explana¬
tion is this : That, as persons in civilised communities
become immunised to a degree by a remote or recent
inoculation by the microbes of the diseases of civilisation,
persons showing no powers of resistance have either
escaped the immunising taint or it has become attenuated
and lost.
The Genesis and Progress of the True Syphilitic Sore . — It
always appears at the site of inoculation at a period vary¬
ing from ten days to six weeks. Where lurks the virus
during this long period ? All the evidence shows that it
must remain hi the habitat of the inoculation. If, as some
404 Venereal Diseases and their Therapeutics .
have supposed, the Hunterian chancre is secondary to a
constitutional infection, it would be reasonable to expect
that during the two months other characteristic lesions
would be seen elsewhere. This opens up the question
whether syphilis can be aborted by the excision of the
chancre. But the infiltration and enlargement of neigh¬
bouring lymphatic glands appear to be almost synchronous
with the induration of the sore, and while there is a great
difference of opinion as to the value of the treatment it
seems reasonable that if seen early the virus may be
removed at once. Further investigations in this direction
would be valuable.
It may commence as an erosion, a papule, or less fre¬
quently an ulcer, ten days or more after exposure. Ulcera¬
tion, if it exists, which is not invariable, is unaccompanied
by the profuse secretion of pus which distinguishes a soft
sore. The essential induration is produced by a sclerosis
of the small blood-vessels and a preservation and infiltra¬
tion of the fasciculi of the connective tissue. It occurs at
the end of the first week from the appearance of the sore.
There are varieties, but the most common chancre is a small
cell-like depression on an elevated and hardened base. The
induration varies remarkably in different tissues.
The enlargement of the lymphatic glands in true syphilis
is progressive, but always begins in those nearest the inocu¬
lation. About six weeks is occupied in the involvement’ of
all the visible lymphatics. For diagnostic purposes, if
necessary, the multiple induration of the posterior cervical
glands is especially valuable.
The Treatment of Syphilis. — The excision ol primary
lesions has been alluded to. It remains to consider the
treatment of syphilis by medicine. Almost from the
earliest records of the disease mercury has as a remedy
enjoyed a position which it still holds. No doubt, in
former times abuse of the drug was usual, and manifesta¬
tions of mercurial poisoning were common. After the
Peninsular war Aix-la-Chapelle obtained notoriety for the
relief of those ailments. It has ever since been frequented
by syphilitics. Steevens’ Hospital was endowed in the
earlier years of this century for the maintenance of beds
By Mr. K. L. Swan. 405
for the treatment of syphilis, and in No. 2 Ward were made
the observations of Abraham Colles, from which were
evolved the description he gave of secondary suppurating
lesions, the advantages of mercurial fumigation, his cele¬
brated law of immunity, and the true nature and accom¬
panying signs of the lymphatic swelling known in every
country as Codes’ constitutional bubo. Wallace also— at
that time surgeon to J ervis-street Hospital — was a frequent
visitor and observer.
The records of treatment furnish curious information re¬
garding the administration of mercury. It seems to have
been considered that its benefits were derived from its
action as a sialogogue. When I first went there as a
student there were certain pewter cups capable of holding
about a quart. The mercury was said to have been per¬
severed with in former years till one, two, or three of these
cups were filled by the patient in the day. In spite, how¬
ever, of changes of thought resulting from its abuse, there
is no remedy to equal mercury in the treatment, at least, of
primary syphilis. It should be given at the very earliest
period a diagnosis is made, and the system should be kept
persistently, although slightly, under its influence for a
lengthened period. The great difficulty in the treatment
of syphilis is the length of time required to combat the
periodic manifestations of the toxins. This difficulty has
been to some extent met by the method of intra-muscular
injection of mercurial cream of Major Lambkin. The in¬
jection is administered once a week, and the dosage is
maintained by slow absorption. I have administered it on
numerous occasions, both in hospital and in private, without
any but the most trifling inconvenience to the patient.
While fully alive to the value of iodide of potassium in the
absorption of the neoplasms of advanced syphilis, I do not
think it can ever take the place of mercury in its early
treatment. The words of Wallace, who introduced it, are :
“ He was not going to dispossess mercury of its well-earned
high rank in the treatment of syphilis, but that we had in
iodide of potassium a remedy completing our circle of
therapeutics.” A few words in allusion to two varieties of
the disease — I should rather describe them as types — occur-
406
Venereal Diseases and their Therapeutics.
ring in individuals completely unprotected by influences
winch confer partial immunity. One, malignant syphilis ;
the second, where tertiary symptoms appear at an early
period of systemic infection— syphilis tertiare precoce. I
will briefly illustrate them by two cases. A woman, aged
forty-five, the mother of seven children, was admitted into
No. 9 Ward, Steevens’ Hospital. The history was unrehable.
There was on admission a rupial ulcer on the back of the
forearm. On close examination I found a small induration
at the cleft between the thumb and index finger. Within
a fortnight throat and nasal symptoms were advanced ; all
the accessible lymphatics were found to be enlarged and
indurated ; a node developed on the frontal bone, followed
by rapid destruction of the soft parts ; almost the entne
frontal bone exfoliated. Hr. Donnelly saw the case at my
request. Rapid cachexia supervened, and she died from
exhaustion.
Syphilis Tertiare Precoce.— A man, aged twenty-eight, at
present in No. 2 Ward, was admitted with a hard sore on the
glands. Within a fortnight he was covered with rupia. I
have never seen such an example. He looked as if limpet-
shells were pasted on to every available portion of skin.
His appearance was remarkable, and he served as a moral
and warning to careless youth. He became very cachectic.
The usual anti-syphilitic remedies were used. Mercury,
the iodides, and a combination of both, were given without
avail. At last I ordered him the tabloids of thyroid extract,
and like a charm his sores were healed. He grew fat and
strong, and is now practically well. The original sore is
still indurated. I have no explanation to offer as to the
result in this case.
The Third Stage of Labour .
407
Art. XXI. — Observations on the Treatment of the Third
Stage of Labour , especially as regards the Delivery of the
Placenta .a By George Cole-Baker, M.D., &c., Univ. Dubl.;
University Examiner in Midwifery and Gynaecology in
tire University ot Dublin, 1896 and 1897 ; Ex- Assistant
Master, and Ex-Master pro tern ., Coombe Lying-in Hos¬
pital, Dublin.
Jewett in the “American Text-Book of Obstetrics,” edited
by Norris, says: — “Not the least important duties of the
obstetrician in the conduct of natural labour fall in the
third stage. Upon the skill and attention given to this
period the immediate safety of the woman and the rapidity
and completeness of her recovery will often in great
measure depend.” With this statement I more than agree,
for instead of the word 44 often ” used above I should feel
inclined to substitute the word 44 invariably ” (provided
always nothing abnormal has arisen at any previous stage
of the patient’s labour), and to me the conduct of the third
stage has always been a time of very great anxiety, and in
very many cases of dissatisfaction.
I use this last word because in no text-book on obstetrics
that I have read — there are, of course, manv that I have
not read — have I seen described what I can call a perfectly
satisfactory method of treatment for this stage of labour, as
far as the delivery of the placenta and membranes is
concerned.
In this country the latter paid of the second stage is
always conducted with the patient lying on her left side,
and it is now the practice to turn her upon her back imme¬
diately it is concluded. This is undoubtedly good treat¬
ment for two reasons at any rate — (1) the obstetrician can
44 control the fundus,” as the phrase is, much more effec¬
tually and with much less physical effort than in the
lateral position; and (2) the change of position is most
acceptable to the patient.
Other advantages are claimed for the proceeding, one
a A Thesis read before James Little, M.D., Regius Professor of Physic
in the University of Dublin, on June 28th, 1899.
408
The Third Stage of Labour.
being that air is less likely to get into the uterine cavity in
the dorsal than in the lateral position. This may be true,
but only in so far as the fact that the uterus can be better
<£ controlled ” in the former than in the latter position of the
patient ; and if this control be not exercised, and the uterus
be allowed to relax and its cavity to enlarge, air or blood
will rush in to fill the vacuum thus created when the patient
is on her back just as readily as when she is on her side,
and if it does enter in the latter position it is not the posi¬
tion that is at fault, but it is because control of the uterus
has not been properly exercised or not commenced suffi¬
ciently early.
This control of the uterus should be commenced the
moment the head or any portion of the trunk of the child
has passed the vulva, and should not be relaxed for a single
moment till the placenta and membranes have been com¬
pletely delivered, and the uterine muscular fibres are
thoroughly well contracted. “ Till the last pin of the
binder is inserted,” say some, but in my opinion this is often
much too soon, and in the vast majority of cases just as
good results would be arrived at if the binder were entirely
dispensed with.
No doubt the binder is pleasant and gratifying to the
patient, and gives her a feeling of support, especially if she
habitually wear a tight-fitting corset, but here its utility
ends in most cases, I believe; and not only that, but very
tight application of binders with the idea of “ preserving
the figure ” is probably responsible for many of the retro¬
versions that are so common after a confinement.
I was first induced to think the binder a “ luxury,” not a
“ necessity,” in very many cases in the following way : — A
gentleman of my acquaintance who went in for horse-
breeding (hunters especially) had a plan of putting his
fillies to stud when they were two years old, and did not
train them till they had had a couple of foals, and yet they
always made up as fine and looked as slim and well as if
they were nulliparae, and as far as the' binder is a preven¬
tive of post-partum haemorrhage, I ask, how often do we
hear of this occurring among the lower animals ?
We now come to ligation of the cord ; but it is not my
409
By Dr. G. Cole-Baker.
intention to discuss the various arguments as to early or
late ligation save to say generally that each individual case
appears to be more or less “ a law unto itself,” and that no
hard-and-fast rule can be laid down that will embrace every
case. My experience is that the best results are arrived at
by postponing ligature so long as strong pulsation exists in
the cord, and the new-born infant is vigorous and lusty,
and apparently doing well on it.
Up to a few years ago it was customary to ligature the
cord in two places only — viz., one ligature at about one and
a half inches from the umbilicus, and the other at about
two inches from the first, on the maternal side of it, and
then to divide the cord between them. Of late years,
however, it has become the practice to ligature the cord
in a third place — i.e., “ as close as possible to the vulva,”
or else to put the second ligature alluded to above in this
position instead of two inches only from the first ligature.
If this latter plan be adopted, needs must that when the
cord is severed a considerable quantity of (certainly some)
blood must escape owing to the length of cord between
the ligatures, and unnecessary soiling of the bed-clothes
and infant is the result. It is easy to render two inches of
cord bloodless by pressure, but difficult if not impossible to
do so with several inches. I am, therefore, strongly hi
favour of applying a third ligature — i.e., the old second
one — at two inches from the first and on the maternal side
of it.
To return, however, to the ligature “ as close as possible
to the vulva ” — its object is to be an index to us that the
placenta has left the uterus and is lying in the vagina.
That it may be of use as an indicator of this fact, however,
it is necessary to observe two precautions — the first (which
is mentioned in a text-book that is before me) is, care must
be taken, by making very gentle traction on the cord, that
there are no coils of it in the vagina which may subsequently
slip out, and induce us to think that the placenta must
have left the uterus by the distance our ligature has moved
from the vulva. The second precaution I have never seen
mentioned, but learned it from personal experience, and
have since seen the neglect of it mislead others more than
410
The Third Stage of Labour.
once. It is this — care must be taken that the placenta is
not already in the vagina when the ligature is applied.
Very often the same pain that completes the second stage
of labour forces the placenta after the child into the vagina,
and if this be the case the value of the third ligature on
the cord as an indicator becomes nil.
In addition to the “ artificial ” indication just mentioned,
that “ the placenta has left the uterus,” there are four other
“ natural ” ones. It will be noticed, if the controlling hand
on the fundus does not keep the uterus, as a whole, jammed
clown into the pelvis, as soon as the placenta has been
expelled by the uterus — (1) that the fundus of the latter
occupies a slightly higher level in the abdominal cavity
than it did at the end of the second stage ; (2) that the
uterus becomes distinctly flattened from before backwards ;
(3) that the uterus becomes more easily movable in the
abdominal cavity; and (4), most valuable sign of all, that
there is a distinct bulging forwards of the abdominal
parietes just above the symphysis pubis, appearing to the
eye exactly like a distended bladder, but having a very
different feel — viz., a spongy or boggy feel.
The knowledge that the placenta has left the uterus is
important, as we now know we may complete its delivery
without further delay with perfect safety to the mother.
As labour itself is divided into three stages, so may the
delivery of the placenta be said to consist of three steps —
viz., (1) the passing of the placenta from the uterus to the
vagina ; (2) from the vagina outside the vulva ; (3) the
complete detachment and delivery of the foetal membranes
after the placenta has passed the vulva. These several
steps may be effected by (1) nature, or (2) artificial means ;
and nature may accomplish any or all of these very
quickly or extremely slowly.
The question now arises — how long is nature to be left
to herself, and how are we to assist her if we elect to do so %
As I have said, nature is sometimes very slow about her
work, and nowadays I fear neither doctor nor patient would
in very many cases be willing to await her will and pleasure,
so long as matters can be hastened with perfect safety to the
patient. It is customary at the present day to give nature
411
By Dr. G. Cole-Baker.
a limited time — from 30 to 45 minutes, provided no contra¬
indication arises — to accomplish the first step of forcing the
placenta out of the uterus, and once this has been done to
resort to artificial means of various kinds to complete the
second and third steps.
Of course, in very many cases nature accomplishes one
or all of the steps of the third stage of labour in a shorter
time than the limit of time above mentioned, and once she
has accomphshed the first step the midwife may at once
resort to artificial means to complete delivery, as no advan¬
tage to the patient is gained by waiting, whereas extra
difficulty in accomplishing the third step may be caused by
delay.
I shall not discuss indications (such as profuse haemor¬
rhage from the uterus) which may necessitate the rapid
termination of the third stage, nor shall I more than allude
to those cases where either the placenta or membranes, or
both, are so intimately adherent to the uterine walls that
they can be removed only by the introduction of the hand
into the uterus.
If nature accomplishes all the steps, so far so good ; but
let us assume that our forty-five minutes’ 44 time limit ” has
expired, the patient certainly and, it may be, the doctor are
anxious to have it all over — what is to be done 1 Ninety-
five, if not one hundred, per cent, of the obstetricians of
to-day would reply, 44 Express the placenta,” and probably
add, 44 by Crede’s method.”
Undoubtedly the proper treatment, I admit ; but what is
Crede’s method "? The description of it given in the text of
many treatises on midwifery is, to say the least of it, rather
involved, and some of the illustrations (notably in 44 Lusk’s
Midwifery,” third edition, p. 224) are positively misleading,
in my opinion. The best descriptions I have seen are to
be found in 44 Spiegelberg’s Midwifery” and 44 The American
Text-book of Obstetrics,” and there is an excellent photo¬
graph of the manipulation of the method in the latter. But
even these are not quite satisfactory, for this reason — As
far as I can see, Crede’s method of 44 expressing ” the
placenta (just as nature herself may do) may accomplish
all, only two, or only one of what I have called the three
412
The Third Stage of Labour .
steps of the third stage of labour ; but it may accomplish
the first step only ;, as I say; and my point is, that here
Crede’s method comes to an end. It is erroneous, therefore,
to say that 44 once the placenta has passed from the uterus
into the vagina, Crede’s method is a useful one of effecting
its further delivery.” Crede’s method is a method of
44 expression,” while to use the empty uterus to push the
placenta through the vulva out of the vagina, by pushing
it (the uterus) forcibly down into the vagina (as advocated
by some obstetricians), telescopic fashion, should more cor¬
rectly be called a method of 44 detrusion.”
When teaching nurses and students how to 44 express the
placenta” from the uterus into the vagina (or completely,
as the case may be), and what sort of pressure to exercise
upon the uterus, I have always illustrated my lecture by
an indiarubber enema bag, and told them to squeeze the
uterus between the thumb placed on the anterior wall and
the fingers (sunk well down behind the fundus and spread
out over the posterior wall), just as they would the enema
bag, and that thus the placenta, if detached, would be shot
out of the uterus, much in the same way that we can shoot
an orange pip across a room by squeezing it between a
finger and thumb.
My own experience is that any forcing downwards and
backwards of the uterus as a whole, by pressure of the palm
of the hand upon the fundus, is wholly unnecessary, if not’
sometimes injurious, as I have more than once seen a
partial prolapse of the uterus (both while it still contained
the placenta and where it was used as what I shall call a
44 detrusor”), brought about by vigorous and energetic stu¬
dents in their efforts to carry out what they believed to be
Crede’s method of 44 expression” of the placenta. So much
for the treatment of the first step of the third stage.
As regards the treatment of the second step — 44 Vis a
tergo non a fronte ” is the almost universal motto of the
obstetricians of to-day, but I cannot say that I look upon
the use of the uterus as a 44 detrusor ” of the placenta as
being an ideal method ; and where more than a very slight
degree of force is required, or where the operator is inex¬
perienced, it is, in my opinion, inadmissible. Once the
413
By Dr. G. Cole-Baker.
placenta has left the uterus, I fail to see that there is any
reasonable objection to drawing it out of the vagina by
gentle (and this will suffice) traction either on the cord or
exerted directly upon the placenta by a large, smooth ring
forceps; and, more than that, am inclined to think that
“traction” at this stage much more nearly resembles what
nature intended than does “ detrusion.” The patient can
materially assist in the procedure by “ bearing down ” and
coughing.
It is scarcely necessary for me to say that in carrying
out either of the above proceedings the hands of the mid¬
wife and his instruments must be (as they must at all times
be) absolutely aseptic.
We now arrive at, to me, the most unsatisfactory of all
the steps — i.e., the third and last one of the third stage.
One method of treatment is to turn the patient back
again into the lateral position, or the “ cross-bed ” position
(the placenta being carefully supported the while to avoid
tearing of the membranes), get her hips well out over the
side of the bed, and allow the weight of the placenta to
deliver the membranes by which it depends. This, I con¬
fess, appears to me to more nearly resemble nature’s method
than any other ; but I have not found it successful in all
cases, especially in those where the placentae are large and
the membranes unusually friable, as is sometimes the case.
Nature only fails us here because we have, so to speak,
interfered with and thereby insulted her earlier in the labour.
I do not necessarily mean actively, but by having become
the “ civilised ” human beings we are and in the process
turned parturition into an artificial rather than a natural
proceeding. The method, therefore, of supporting the
placenta, allowing no weight or traction on the membranes,
and detaching and delivering the latter by torsion, and,
perhaps, a suspicion of traction on them, seems to give
better results, but it is not absolutely satisfactory.
If too little torsion be made, the membranes may not
become entirely detached ; if too much, there is great
danger that a larger or smaller portion, which may not be
missed even on the most careful examination of the pla¬
centa, will be retained to the possible danger of the patient.
414
The Third Stage of Labour .
Again — and I now come to a difficulty which I have met
with, but never seen or heard mentioned — it is this. A
labour has been absolutely normal from the commence¬
ment to the end of the second step of the third stage, but,
arrived there, wheedle and coax the membranes as you will
they will not budge. What has happened? The uterus
has become firmly contracted (a condition that is in every
way desirable in most cases), and the membranes are
nipped by it so tight at the internal os that escape they
cannot. Sometimes, if you are very patient, the uterus
will relax its grip, the membranes slip through, and all will
be well, but frequently I have known the internal os hold
on relentlessly, and there was nothing for it but to intro¬
duce one or two fingers up to or through the internal os,
and thus induce it to let go its hold. This simple fact — I
mean being compelled in some cases (very few, perhaps, it
may be said) nolens volens to introduce even one finger
into the vagina, let alone the cervix — dispels my notion of
the ideal. How is it to be avoided % I confess I do not
know.
As to the mode in which the placenta is normally
delivered, whether foetal surface first, with the membranes
inverted, or edgeways, is a matter of trifling importance,
but I am inclined to think that the latter is the more usual,
and, at any rate, the more natural.
Whether the cord be pulled upon or not, the formation
of a haematoma behind the placenta assumes that the pla¬
centa is more adherent at its margins than elsewhere, and
evidence of this fact is not forthcoming, as far as I am
aware. Against Schultze's theory, too, is the fact that, if
it were correct, the delivery of the placenta and membranes
would always be followed by the delivery of a blood clot
of greater or lesser magnitude, and this most certainly is
not so. On the other hand, the assertion of Matthews
Duncan that the placenta is never delivered foetal surface
first, unless some traction has been made upon the cord,
appears to infer a more or less central insertion of the cord,
and this is not always the case, even when the foetal
surface does present and the membranes are inverted. The
method of the delivery of the placenta seems to be depen-
By Dr. G. Cole-Baker. 415
dent entirely on its “ site in the uterus. So much for the
“ delivery ” of the placenta.
I now come to the means by which the placenta is
“ detached ” from the walls of the uterus, and this is in¬
teresting, inasmuch as it is effected by two distinctly
opposite processes, according as the placental site is in the
upper (contractile) or lower (distensile) uterine segment.
I found it extremely difficult to make students or nurses
comprehend these processes till I hit upon the following
simple expedient : — Having procured two indiarubber toy
balloons, the one distended with air, and the other collapsed,
I gummed a piece of paper on each. I then punctured the
distended one, and inflated the collapsed one, with the
result that in each case the bits of paper were at once
detached — in the one case, because the surface to which it
was adherent had become too small to hold it (as does the
upper uterine segment) ; in the other, because the opposite
had happened, the surface of the balloon (as does the
“ lower ” uterine segment during labour) had become too
distended for the bit of paper to cover.
In conclusion, I shall merely enumerate the points to
which I desire to call attention. "They are as follows : —
1. The great importance of the careful treatment of the
third stage of labour, and unceasing control of the uterus
from just before the commencement of this stage of labour
till it is concluded, and afterwards if necessary.
2. The binder in many cases is a luxury, and superfluous.
3. The advantages of three ligatures on the umbilical
cord, with some precautions to be observed in their applica¬
tion.
4. That Crede’s method of expression relates only to the
first step of the third stage.
5. That traction (vis a fronte) is equally good, if not
preferable, treatment to “ detrusion ” in the second step of
third stage.
6. That an ideal and perfectly satisfactory treatment for
the third and last step of the third stage has yet to be
described.
416
Innominate Aneurysm .
Art. XXII. — Innominate Aneurysm .a By James Uraig,
M.D. ; Physician to the Meath Hospital.
The case which I desire to bring under the notice of the
Academy is that of a gentleman who suffered from an
aneurysm of the innominate artery, which has become
entirely quiescent after a long period of marvellous patience
and dogged perseverance in carrying out the principles of
treatment by rest, a moderate quantity of food, and large
doses of iodide of potassium.
To Dr. Little, who is his usual medical attendant, I am
indebted for permission to relate the case.
Case. — The patient, aged sixty-five, has been twice married, is the
father of five children, two of whom are the product of his second
marriage. He has suffered as long as he can remember from bilious
attacks, which he considers to be of a gouty nature, and accordingly,
in treating them as such, he has been for many years a disciple of the
vegetarian school of dietary and a patron of all that wide class of
non-alcoholic beverages which goes by the name of mineral waters.
He is positive that he never contracted syphilis. During a
number of years past he has spent from six to eight weeks annually
at one or other of the Continental spas, notably Carlsbad and
Marienbad. He has led a busy life since his youth, for after a
short career as an apothecary’s assistant and as a medical student,
he then settled down to make money, and in this praiseworthy
avocation he has been eminently successful. The knowledge of
therapeutics which he acquired in his younger days formed an
unstable basis on which he has ever after been attempting to build
a fabric of medical lore, so that one might perhaps truthfully sug¬
gest that here the little learning had indeed become a dangerous
thing. He reads his British Medical Journal more assiduously than
* his Bible, and no volume of modern fiction could arouse in his mind
a fraction of the interest which a treatise on aneurysm or diet calls
forth.
I mention these facts because in the management of the case one
had to give reasons for everything that was done, and endeavour
to lay to rest a spirit of theorising which is never helpful to
recovery in any form of disease.
Physically he is spare, looks older than his years, but is remark-
a Read before the Section of Medicine in the Royal Academy of Medicine
in Ireland, December 16, 1898.
417
By Dr. James Craig.
ably energetic. His face is of a dull yellowish-grey colour, and
suggests a nervous temperament.
He has been subject to constipation since his boyhood, and he
attributes the actual cause of the aneurysm to the violent straining
efforts he forcibly induced in order to secure a motion from the
bowels on June 11th, 1897. That night he felt a pain in his chest,
for which Dr. Little was consulted three days subsequently. The
latter saw him on several occasions at this time, which was just
on the eve of his summer holiday, but no manifestations of
aneurysm had then made their appearance. On June 23rd
Dr. Raverty, of Bray, who had been his family attendant in the
country, was called in, and believing that the signs of an innominate
aneurysm were presenting themselves he called to his aid
All . Wheeler s skill, and the latter confirmed his diagnosis, but
deemed any operative interference to be inadvisable. Iodide of
potassium, morphia, trinitrin, and calomel were ordered. A week
later — on June 30th — I saw the case with Dr. Raverty, who, at
the patient’s own request, transferred him from that date to my
care. I concurred at once in the diagnosis, but at the same time
expressed a fear that the arch of the aorta itself was also dilated
on account of the manner in which the right carotid and sub¬
clavian arteries were pushed upwards.
On Inspection there was a distinct pulsating tumour pushing
forwards the right side of the manubrium sterni, the second right
costal cartilage, and the inner end of the right clavicle, which, in¬
deed, was partially luxated in a forward direction. The superficial
veins in this region were distended as well as the veins in the right
side of the neck and in the right arm. The right subclavian artery
was visibly pulsating above the clavicle.
On Palpation the expansile character of the tumour was con¬
veyed to the hand, and a thrill could be detected. The right
radial pulse was somewhat smaller and appreciably later in time
than the left. There was no tracheal tugging to be felt.
On Percussion a dull note was elicited over the seat of the
tumour, and it extended for an inch to the right of the manubrium
sterni, and an inch and a half downwards in a vertical direction
from the right sterno-clavicular articulation.
Auscultation revealed a systolic bruit over the seat of the pulsating
tumour.
He complained of a throbbing sensation in his chest and neck,
as well as violent pains of a more or less spasmodic nature which
radiated from the upper part of the thorax towards the neck, the
2 D
418 Innominate Aneurysm.
back of the head, and down the right arm. He was fidgety, sleep¬
less, and excitable. His tongue was coated, his pharynx was pain¬
ful and congested, his voice at one time was weak and at another
hoarse. He lay day and night in bed between woollen rugs, and
was clothed in warm combinations, long stockings, and a dressing
gown.
I increased the iodide of potassium to 20 grs. thrice daily,
applied three leeches at once and subsequently ice bags to the
tumour; ordered a draught of chloral hydrate and bromide of
potassium to procure sleep and to counteract the restlessness. He
refused point blank to make use of any meat, so his diet was fixed
at about two pints of fluid nourishment in the 24 hours, consisting
chiefly of milk and gruel, with pellets of ice to relieve thirst, and a
liberal supply of grapes and ripe pears or other fruit.
Sir. C. Nixon and Sir Wm. Stokes saw him with me in the
course of the next fortnight, and they entirely agreed in the
diagnosis and treatment, except that Sir Wm. Stokes suggested
\ gr. hypodermic injections of morphia to be administered at night
in place of the draught of chloral.
X need not weary the Academy with all the varying details
of the case during the months of July and August. The
morphia was stopped at the end of four weeks. The pulse
was carefully watched, and although it became at times both
irregular and intermittent and greatly increased in rhythm
on the slightest exertion or excitement, its usual average was
74. At intervals, when the pulse became continuously rapid
or a crop of acne spots appeared on the skin, the iodide was
stopped. Occasionally the temperature went up to 100° or
101° F., but more usually, when a feverish state was com¬
plained of, it was found that the thermometer registered a
subnormal range. Once under great persuasion he partook
of an ounce of roast chicken, and the result, according to his
own account, was most injurious.
Marienbad salt was taken early every morning and was
followed in a few hours by one or two fluid evacuations from
the bowels. About the middle of August, and then for
several days in succession, the tumour showed signs of
quiescence, but the pulsation again became vigorous and
dashed our hopeful expectations to the ground.
Towards the end of the month, however, I was satisfied
419
By Dr. James Craig.
that the tumour had become distinctly smaller, although
the pulsation had not disappeared. I had arranged to
leave town on the 1st of September in order to spend a fort¬
night in the country, and on several occasions before my
■departure he was moved to a lounge chair, where he
remained for a few hours at a time. This was done
because he had all along insisted that he must betake
himself to the Riviera in the middle of September, and I
had promised that in order to prepare him for the journey
he should be allowed to sit up at the termination of two
months in bed, whether or not solidification had taken
place in the aneurysm. During my absence he was still
to continue the treatment as before, but was to be lifted on
to a rocking chair and remain there for a few hours daily.
I did not see him again after my holiday, but Dr. Little,
who had returned to town in the meantime, saw him
before he started for Monte Carlo on the 17th of Septem¬
ber. Dr. Little then ordered him a mixture containing
chloride of calcium and advised the application of small
blisters over the seat of the tumour. The chloride of
calcium was persevered in at intervals for a period of only
three weeks, because, as the patient subsequently explained
to me, “although it seemed to solidify the aneurysm it
raised the arterial tension.”
He remained at Monte Carlo for three months and
-during all that time his programme was unvarying, and
carried out according to his own specific directions as
follows : —
Diet — One pint of milk flavoured with coffee was par¬
taken of four times a day, with a roast apple as a second
course on each occasion.
Medicine — From 15 to 30 grs. daily of iodide of potassium
were taken in milk, and a dose of Marienbad salt was the
unfailing laxative used each morning.
General — The entire day was spent in the garden of the
hotel in a comfortable American rocking chair with a long
back and a long seat, and to this place of rest he was carried
from his room in the morning and back again at night, so
that walking was not attempted.
420
Innominate Aneurysm.
During these months he considers he got gradually free
from all the symptoms.
At the beginning of the present year he went to the
Italian Riviera, and here he began to walk about. In
February he paid a visit to Dr. Little, who was then in
Nice. Later on he migrated to his beloved Marienbad,
where he indulged in plenty of walking exercise and
became less abstemious in regard to his food, and here,
too, he felt free from all his troubles, although he still con¬
tinued to use the iodide of potassium.
He returned to Dublin during the autumn, and in
November, 1898, 18 months after the onset of his symptoms,
I put him through a careful examination, and unless for a
slight prominence and diminished resonance where the
tumour had existed there was absolutely no physical signs
of an aneurvsm to be found. He looks older and has
t /
acquired a slight stoop in walking, otherwise he is in
excellent health and spirits, has increased in weight, and
is capable of the average amount of physical exertion. In.
his pocket he carries small phials of iodide of potassium in
solution, and as the spirit moves him he swallows a dose,
just as if it were the elixir of life.
GEOPHAGY.
The habit of eating earth, or geophagy, as it is technically called,
is more widespread than is generally supposed. In some parts of
Germany a fine clay is spread upon bread, under the name of stone-
butter. In upper Italy and in Sardinia earth is sold in the markets.
In the extreme northern part of Sweden and in the peninsula of Kola
an earth composed of infusoria, and called mountain flour, is baked
in bread. In Persia earth is used in the manufacture of certain
sweetmeats. In tropical regions the use of earth as an article of
food is well known ; but it is also employed as a medicine in Nubia,
and among different tribes its use has a religious meaning as well.
Many explanations are offered for such a widespread custom. It is
not impossible that these various earths have more or less flavour,
and that they supplant to a certain degree the use of salt. — Medical
Neivs, June 3, 1899.
PART II.
REVIEWS AND BIBLIOGRAPHICAL NOTICES.
- -
The Principles which govern Treatment in Diseases and
Disorders of the Heart . The Lumleian Lectures
delivered before the Royal College of Physicians, London.
By Sir R. Douglas Powell, M.D. Lond. ; Physician-
in-Ordinary to Her Majesty the Queen ; Physician to the
Middlesex Plospital, &c. London : H. K. Lewis. 1899.
Pp. 118.
These lectures are well worth reading. They contain
nothing that is startlingly new ; they are not the product of
a young man in search of notoriety. They are, on the
contrary, the careful review and quiet outcome of the
experience of a physician of many years’ standing in his
profession ; and it is precisely such experience that a writer
needs who takes in hand to write on the subject of the
treatment of heart disease. The progress of gradual heart
failure is so slow that many cases must be watched for years
before the physician in charge can arrive at really reliable
and valuable conclusions.
The first lecture treats of cardiac disorders which depend
on or have some relation to some lesion of the nervous system,
such as cardiac neuroses, exophthalmic goitre, tachycardia.
Sir D. Powell has very little opinion of the efficacy of drugs
in the latter two conditions ; in Graves’s disease his recom¬
mendation is “imprisonment for six months, and under
surveillance for from two to five years afterwards.”
The second lecture treats of acute inflammatory diseases
of the heart and their treatment. The author’s remarks on
the necessity of prolonged rest after a recent endocarditis
are weighty and valuable ; and not only so, but he also shows
how complete rest in rheumatic fever diminishes in a great
degree the tendency to heart complications. The sections
on heart failure are good ; the chief blot which we have
422 Reviews and Bibliographical Notices.
noted is that there is no reference to the value of mercury,
whether in the form of Baly’s pill or in some other combina¬
tion, in cases of heart failure associated with engorgement
of the venous system and dropsy.
In the third lecture Sir D. Powell considers the use of
exercise in the treatment of heart disease. He considers the
graduated exercises of Schott, Oertel, and others, useful in
certain cases ; but he considers that in many individuals
ordinary exercises may be as useful as these systems. In the
case of young people — “ I think,” he writes, “ special heart
exercises are better avoided : we do not want to make heart
6 crocks ’ of our young people.” He gives a table of 14 cases
of septic endocarditis treated with antistreptococcic serum,
with three recoveries. He has also made use of hypodermic
injections of yeast culture in a few cases of this disease, and,
although the cases are too few to admit of positive conclusions
being drawn from them, he seems inclined to think the
treatment is a useful one.
Golden Rules of Medical Practice. By A. H. Evans,
M.D. Lond. ; House Surgeon, Westminster Hospital.
Bristol: John Wright. 1899. Pp. 71.
This little work contains a number of rules relating to
medical topics. We do not think it would be at all difficult
to bring together a second series of rules, equal in number to
those in the work before us, and equally “golden” in quality.
We believe that the man who really knows his work will not
need such a book as this ; while he who is ignorant had much
better try to learn something rather than trust to such a
pocket companion as these “ Golden ” Pules.
Rough Notes on Remedies. By Wm. MURRAY, M.D., F.R.C.P.
Lond., Newcastle-on-Tyne. Third Edition. London:
H. K. Lewis. 1899.
This booklet of 142 pages deals with some of the items of
an exceedingly interesting department of scientific observa¬
tion. The author modestly observed in the preface to the
former issue of this little work — “ However much it may
423
Ashby — Wright — Diseases of Children.
fail in detail I feel assured that the main lines of this
inquiry are in the right direction. If these lines of investi¬
gation were followed by others, who have time, oppor¬
tunity, and experience, it would inevitably lead to an
enhanced view of our old remedies, which have too often
been regarded as exhausted of all their virtues by previous
research, do prove that our knowledge of these old-
fashioned drugs is not exhausted , may lead to renewed
inquiry on the part of many who now hide their light
under a bushel, and never disclose their experiences.”
Those who have given most earnest and anxious atten¬
tion to the subject best know how frequently physical
explanations of facts and phenomena are deplorably at
fault when attempts are made to apply them without
special limitations to the modification of the functions of the
human body, whether in health or disease. Accordingly,
humiliating as the fact is, it is not the less true that our
best knowledge of our best therapeutic remedies is purely
empirical. With this dogmatic statement of our own, we
cordially recommend the perusal of Dr. Murrays remark¬
able series of clinical and therapeutic facts to the notice of
every earnest student of his profession.
The Diseases of Children : Medical and Surgical. By
Henry Ashby, M.D. Lond., F.R.C.P., Physician to the
Manchester Children’s Hospital ; and G. A. Wright,
B.A., M.B., Oxon., F.R.C.S. Eng., Surgeon to the
Manchester Children’s Hospital. Fourth Edition,
thoroughly revised. London : Longmans, Green & Co.
1899. 8vo. Pp. 872.
The fourth edition of this excellent and popular work has
been carefully revised and brought up to date. It is now
one of the best illustrated works on diseases of children in
the market, for twenty-five new photographs and fourteen
plates, chiefly of skiagraphs, have been added to the numer¬
ous plates and drawings in previous editions. Some sixty
pages of new matter have also been added to the text.
We notice that Mr. A. Wilson, F.R.C.S., has re-written
424 Reviews and Bibliographical Notices .
the chapter on Anaesthetics for Children — a difficult subject,
which he has ably handled.
There is little, if anything, to call for hostile criticism in
this new edition of a work which has long since come to be
an acknowledged authority on the sad and pathetic subject
of which it treats.
Manual for the Church Lads' Brigade Medical Corps .
London : Church Lads’ Brigade. 1899. Pp. 122.
This little manual (which is founded on the S. John Ambu¬
lance Handbook) deals with Elementary Anatomy, Ban¬
daging, First Aid, Stretcher Drill, and Camp Arrangement
and Eoutine. It is very well drawn up, clearly printed, and
well indexed.
The Medical School Calendar for Scotland , 1899-1900.
Edinburgh : E. & S. Livingstone. 1899. Pp. 439.
This guide unravels the somewhat complex arrangement of
licensing bodies in Scotland, and traces out the course of
study for each. The most interesting portion for readers
outside Scotland is the large and well-arranged collection of
Examination papers.
The Medical Annual Synoptical Index to Remedies and Diseases.
For the Twelve Years 1887 to 1898. Bristol: John
Wright & Co. 1899. 8vo. Pp. 451.
Whether the happy purchaser of this book possesses, or
does not possess, a complete set of the volumes of the
i( Medical Annual ” for the past twelve years to which it
supplies an index, is to some extent immaterial. In either
case this “ Synoptical Index to Bemedies and Diseases ”
will prove to him a mine of information. The Editors, or
the publishers, have aimed, and not unsuccessfully, at
producing a volume which will fulfil all the requirements
of an ordinary index and at the same time contain in a
very condensed form these facts which are likely to be
wanted for reference in everyday practice.
Axel y. Grafstrom — Medical Gymnastics. 425
In the first place, a complete index to the twelve volumes
has been compiled by arranging all subjects under those
headings which would most likely attract the practitioner
in search of them. Next, to each article has been added a
chronological synopsis of the suggestions respecting treat¬
ment which have year by year been made by the specialists
who write the original articles in the “ Medical Annual,”
or which have appeared in the medical press.
The book is arranged as follows : — Part I. supplies an
index to new remedies and old remedies with new uses.
It extends to 92 pages. Then 291 pages are devoted to
“ Diseases ” in Part II. The remaining contents are —
alterations in the British Pharmacopoeia, 1898 ; test-types
by Percy Wilde, M.D. (a reprint from the “ Medical
Annual” for 1887); pages for memoranda, and a short
supplementary index.
The price of this useful work is seven shillings and
sixpence net.
Medical Gymnastics , including the Schott ( Nauheim ) Move¬
ments ; being a Text-book of Massage and Mechanical
Therapeutics generally. By Axel v. Gkafstrom, M.D.
London : The Scientific Press (Limited). 1899. Pp. 139.
This manual teaches clearly and concisely, as far as print
can teach, the different methods of massage. The author,
however, with the cheerful optimism so often observed in
specialists, gives a widely-extended list of conditions in which
mechanotherapy is useful.
For example : — To avoid difficult labours massage is to be
used, so as “ to carry the increased nutrition towards the
mother’s muscular system — that is, from within outward.
By this the development of the foetus will be retarded, and
after a normal and comparatively easy labour a normal-sized
child will be born.” Probably the words “ normal ” and
“normal-sized” in the above paragraph are more exactly
correct than the author intends !
The treatment recommended for nocturnal incontinence of
urine in young children is complicated, and of an objection¬
able nature. Indeed the treatment of several conditions —
426 Reviews and Bibliographical Notices.
chronic seminal vesiculitis, for example — might well be
omitted.
Although in the treatment of strangulated hernia massage
is only another name for “ taxis,” the other name is a
dangerous one, as massage is undertaken by a much wider
circle than would resort to taxis.
South African Health Resorts. The Voyage to South Africa
and Sojourn there. London: Donald Currie & Co. 1899.
Pp. 145.
This handsome advertisement contains papers on “ The
Climate of South Africa” (Dr. Alfred P. Hillier), “ The
Cape as a Health Resort” (Dr. C. Lawrence C. Iiirman),
“ South Africa as a Health Resort” (Dr. E. Symes Thomp¬
son), and a number of chapters dealing with the voyage,
means of getting about, hotels, and so forth. There are
also appendices containing extracts from papers and books
touching on South Africa as a health resort, and there is a
good bibliography which will be of use to intending travellers.
The maps and illustrations are excellent, and medical men
will get many hints as to when and whither they should send
out patients — ivhen the war is over !
The Medical . Digest , or Busy Practitioner s Vade-mecum .
Appendix, including the years 1891 to March, 1899. By
Richard Neale, M.D., Lond., Member of the Dutch
Medical Society of Batavia, Java. London : John Bale,
Sons & Danielsson. 1899. 8vo. Pp. 261 -J- xxxiv.
In his Preface Dr. Neale explains that this second Appendix
to his well-known “ Medical Digest ” has been incorporated
with the Appendix published in 1895, in order to facilitate
reference. The journal called Clinical Sketches had been
already (in 1895) added to the periodicals included in the
Digest.
To make proper use of the Appendix, the Index of the
edition of 1890 must first be consulted for any given subject,
and then the corresponding section in the Appendix must
be referred to in order to see whether any fresh matter has
427
Bacon — Blake — Manual of Otology.
been added. If the Index of 1890 does not refer to the
subject sought for, the inquirer must turn to the Appendix
Index, in which new subjects alone are noted.
In undertaking and carrying to a successful issue his
herculean task of reference Dr. Neale has conferred a boon
on the medical reading world. W e have often had occasion
to consult the Medical Digest, and never without obtaining'
the information for which we sought.
A Manual of Otology. By GRAHAM BACON, A.B., M.D.,
Professor of Otology in Cornell University Medical
College, New Pork; Aural Surgeon, New York Eye and
Ear Infirmary. With an Introductory Chapter by
Clarence John Blake, M.D., Professor of Otology in
Harvard University. With 110 Illustrations and a
Coloured Plate. London : Henry Kimpton. 1899.
This beautifully printed and well illustrated little volume
forms an important addition to the very convenient and
tastefully prepared series of professional manuals which
have been published of recent years by Mr. Henry Kimpton.
It includes 398 pages, of which the last 12 are occupied
by a good index. Chapters I. and II. deal respectively
with the “ Anatomy and Physiology of the Ear ” and the
“ Methods of Examination of the Ear ; ” — they are written
in an exquisitely lucid style, and form an admirable intro¬
duction to the body of the work. Twelve other chapters
deal with the various morbid conditions of the Auditory
Apparatus. The last of these (Chapter XIY.) is on the
interesting subject of Deaf-Mutism.
The author modestly tells us in his preface that he has
‘ 4 especially tried to meet the demands of the student by
giving him a short and compact treatise of the subject,
and at the same time affording him a book of easy reference,
since he may not always find the time necessary for con¬
sulting the many excellent and more exhaustive treatises
upon otology which have been published not only in this
country, but also in England and on the Continent.
“ In a work of this character it is impossible to describe
all the operations mentioned in the larger treatises on
428 Reviews and Bibliographical Notices.
aural surgery, but a sufficiently full consideration is given
to those particular diseases of the ear with which the
student and practitioner will frequently meet to enable
them to properly understand the condition and apply the
appropriate treatment. So far as is possible, I have been
guided in the selection of material by the results of my
own experience. I can fairly claim for the volume the
merit of practicability.”
We entirely endorse the very unpretentious account
given in the above quotation. In the beautifully clear
style, which seems to be a special gift of our transatlantic
confreres , Dr. Bacon gives a necessarily short, but lucid and
suggestive account of the causes, symptoms, complications,
and treatment of the principal morbid conditions of the
auditory organs. It is obviously the work of a master of his
specialty; and the results of his personal experience are laid
before the reader without a trace of the pretentious dogma¬
tism which so often irritates during the perusal of works of
this kind. We consider the volume an excellent intro¬
duction to the important subject with which it deals, and
cordially recommend it to the attention of every student
and general practitioner.
Year-Book of the Scientific and Learned Societies of Great
Britain and Ireland . Comprising Lists of the Papers
read during 1898 before Societies engaged in Fourteen
Departments of Research, with the names of their authors.
Compiled from Official Sources. Sixteenth Annual Issue.
London: Charles Griffin & Co., Limited. 1899.
The present issue of this excellent annual gives — (1) an
account of scientific work done by the various departments
throughout the year; (2) a record of progress. It is a
convenient handbook of reference.
In most instances the lists t>f papers have been contri¬
buted directly by the Societies. Where papers are not
given, their absence is often to be attributed to the fact that
the society in question does its work in another way. The
names of those societies concerning which no information
has been received are entered in the index only.
Index- Catalogue, Surgeon- General's Office , U.S.A. 429
The value of the work to those engaged in scientific
work can hardly he overrated, and there is no one engaged
in literary work to whom it may not be useful.
Index- Catalogue of the Library of the Surgeon- General's Office ,
United States Army . Authors and Subjects. Second
Series. Yol. IV. D. — Emulsions. Washington: Govern¬
ment Printing Office. 1899. 8vo. Pp. 917.
Major James C. Merrill, Surgeon, U.S. Army, and
Librarian in the Surgeon-General’s Office, informs us that
this, the fourth, volume of the second series of the Index-
Catalogue of the Library of that office includes 9,628 author-
titles, representing 4,133 volumes and 8,523 pamphlets. It
also contains 8,828 subject-titles of separate books and
pamphlets, and 28,316 titles of articles in periodicals.
The Library of the Surgeon-General’s office now contains
130,708 bound volumes and 220,839 pamphlets. It must
thus be the largest medical library in the world.
LITERARY NOTE.
Messrs. Rebman, Ltd., announce the following new books for
immediate publication: — Yol. 1 of “An International Text-book
of Surgery,” by British and American authors, in 2 vols, edited by
A. Pearce Gould, M.S., F.R.C.S., of the Middlesex Hospital, and
J. Collins Warren, M.D., LL.D., of Harvard Medical School. A
new “Text-book of Diseases of the Nose and Throat,” by D.
Braden Kyle, M.D., of Philadelphia. A work on the “Hygiene
of Transmissible Diseases,” by Dr. A. C. Abbot, of Philadelphia.
One on the “ Pathology and Treatment of Sexual Impotence,” by
Yictor C. Yecki, M.D. Also the following A Text-book of
Physiology,” by Prof. Winfield S. Hall, of Chicago. “ Minor
Surgery and Bandaging,” by Henry R. Wharton, M.D. (4th ed.)
Yol. 1 of “A Text-book of Surgical Anatomy,” by Professor John
B. Deaver, of Philadelphia. Messrs. Rebman also announce as in
the press new editions of Dr. Freyberger’s “ Pocket Formulary for
the Treatment of Diseases in Children.” Mr. Bland Sutton’s and
Dr. Giles’ “ Diseases of Women.” Prof. Krafft-Ebing’s “ Psycho-
pathia Sexualis,” translated from the last edition.
PART III.
MEDICAL MISCELLANY.
Reports, Transactions , and Scientific Intelligence.
- -
An Address on Recent Medical Progress and Celtic Medicine,
delivered in the Mater Misericordice Hospital, Dublin .a By
Thomas More Madden, M.D., F.R.C.S.E., M.A.O., ( Honoris
Causa), Royal University of Ireland ; Obstetric Physician and
Gynaecologist to the Hospital, &c.
INTRODUCTION.
The enduring influence of old usage on even the most pro¬
gressive of professions, is manifest on the present occasion. Thus
in the earliest records of medicine we find that the neophytes/
initiation into the temple of dEsoulapius was accompanied by
elaborate ceremonials, concluding with an exhortation or Address
to the probationer, and the witnesses of his reception. Of those
ancient rites one alone survives. The modern medical student is
no longer crowned with garlands as his predecessors; were on their
entrance into the Grecian Fane. The vestal’s song is no longer
raised, nor are the libations now poured forth — at least in pub¬
lic — in his honour. Nevertheless from that remote period down
to these closing days of the nineteenth century he has remained
unemancipated from the penalties of the Introductory Address on
the commencement of his (course.
In accordance therefore with that timer-honoured observance,
I have, by the favour of my colleagues, been deputed on this
inauguration of the Thirty-eighth Annual Session of the Mater
Misericordise Hospital, to say a few words of welcome and counsel
to our class and to those; who. are; about, to join our ranks. I
am, moreover, charged by the Sisters of Mercy as well as by the-
Medical Board to express their thanks to each one of this dis¬
tinguished assemblage of the friends and supporters of the insti¬
tution for the honour Conferred upon us. by your presence to-day.
a An Inaugural Address delivered on the opening of the Thirty-eighth.
Annual Session of the Institution, on Monday, October 23, 1899.
Recent Medical Progress. 431
GROWTH AND PRESENT POSITION OF THE MATER MISERICORDHE
HOSPITAL.
The fact that nearly twenty years ha,ve elapsed since I last
delivered an Introductory Address in this place, recalls to my mind
the alterations which within that period have occurred in the
Mater Hospital, in the science therein cultivated and in the
personnel of its staff.
With regard to the last-mentioned of these changes I may
observe that although those who, like myself, have passed,
N el mezzo del cammin di nostra vita,” cannot but be thus
reminded of how rapidly “ the old order giveth way to the new,”
there nevertheless remains in all these mutations a revivifying
assurance of the inherent stability and growth of this great
institution. For if, since then, we have to deplore the loss of
four of our esteemed colleagues — of whom none were
more justly valued and deeply lamented than Dr. Boyd,
over whose untimely grave we have recently mourned —
and whlo now rest from their labours; in the well-
founded hope of that mercy promised to the merciful and to
those who' have faithfully ministered to the poor and suffering —
their places have been filled by others so' worthy of their office
and of the fame of their predecessors, as those by whom the
standard of the hospital is now upheld in the van of medical
progress. And thus, unaffected by the fleeting shadows of its
successive servitors, does our institution continue its two-fold
mission of humanity and of science with a vitality developing
with its maturity.
In the establishment of the Mater Hospital the Sisters of
Mercy, by whom it was founded close on forty years ago, and by
whom it has since been maintained, with little assistance beyond
the inexhaustible benevolence of Irish charity, put before them¬
selves a high ideal, the fruition of which you now see in this
institution, which, in an independent official report, has been
aptly described as “ The Queen of Dublin Hospitals, ”
Of the work done here it may suffice to1 say that during the
past year alone o,522 patients have been treated within the wards 5
23,061 cases were relieved in the extern departments ; and 696
operations (not including gynaecological and eye operations) were
performed in the theatre of the hospital. Nor is there any single
form of disease or accident that may afflict mankind excluded
from these portals, which, like unto' that Divine Mercy of which
this institution is the creation, are ever freely open to all who
432
Introduc tory A ddress .
are impelled by suffering and poverty to seek its succour, with¬
out distinction of creed, or race, or class.
Within the period covered by this Address the vital importance
of thoroughly aseptic conditions in all that appertains to the care
and treatment of the sick has become universally recognised.
With this object, therefore, the Sisters of Mercy have incurred, a
large expenditure to enforce in accordance with the views
of their medical staff the teaching of sanitation. Hence lour
operating theatres have been reconstructed, ventilation and
drainage improved, and a very efficient and well-trained nursing
staff provided for our public and private wards, as well as for the
necessities of general practice throughout every part of the
country wherein the services of the Mater nurses are in constant
requisition.
Finally, it may be mentioned that the incalculable advantages
of a new Convalescent Asylum in the most, hygienic surroundings
are about to be afforded to our patients on their discharge from
hospital.
Whilst such consideration has been given to the primary
purpose of the institution, those entrusted with its administra¬
tion have in no wise been oblivious of its secondary and almost
equally important function — viz., that of serving as a centre of
clinical medical education and scientific teaching. Accordingly we
have been here provided with one of the first, and probably the
best equipped, pathological laboratories attached to an Irish
hospital. This: department, on the researches of which the
present practice of medicine is so largely dependent, has been
placed under the direction of an authority whose name is
recognised wherever modern pathology and bacteriology aie
studied. In like manner the first adequate installation in Ire¬
land of the apparatus necessary for that Rontgen Ray work, by
which so many of the obscurities 'of medico-chirurgioal practice
are now elucidated, was here instituted. A similar desire to keep
well abreast of the flowing tide of modern progress was shown in
the establishment of the special office of anaesthetist, which has
been well justified by the consequent immunity from risk afforded
by the improved methods of anaesthesia, employed here.
Lastly, amongst the changes effected in the hospital since my
former Address, the increase in its resident staff is one of the
most important. In no institution in this country has larger
provision been made for those resident appointments so neces¬
sary for the work of a great hospital, and of such advantage to
the future interests of junior members of the profession. Hence
Recent Medical Progress. 433
we are mow afforded the services of a resident staff consisting of
two house physicians, four house surgeons, and eight clinical
assistants, always available for the emergencies of the institution.
These gentlemen, and their predecessors, have fully borne out their
selection by the positions so many of them have subsequently
attained, as well as by the work they have here accomplished.
By similar men have the junior appointments in this hospital
been filled throughout the many years of my connection with it,
and by them has its reputation been maintained, and the in¬
fluence of its clinical teaching been dispersed abroad and at
home, orbi et urbi.
Thus in every clime, or place, or circumstance, when medical
men have faced death to save the lives of others, from the fever-
stricken districts of our own land to the malarial swamps of
Africa,, the plague-infested cities of the Far East, or the battle¬
fields of the Soudan, the Indian frontier, or of the Transvaal,
there have the quondam students of the Mater Hospital been
found discharging their mission of mercy to humanity.
INFLUENCE OF BACTERIOLOGICAL DISCOVERY ON THE PROGRESS
OF CLINICAL MEDICINE.
Turning from the work of our hospital and its alumni
to that of the healing art, of which it is the clinical theatre,
we find here as elsewhere the most distinct imprint of
recent progress in every department of practical medicine, sur¬
gery, and gynaecology, a, si well as in ophthalmology, dermatology,
and the other special branches of modern medico-chirurgical
science. The rapidity of this advance has been such that the
highest professional accomplishments attainable' twenty years
ago have already become almost as obsolete for a student as the
knowledge of Hippocrates in physic, or the skill of Ambrose
Pare in surgery, might prove, could either be now tested by a
modern Conjoint or Royal University Medical Examination.
So many and complex are the factors in that revolution in
medicine that it would be useless to attempt any survey, how¬
ever brief, over a field of such extent. Nevertheless, I may,
perhaps, be permitted a passing allusion to one point, which,
trite as it must be to every member of the profession, may
possibly interest some of our junior friends present, as
affording a master-key to many of the most signal triumphs
of recent medical and surgical practice — I refer, namely, to
the germ theory of disease. On that doctrine, moreover,
largely rests the foundation of modern Preventive Medicine and
2 E
434 Introductory Address.
Sanitary Science, by which the limitation of disease, the pro¬
longation of life, and the increment of the welfare of the com¬
munity haye been so signally accomplished within the past few
Recent, however, as has been the acceptance of the germ or
bacterial ’theory, that dogma was originally promulgated more
than two hundred years ago by Leeuwenhoek, and was subse¬
quently reiterated at intervals down to the middle of the present
century by other writers. But those earlier teachings had appa¬
rently as little practical influence on older ideas as erstwhile had
the voice of the inspired Precursor whose proclamations of far
higher and more certain truths once fell unheeded in the Pales¬
tine wilderness.
Nor was it until long after the actuality of the facts estab¬
lished in our (own time by Pasteur, Lister, and Koch had been
demonstrated beyond controversy that this theory became uni¬
versally adopted as the basis of a new pathology and thera¬
peutics. And only since then has the medical practitioner been
furnished by the bacteriologist with an accurate knowledge of the
aetiology of many of the formerly obscurest forms of disease. Thus, for
instance, we now know that diphtheria, septicaemia, cholera, tuber¬
culosis, lupus, typhoid, as well as countless other maladies,
including the malarial fevers of equatorial regions, and the
bubonic plague which in former times wended its path of devas¬
tation from, its remote habitat in the east, even to this sear girt
western land, and with a revisitation of which ve are at
present apparently threatened, are. one: and all distinctly trace¬
able to bacterial virus, communicable, in each instance, by
specifically infective micro-organisms. These pathogenic or
disease-bearing microbes, to whatever class they belong, whether
bacteria, bacilli, spirilla, streptococci, or however else named,
possess certain common characteristics. Thus they present
themselves as microscopically minute organisms capable of rapid
and indefinite self-reproduction within the system to which they
may gain access, and consisting essentially of a single cell by the
distinctive form of which, in each case, their classification and
attributes can be differentiated.
Such are the prolific seeds of disease with which the air we
breathe, the water we drink, the food we consume, so teem that
our existence would he impossible were it not for that constitu¬
tional conservative force which in former times was described as
the Vis medicatrix Natures, and which, as we know, is mani¬
fest in the physiological defensive action of the leucocytes or
435
Recent Medical Progress.
white corpuscles of the blood. These, by their power of ingest¬
ing, and rendering innocuous, such injurious particulate matter
as may have gained access to the system, act as the garrison of
the beleagured citadel of life, and so under normal circumstances
repel the invading hosts of the pathogenic microbic enemies by
which it- is surrounded.
Legion, however, as, is the number of our bacterial •
foes, a still larger proportion of microbes fulfil functions of
vital importance and utility in the economy of nature. Such, for
instance, are the micro-organisms by which the oxidisable and
nitrogenous material of effete and decomposing organic matter
is seized upon and resolved into its proximate elements. In
this way, then, is restored to* the Universe, for the maintenance oi
vegetable and animal existence,, that indispensable stock of
chemical constituents in default of which this fair world of ours,
would in time inevitably become reduced to the lifeless deso¬
lation of its pale-faced satellite —
“ See ! all things with each other blending,
Each to all its being lending,
All on each in turn depending,
Floating, mingling, interweaving —
Rising, sinking, and receiving
Each from each, while each is giving
On to each, still upward tending,
And everywhere diffused is Harmony unending. ”
It would be impossible in this Address to dwell on our further
indebtedness to the bacteriological scientists who* have not only
added to our knowledge of the aetiology of diseases, but have,
moreover, armed us, with the newer weapons, of sero-therapy and
specific antitoxins now available for their treatment or preven¬
tion.
The same reason also precludes my present reference to the
many other modern developments of practical medicine and
therapeutics, which are so fully set forth in our Senior Phy¬
sician’s well-known “Hand-Book of Hospital Practice,” and
which clinically are daily expounded in the medical wards of this
hospital.
SURGICAL PROGRESS.
In the domain of Surgery the evidence of rapid advance since
my former Address is yet more apparent than in that of Medi¬
cine, as may be exemplified by a moment’s reference to the
upgrowth and development of antiseptic chirurgical practice
within that period. The fruits of this are, perhaps, most con-
436 Introductory Address.
spicuous in the successful operations now resorted to m countless
caSes — such, for instance, as tubercular peritonitis, renal, intes¬
tinal, gastric, and other diseases, and lesions within the
peritoneal cavity— from any effective intervention with which our
predecessors were almost necessarily debarred.
These procedures, with many others of equal importance that
need not be here enumerated, which in my youth, were
either altogether undreamt of, or which, if occasionally attempted,
were then associated with such fatality as to preclude their
general performance, are now daily accomplished with
smaller risk than might have attended the opening of a
whitlow in pre-antiseptic days. Nor is it, necessary to remind my
auditors that this vast improvement in the practice of surgery is
largely traceable to the example and teachings of Lord Lister,
whose well-deserved elevation to the peerage can add but little
to a, fame that must endure as long as the art of surgery is culti¬
vated. For although the- original paraphernalia and doctrines of
antisepticism have already become so modified and improved
that many surgeons now aim at the annihilation of sepsis by
absolute surgical cleanliness, to which all active germicidal agents
are but essential adjuncts-, nevertheless, for all this, we still
remain primarily indebted to- him whose name has been just
mentioned as the pioneer of the non-sept-ic surgery of the present
time.
RECENT GYNAECOLOGY.
In this connection I cannot altogether refrain fiom
alluding to the branch of medicine with which I am most inti¬
mately concerned. But however tempted I may be to dilate on
the progress of modern Gynaecology, I shall confine, within the
narrowest possible limits, my reference to> a subject that, how¬
ever interesting to myself, would probably prove intoleiably
wearisome to the majority of my present audience..
It will, therefore, be enough to say here that this youngest
of the tripart divisions of the healing art has exhibited a pro-
gressive development fully equal to that of either of its medico-
chirurgical parent sciences, and that this specialism, the very
name Of which was unknown in my student days, has within
the past few years advanced by leaps and bounds to its
present prominence in the foreground of medical progress.
The diseases and abnormalities of what was formerly the
terra incognita Australis of Pathology — viz., the region of the
uterus and its appendages, have now become as accurately
Recent Medical Progress. 437
differentiated and as successfully treated as those of any of the
external structures of the body. Thus, for instance, fibre-
myomata and carcinoma of the uterus, the various displace¬
ments or that organ, the affections of the ovarian and tubal
adnexa, with numberless other gynaecological disorders, the
victims of which were formerly, in many instances, abandoned
to lives of hopeless misery, have now been brought within the
reach of accurate diagnosis, and generally successful treatment.
So great has been the improvement, that in operations of such
gravity as ovariotomy there is now practically no appreciable
death-rate, whilst in other; proeedfusres: — such asi hysterectomy — the
terrible fatality of one in three or four that existed within the
last twenty years has now been reduced to less than one per
cent, of such cases.
The limits of time available for this Address prevent any
reference here to those other no less important subdivisions of
our art, such as ophthalmology, dermatology, and pharmacology
that are specially cultivated in this hospital.
THE FUTURE OF YOUNG MEDICAL MEN.
Before bringing to a close observations which have probably
already proved sufficiently prolonged, I must, in imitation of
the postscript to a lady’s letter, in which the gist of the
communication generally lies, add a few words especially
addressed to the members of our class in whose behalf a lecture
of this kind is primarily intended.
To you, gentlemen, I therefore venture to offer, as I did to
your predecessors here “ Twenty golden years ago,” my
sincere congratulations on your selection of the profession of
Medicine. For although, since then, the requirements of the
Examination Boards have been vastly increased in extent and
stringency ; although our calling has become now so over¬
crowded, in many places, that the struggle of early professional
life must too frequently be waged under1 circumstances of
keenest competition and ill-remunerated toil; and although,
moreover, the disciples of the healing art, and more especially
the ill-requited members of the Poor Law Medical Service,
may not hope for positions of such emolument or of dignified
repose as are reserved for the successful lawyer or the victorious
soldier, or expect aTo close in shades like these, a youth of
labour with an age of ease;” nevertheless medicine still retains
gifts and advantages above those of any other earthly profession.
Assuredly our calling affords the largest opportunities that
438 Introductory Address.
man can enjoy for benevolence to humanity. . Moreover, not
merely does it arm, us with the power of relieving suffering,
prolonging life, restoring banished reason to its dominion over
matter, and mitigating the pangs attendant on the departing
spirit’s separation from its frail tenement, but even from, that
more material point of view which may possibly be no less
important jto. you than to myself. Sit also offers other com¬
pensations to its followers.
Unlike almost every other profession, Medicine is cosmo¬
politan, and wherever acquired may be practised in ail climes
and circumstances wherein man when stricken by disease or
accident must of necessity still turn, as he did in the Homeric
days of old, to “A wise physician, skilled his wounds to heal,
for respite from suffering or from death.
Not until pain be annihilated, and death be isw allowed up
in the final victory )of eternity over time, need any well-
qualified practitioner of medicine who is blessed with the
essential attributes of rectitude of conduct' — -kindness of heart,
sympathy of demeanour, and energy of character— ever doubt
his ability to secure, by the exercise of his profession, in any
part of the world, a sufficient competency and an honourable
position.
To that goal there are many paths now open. Thus, for
instance, the young practitioner may select for his future career
the medical departments of the Army or Navy, or those of the
Civil Service', under its Poor Law Lunatic Asylums, or Prison
Boards. Or should he prefer, as our Consulting Physician
well put it in an Address delivered here many years ago,
“ to devote himself to the service of the public rather than to
the public service,” he may db so in private practice either at
home or abroad, or may readily find occupation for a time as
a surgeon in the service of the Mercantile Marine.
IMPORTANCE OF CLINICAL STUDY.
But wherever your future lot be cast, and whatever else may
conduce to your prosperity, you should ever bear in mind that
the foundations of such success must be laid on the solid rock-
bed of Clinical Knowledge, to which all other branches of
science, however essential, now included in the medical curricu¬
lum, are but accessory and subservient.
Time-worn as this text may be, its paramount importance
cannot be too strongly impressed on those who are now our
fellow-students in that vast field of clinical medicine, the full
Recent Medical Progress. 439
exploration of which.- would be beyond the capacity of the
longest and most laborious life, and which may therefore well
engage your unremitting attention during the brief period of
your student days;. To utilise clinical study, however, even
the most zealous attendance on hospital practice will avail little
if you do not at the same time cultivate the: art of noting
down the history of the cases that there come before you.
Such notes will prove an invaluable store of experience, and
will also serve to further the habit of rapidly grasping the
salient features of each case, and thus acquiring that Mens
medica which is essential for every practitioner. With the
view therefore of stimulating the development of this most
important faculty, the Leonard prizes in medicine and surgery
are here offered, and will, we trust, be the objects of a well-
contested competition at the close of the ensuing Session.
Gentlemen, on entering the medical profession you must
assume many responsibilities as well as gain some privileges.
On you, therefore, it will devolve to support the reputation of
your calling, by a conscientious zeal in the honourable discharge of
your great mission to the poor and suffering. Moreover, it will
be your duty to add your mite of experience and of knowledge
to that cairn of medical science which has been brought up to its
present height by the aggregation of the individually minute
contribution of your predecessors, and so maintaining the
great traditions of Irish medicine, to hand it down to your suc¬
cessors improved and perfected by your labours.
CELTIC MEDICINE, ITS HISTORY AND LESSONS.
In this connection, I may for a moment refer to the too1 gene¬
rally forgotten fact that Irish medical men can lay claim not
only to the traditions they inherit from their more immediate
predecessors, but also to a history deserving of larger consider¬
ation than is now commonly given to it. For, as I have else¬
where shown, the practitioners of the healing art in this: country
are, in truth, the legitimate heirs of the oldest professional
culture of which there are in existence the records in the living
language of any European nation. Let me, therefore, remind
you that in distant ages; when the: lamp of medical knowledge was
unkindled in most other countries, its light shone with compara¬
tive brilliancy in this remote Ultima Thule , as may be easily
proved by incontrovertible historical evidence. Thus, for
instance, there are still extant and accessible in the libraries of
the Royal Irish Academy and Trinity College in this city, as well
440 Introductory Address.
as in other similar collections elsewhere, a vast body of ancient
Gaelic MS. documents, in many of which the distinguished
history and high character of early Irish medicine are well illus¬
trated. .
From these sources we find that from the oldest period ot
authentic history the classic literature of Greek and Roman
medicine, as well as a still more ancient native leechcraft, was
cultivated in our own country even in those far-off ages. Whilst
at the same epoch therapeutics, materia medica, and anatomy
were studied, and surgery, gynaecology, and obstetrics, were
practised in Ireland, where the hereditary followers of the heal¬
ing art were then held in high honour, A ay, more, we have
clear evidence, which I have elsewhere sufficiently adduced,
to show that the marvels of modern hypnotism and the
employment of anaesthetics, on which we plume ourselves as the
most beneficent discovery of the present age, were, although in
cruder forms, here anticipated by our remote predecessors.
Amongst the numerous collegiate centres of professional as well as
of ecclesiastical learning with which this Insula Sanctorum et
JJoctorum was studded over between the sixth and sixteenth
centuries, and the very ruins of many of which, such as Clonmac-
nois, Cashel, Meelick, Portumna, Lismore, and Monasterboice,
still attest the culture and art as well as, the piety of their
founders, one, at least, is of special interest to, us as of a dis¬
tinctly medical origin— viz., Tuam Brecain, near the present
town of Belturbet. This college, as Dr. Healy, Bishop of Clon-
fert, has shown, was established by a medical practitioner of no
little eminence, Saint Bricin, whose chirurgical skill, more
especially in cerebral surgery, is celebrated in our oldest annals.
All the various faculties of these Celtic Catholic Universities,
for such was the character of many of them, were for long ages
crowded with students from every part of Europe, who in some
of them were subjected to a course extending over a period far
more protracted than even that of the modern medical student.
From these institutions also were sent forth men such as Alcuin,
the founder of the University of Pisa, Johannes Scotus, Erigena,
who in the ninth century was regarded as the' ablest writer of
that age as well as the first professor of philosophy in Paris, and
countless others, to diffuse the lights of learning and science as
well as of faith to the ends of the earth.
Nor did that long intellectual pre-eminence cease in medicine,
at least until some little time after the ruthless destruction of
441
Recent Medical Progress.
the Irish Monastic Universities durng the reigns of Henry VIII.
and Elizabeth, and even down to the middle part of the seven¬
teenth century we find the far-extending fame of Irish medicine
referred to> by authorities of such eminence as Van Helmont.
To the destruction of those Celtic Universities may, moreover, be
attributed the origin of the disabilities in the matter of higher educa¬
tion that for three centuries have pressed, and still press, heavily
on the majority of the Irish people, and on none more forcibly
than on those of them belonging, as so many here do, to the
medical profession.
The latter, during all these generations, have been thus un¬
fairly handicapped in the race of existence by the impossibility
of securing, in accordance with their conscientious convictions,
that full measure of academic training within the halls of a
university which is so conducive to success in the higher walks
of professional life or public employment, and which is accessible
to their compeers of every other persuasion.
We may, however, rest well assured that in this, as in all other
matters, justice, although long delayed, must, like that truth on
which it is founded, eventually prevail. And therefore can we
confidently anticipate that this last vestige of the dark shadows
cast o’er our land by the successful intolerance of a by-gone
age may for ever be swept away in the near day-dawn of the
Twentieth Century, which we trust will usher in the final and
equitable adjustment of the Irish University Question.
Whether in our day this long-cherished hope be realised or
not, will, however, we are equally confident, in no wise affect
your kindly relations and zealous co-operation in the mission of
medicine with your brother practitioners of all other schools and
denominations. Nor need we attempt to stimulate your esteem
and respect for men amongst whose* professional ancestors were
included names such as those of Cusack, Carmichael, Graves, or
Stokes, which at home and abroad are* as imperishably engraved
on the annals of our science as those of their Catholic com¬
peers* — Corrigan, O’Reilly, Lyons, or Hayden; or who, like the
Anglican founder of Sir Patrick Dun’s Hospital, or Bartholomew
Moss, to whom Ireland owes her great school of midwifery, the
Rotunda ; or Dr. Richard Steevens, by whom the hospital which
bears his name was established1 — have left in our city enduring
monuments of a medical benevolence as far above all sectarian
considerations as that of the founders of the four Catholic hospi¬
tals which are so largely supported by Irish charity in Dublin.
442
Introduc tory A ddress .
In conclusion, I would only venture to express my trust that in
the fulness of years, you, gentlemen, may one and all leave
behind you such imprints on the sands of time a,s those I have
just named did. Thus will you not only honour yourselves and
your calling, but also perchance reflect some of your well-won
credit on your clinical Adinci Mater and on those who were once
your teachers in the Mater Misericordiae Hospital.
ALVARENGA PRIZE OF THE COLLEGE OF PHYSICIANS OF
PHILADELPHIA.
The College of Physicians of Philadelphia announces that the next
award of the Alvarenga Prize, being the income for one year of
the bequest of the late Senor .Alvarenga, and amounting to about
one hundred and eighty dollars, will be made on July 14, 1900,
provided that an essay deemed by the Committee of Award to be
worthy of the prize shall have been offered. Essays intended for
competition may be upon any subject in medicine, but cannot have
been published, and must be received by the secretary of the
college, Thomas R. Neilson, M.D., on or before May 1, 1900.
Each essay must be sent without signature, blit must be plainly
marked with a motto and be accompanied by a sealed envelope
having on its outside the motto of the paper and within the name
and address of the author. It is a condition of competition that
the successful essay or a copy of it shall remain in possession of
the College ; other essays will be returned upon application within
three months after the award. The Alvarenga Prize for 1899 has
been awarded to Hr. Robert L. Randolph, of Baltimore, Md., for
his essay entitled — u The Regeneration of the Crystalline Lens.
An experimental study.”
STAB WOUND OF THE THORACIC DUCT.
W. H. Lyne, M.D. [Maryland Med. Jour ., September 10, 1898),
reports the above condition in a negro aged 24. An oblique stab
wound about one inch long, depth unknown, was found above and
behind the left clavicle and parallel with the outer border of the
sterno-cleido-mastoid near its attachment. A longitudinal wound
of the thoracic duct was therefore possible. An abundant fluid milky
was steadily escaping. The wound was cleansed, packed with gauze,
and bandaged. On removing the dressing about seven hours after¬
wards, the escape of chyle had completely stopped, and the dressing
was reapplied. Recovery was prompt, except for a slight suppu¬
ration.
CLINICAL RECORDS.
Six Cases of Alcoholism treated successfully by Inhibition of
Alcohol , by Massage and Bromides. By James R. Wallace,
M.D., F.R.C.S .1., Surgeon to the Home Hospital, Calcutta.
I have for many years in practice treated numerous cases of
alcoholism by absolute stoppage of alcohol, by a regular system
of massage and by the administration of potassium bromide
with cinchona and capsicum.. By alcoholism, I mean the fre¬
quent imbibition of whisky, brandy, beer or champagne for days
and weeks together, resulting in a complete vitiation of digestion,
insomnia, mental and nervous irritability and prostration, and
often delirium tremens. I employ the method of treatment
I now advocate, namely, absolute rest in bed, massage, inhibition
of alcohol and the use of bromide, cinchona and capsicum on the
following principles. Rest in bed exercises a distinctively calma¬
tive influence upon the brain and nervous system, massage as a
form of passive exercise not only regulates the circulation and
tones the muscular system, but has a marked moral influence in
pacifying the “ turbulence” of the central nervous organism. It
also has a peculiarly calmative somnolent action. I believe
that in all cases alcohol acts as a narcotic poison, and that
the immediate withdrawal of the poison or its absolute stoppage
is an essential factor to the cutting short of the deleteriousness
of the cumulative poison and to a rapid recovery from its effects.
I do not believe that in such leases the use of alcohol should
be gradually withdrawn, nor1 do> I believe that the administration
of the smallest doses of this narcotic during the course of illness
arising therefrom does anything else but positive harm. In
the three drugs I have mentioned we have a valuable combination
of an effective nerve and brain sedative in bromide, a good
digestive and alterative in cinchona, and a, splendid restorative
stimulant in capsicum,. This routine treatment was adopted
in each of the following cases : —
Case I. (No: 4 in Hospital Case Book). — Miss - , an English
woman, 25 years of age, was admitted into the Home Hospital on
the 26th of November, 1898, suffering from insomnia, great mental
excitement, persistent vomiting, diarrhoea and nervous prostration.
She had been drinking hard for almost six weeks, and indulged in
444
Clinical Records.
a mixture of beverages — -whisky, beer, champagne and liqueurs.
Four large bottles of beer, three pints of champagne-, five or
six glasses of whisky and four or five glasses- of liqueur formed
the ordinary total of a day’si drink. She had not slept for several
nights, could not retain any food (though she retained the- stimu¬
lants), her bowels were much relaxed, her tongue- was coated with
a thick yellowish-brown fur, her hands were very tremulous, and
she was quite excited, nervous and hysterical. On examination,
no organic disorder of any kind was discovered. She was- put to
bed and massaged from head to- foot- for half-an-'hio-ur. She was
given iced gruel, an ounce- at a time every hour. The mixture,
containing bromide, capsicum and cinchona, was given every three
hours. All alcohol was stopped. Within twenty-four1 hours the
diarrhoea and vomiting ceased. Massage, which was done
every four hours, helped by the mixture, procured sleep- in six¬
teen hours. On the following day solid food was allowed, and the
treatment continued. After the fourth day the patient slept
naturally for several hours at a time, all the nervous symptoms
had subsided, and her digestion seemed quite restored. She
was discharged cured on the 3rd of December — eight days- after
admission.
Case II. (No-. 14 in Hospital Case Book). — Mr. - , a Euro¬
pean, aged 50, an old beer drinker, corpulent and in good general
health, had been on the “burst” for almost three weeks-. He
had been drinking as many as 25 large bottles of beer daily
with a couple of pints of champagne thrown in by way of a
change, and he had drunk this allowance with a trifling difference
for three weeks. He was brought into the Home Hospital on the
6th of January with threatened delirium tremens. All liquor
stopped, massage every three hours for 20 minutes at a time.
Same mixture as above, milk diet. Within 24 hours the- exces¬
sive nervous irritability and mental illusions ceased, and he slept
for three hours. Within 48 hours hisi condition was perfectly
normal, and he was- allowed to leave- the hospital on the evening
of the 8th, as he desired to do- so.
Case III. (No. 22 in Hospital Case Book).— Mr. ^Scotch¬
man, aged 30, general health good, had been drinking heavily
for a week, imbibing a mixture of whisky, beer and gin. Ex¬
cessive vomiting, diarrhoea, sleeplessness and very marked tremu¬
lous excitement. Same treatment as above-, nothing given espe¬
cially for Vomiting or diarrhoea-, which both subsided without
Clinical Records. 445
treatment. He was discharged in 48 hours, in a normal con¬
dition.
Case IV. (No. 50 in Hospital Ca:se Book). — 'Mrs. - , an
English lady, aged 50, the mother of several grown-up children,
was brought into the Home Hospital by her friends on the 9th of
May. She was much emaciated and was suffering chiefly from mel¬
ancholia and insomnia with occasional illusions. She had been
drinking wines of all sorts and beer in large quantities for nearly
three weeks. During the three days before her admission her
friends had managed to prevent her having her usual drinks,
but she resorted to eau-de-Cologne and methylated spirits, drink¬
ing about a quart of each every day. The melancholia had ap¬
peared since she resorted to the spurious drinks. She was
treated on the above lines, and within 48 hours she slept well, and
was cured within five days, being discharged on the 14th of May.
Case. V. (No. 53 in Hospital Case Book). — Mr. - , an
Englishman, aged 30, in the best of health organically, was ad¬
mitted into the Home Hospital on the 14th of May with delirium
tremens. There was no accommodation for him in the special
department, so he was placed in the surgical room ton the third
floor. He had been drinking very heavily for six weeks and im¬
bibed two squares of gin each day. His friends, who brought
him to the hospital, stated that he had twice tried to commit
sucide by jumping over-board the steamer that brought him to
Calcutta. He was placed in charge of a special nurse, with two>
strong male attendants to keep watch over him. An hour after
admission be became exceedingly boisterous, and was terrified
by the ugliest possible spectres and illusions. He rushed franti¬
cally out of his room and was about to throw himself over the
balustrade of the terrace, but he was quickly chased and pre¬
vented. A dose of bromide, cinchona and capsicum mixture was
given him, and he was coaxed to his bed, when he was steadily
massaged for an hour, after which he' took a cupful of milk gruel.
Two hours later a second dose of mixture was administered and
he was again massaged. He slept for half-an-hour, when he woke
up suddenly as though stricken with terror, rushed out of the
room, and made a second attempt to throw himself over the ter¬
race. His attendants soon had him in hand, and he was brought
to bed and the doors of his room were then closely barred. The
mixture was given every four hours ; he was fed with milk
gruel every two hours ; he was massaged every four hours. He
446
Clinical Records.
was wakeful and excited about all sorts of imaginary objects
which kept him from sleeping till 3 a,m„ He then dozed off,
and did not wake till 8 o’clock. This condition of mental
and nervous excitement and timidity lasted for three days, gradu¬
ally lessening each day, but after1 tne first day he had spells of
sleep for two or three hours, with a similar period of wakefulness.
The effect of the treatment, especially the massage, was most
remarkable in this case. It seemed to have a marvellous in¬
fluence in allaying mental fear, and it seemed as though the
effect was chiefly of a moral character, because as long as it
lasted the patient appeared to feel that he was protected, and
that he was safe from the imaginary enemies that' tortured him
in so real a fashion. The patient was eight days in hospital, and
was discharged on the 20th of May, though he was really well
enough to be left alone on the fifth day after his admission.
Case VI. (No. 69 in Hospital Case Book).— A young unmarried
Irish lady, aged 25, was admitted into the Home Hospital on the
23rd July for delirium tremens. She was otherwise in good
robust health. She had been drinking for nearly two months,
indulging chiefly in champagne and liqueurs. She had. not slept
for four days. She was in a state of wild horror from the
presence of spectres. Bromide, cinchona and capsicum mixture
was given her every two1 hours. She took her nourisiiment
(milk gruel and soup) fairly well, and permitted massage to> be
performed regularly every three hours. It was remarkable' how
calm and uninfluenced by fear she was during the process of
massage, but became terrified immediately it was stopped. For
twenty-four hours she did not sleep, but after that she dozed for
an hour or two at a time. The second, third and fourth days
of treatment found her1 better each day, and on the fifth, day
all cerebral and nervous excitability had subsided.
Remarks. — These cases form a fairly instructive series with
varied symptoms, identified with the definite stages of alcoholism.
All were treated alike, except in the matter of lessening' the inter¬
val of dosage', both of medicine and massage, to' cope with the
intensity of the alcoholic manifestations. I believe they suffi¬
ciently illustrate a, plan of treatment that' may be relied upon as
promising fairly uniform successful results. I look upon the
administration of massage in such cases as, a very powerful ad¬
juvant in the therapeutics of alcoholism, largely on account of
Clinical Records. 447
its moral effect on the tremulous and unstable condition of the
central organism.
Old Standing Middle Mar Disease , giving rise to Cerebral Symptoms.
Operation on Mastoid Cells: Relief. By James R. Wallace,
M.D., F.R.C.S.I. ; Surgeon to the Home Hospital, Calcutta.
S. S., an Anglo-Indian, aged 22, married, had suffered from
auricular trouble from infancy, the sequel of measles. Beyond
a continuous discharge' of muco-purulent: matter from the left ear,
more copious at times than at others, there were no> symptoms
to cause distress or anxiety till about a year before admission into
the Home Hospital. I was then consulted about certain cerebral
symptoms, such as sudden giddiness, with transient staggering
gait, attended by nausea and headache, and distinct pain, located
in the left mastoid region. Buzzing and whirling sounds were
also complained of on the affected side. The first; of these un¬
pleasant manifestations occurred after a bath in the river, when a
good deal of diving and swimming were done. With free pur¬
gation, the administration of small doses of iodide of potassium
and icinchonai, and the inunction of biniodide of mercury with
belladonna behind the ear and over the mastoid cells, and by
packing of the auditory canal with iodoformised cotton, the
symptoms rapidly subsided. Two or three months later there
was a repetition of the attack, and it was relieved by similar
means. About three months before admission into the hospital
these attacks became more frequent and more severe, and I sug¬
gested the operation of opening the: mastoid cells:. About this
time the discharge from the ear became distinctly offensive and
sanguino-purulent. The general health was good, and this was
indicated by the patient’s appearance. About the middle of
November there' wa-s: a very marked aggravation of the' cerebral
symptoms, the pain in the: mastoid region became severe and
was attended with a sense of throbbing. There was marked
hemicrania, nausea, faintness and a good deal of facial pallor. I
advised a consultation with Colonel R. Havelock Charles, I.M.S.,
and Dr. Caddy, and as a result the operation was decided upon.
The patient was admitted into the Home Hospital on 20th of
November, 1898, and after a day’s rest in bed he was
subjected to the operation on the 21st of November. He
was chloroformed by Dr. Feldstein, while Doctors Coulter
and Caddy assisted me at the operation. I made a
448
Clinical Records.
two inch semilunar incision parallel with the free border of the
auricle, commencing above and terminating near the apex of the
mastoid process. I dissected the flap after cutting through the
periosteum, and carefully peeling it off the bone1. I removed the
outer osiseous table with hammer and chisel. Having done' so, the
gouge was used, till the whole Of the cancellous tissue of the
mastoid cells was removed, and the internal auditory meatus
reached. The cancellous tissue was a good deal necrosed, but
the bony structure adjoining the meatus was extremely hard
and eburnated, so that gouging became very difficult indeed.
The air-cells were' not seen in the position where they are usually
met with. Having created a free channel of communication
from the mastoid to the external ear, the wound, after thorough
cleaning, was accurately (sutured with horse hair. The patient
bore chi or form well, and the operation afforded complete lelief
to all the distressing head symptoms. He slept well, took his
nourishment nicely, and the wound healed by first intention
in about a week. The subsequent progress of the case was
satisfactory, and though the patient left the hospital on the
9th of December and was doing well for some days after, while
I attended him at his home, he was finally placed under Dr.
Caddy’s care.
The points of interest in this case are, its association with
measles in infancy, the grave and sudden risk brought on by a
septic condition of the discharge, and the immediately beneficial
results of the operation.
Hereditary Syphilis in an Infant resembling Cretinism, cured
by Mercury. By James R. Wallace, M.D., F.R.C.S.I., Surgeon
to the Home Hospital, Calcutta.
J. T., an Anglo-Indian male child, aged 6 months, well nourished,
being nourished by the mother, was admitted into1 the Home
Hospital on the 9th of November, 1898, suffering with characteristic
symptoms of inherited syphilis. There were condylomata about
the anus, scrotum, and angles of the mouth, and all the general
appearances of cretinism. There was a vacant, imbecile appear¬
ance about the face, the eyes were large and bulging, the fore¬
head bulged prominently, the fontanelles were large and gaping,
and the whole head had the appearance of being hydrocephalic.
The hands, up to an inch beyond the wrists, were swollen, not
by oedema, but by what was undoubtedly perioisteal thickening of
Clinical Records.
449
the phalanges, carpus and metacarpus. No other part of the
bony system was similarly affected’. The child’s organs were
apparently healthy. For a fortnight previous to going into* the
hospital, the child had had “ fits, ” and it was for the treatment
of these fits that the mother consulted me. They had occurred
daily and some times twice daily, from the date of their first ap¬
pearance. Within an hour of its admission into hosptal the
child was attacked with one of these paroxysms. It uttered a pec .1-
liar cry of pain, the face was fear-stricken in appearance, a distinct
but short convulsion followed, in which the upper and lower limbs
were equally involved ; there were facial twitchings and distor¬
tions, followed by utter prostration for about fifteen minutes, with
complete unconsciousness. I watched the fit from beginning to
end, and came to the conclusion that it was due' to the presence
of fluid in the ventricles of the brain, dependent upon a tubercu¬
lar or syphilitic taint. The mother bore evident signs of syphi¬
litic infection, in the form of psoriatic onychia. I have seen but
two cases of cretinism in Calcutta, where I have now practised
for lover 20 years. Both were the children of English parents in
good circumstances. Both cases were: treated as suspicious of
hereditary syphilitic contamination, and mercurials were given
internally and externally wth good effect. One case occurred
about ten years: ago, and the little boy referred to' is now living
and fairly well, though he is a weak sample of humanity. The
second case occurred about six years ago. In addition to
mercurials, he was given small doses of thyroid extract. He
completely recovered, but died about a year ago' from cholera.
The present case so closely resembled the two just quoted, that
I would be inclined , to describe it as an instance of cretinism
associated with congenital syphilis. In the present case calomel
in b grain doses was given once daily and mercurial ointment
with lanolin, in the proportion of 1 to 7, was rubbed freely over
the whole caput and into the affected hands and forearms. A
mixture containing one grain of iodide and two of bromide of
potassium in sweetened cod liver oil was given twice daily. The
mother’s nourishment was disallowed. There was no difficulty
in weaning the infant, and it seemed to thrive better on milk
and gruel. A fit occurred each day for three days, and then
there were no more. The child was detained in hospital for
eleven days. Its appearance had much improved, especially in
the matter of looking more intelligent. The head had visibly
diminished in size. The bowels, which had been constipated for
two months, had now become quite regular, and the child was
2 F
450
Clinical Records.
taking its food well and sleeping well. For a month, later I saw
the child weekly. The treatment a® above described was con¬
tinued with remarkable efficacy. Up to the1 present, time, after a
period Of ten months, the child seems practically quite well.
I do not of course attempt to. confuse hereditary syphilis with
cretinism, but I record this case as peculiar in the matter of the
interassociation of cretinism vrith congenital syphilis, especially
as I have come across two1 other1 cases of a similar type, and
therefore the experience is instructive!.
MEDICAL BOOK-KEEPING WITHOUT BOOKS.
Dr. Thomas Nelson describes (j Birmingham Medical Review ,
September, 1899) a method of keeping medical accounts by means
of the card system. The cards serve as a visiting list, a record of
home work, and a ledger. They are distinguished by colour, and
are arranged in compartments numbered according to the days of
the month for “live” cards (f.e. those referring to cases under
treatment), afterwards they are passed into an alphabetical series
which can be easily referred to for sending out accounts or marking
their payment. Paid off accounts move to another case, so the
three series represent “live” cards, account owing cards, and paid
cards. Brief notes can be entered on the cards, so that in their
last stage they also form case cards.
PNEUMOTHORAX FROM GAS-PRODUCING BACTERIA.
Dr. F. Gf. Finley reports ( Montreal Medical Journal , Oct., 1899)
a case of pneumothorax, due to gas production by the Bacillus coli.
The production of gas followed the rupture of a sub-diaphragmatic
abscess into the pleura.
THE TREATMENT OF ASTHMA.
Von Noorden {Miinchener med. Wochenschrift , September 27, 1898)
recommends atropin, which was introduced by Trousseau. Begin¬
ning with 2^-q gra’n °f atropin, the dose is increased to yy grain
after two or three days. After the maximum of grain is reached,
the dose is gradually reduced, the whole course lasting four to six
weeks. Constant medical supervision is necessary, but no evil
effect is observed, if the drug is given in this Avay. Though
atropin does not influence the severity of the attacks, it lengthens
the intervals between them very considerably, and, though it may
not cure, causes lasting improvement, unless the case is complicated
by emphysema or chronic bronchitis.
ROYAL ACADEMY OF MEDICINE IN IRELAND,
President— Edward H. Bennett, M.D., F.R.C.S.I.
General Secretary— John B. Story, M.B., F.R.C.S.I.
SECTION OF STATE MEDICINE.
President— H. C. Tweedy, M.D.
Sectional Secretary — Ninian Falkiner, M.B.
Friday, April 28, 1899.
The President in the Chair.
Room Disinfection , with Special Reference to the use of Formic Aldehyde .
By Drs. Littledale and Kirkpatrick.
[These communications will be found at pages 414 and 420
respectively of the number of the Journal for June, 1899 Yol
CVIL]
Dr. Ninian Falkiner, reviewing the action of chemical disin¬
fectants, said they acted in three ways — by “ oxidation, direct or
indirect, reduction, or by coagulation of albumen. ” Referring
to the manner in which the disinfecting action of the formalin
vapour stops at a clearly defined line in the culture tube, it suggests
that the limit was caused by a chemical change in the vapour
itself, produced by its action as a chemical oxidiser, it being
reduced to the condition of an alcohol.
Dr. Knott was inclined to believe that the stoppage of penetra¬
tion at a certain line in the culture tube was due to eddying
currents generated by the disinfectant, and that the explanation
was physical rather than chemical.
Dr. H. C. Tweedy said that anyone working much among the
poor knew the great objection they had to disinfection as carried
out at present ; a more effective and less disagreeable process was,
therefore, much to be desired.
Dr. Littledale, replying, said the penetrating action of the
vapour appeared to be inversely proportional to the vitality of the
bacteria a point which seemed to favour the suggestion made by
Dr. Ninian F alkiner . Their experiments had not given formalin
an exhaustive trial, as they had used a very weak gas.
452 Royal Academy of Medicine in Ireland.
Dr. Kirkpatrick pointed out that amongst the advantages
which formalin had over other gaseous disinfectants was the ease
and rapidity with which it could be used. The result did not
depend so much on the length of time objects were exposed to the
gas, but rather on its initial force. Six or seven hours would be
sufficient to thoroughly disinfect with this vapour, and on opening
the doors and windows after this the smell at once disappeared,
which was not the case with sulphurous acid or other gaseous
disinfectants.
Cancer in Ireland.
Dr. Hartley read a paper on cancer in Ireland. After con¬
trasting the deaths from cancer in Ireland and England— the
former rate being roughly only 70 per cent, of the latter— he
illustrated by maps its very unequal incidence in different localities,
the parts most affected being the east of Ulster, Dublin, and Carlow.
In conclusion he moved a resolution that the Academy should
appoint a committee to investigate the distribution of the disease
in Ireland.
Dr. T. W. Grimshaw, C.B., Registrar-General, in seconding
the resolution, remarked that the maps which were before them
showed that cancer was prevalent in the most anglicised parts of
the country ; for example they might look at Carlow, which they
knew to be an old English colony, and Dublin, containing a large
proportion of the population of English descent. Registration was
not as long in vogue in Ireland as in England, and consequently
the returns were less reliable, as they had often to trust to memory
for the ages of middle-aged people. Dr. Haviland had noted the
fact that cancer prevailed where there were sluggish rivers of con¬
siderable size and liable to overflow their banks, but they were
ignorant as to the exact bearing this fact had on the occurrence of
the disease.
Dr. John W. Moore, President R.C.P.I., explained the pre¬
ponderance of cases in Dublin and Belfast by the fact that in
country districts the doctors were often reluctant to give cancer as
a cause of death, owing to the existing dread of the disease, on
account of its hereditary nature ; also the diagnosis of cancer was
usually verified in the city hospitals by a necropsy, which was not
the case in the country ; in addition Dublin and Belfast received
cancer patients from all parts of the country.
Dr. Knott also spoke.
The resolution was adopted by the meeting.
The Section then adjourned.
Section of Obstetrics.
453
SECTION OF OBSTETRICS.
President — F. W. Kidd, M.D.
Sectional Secretary— John H. Glenn, M.D.
Friday, May 26th , 1899.
The President in the Chair.
Specimens.
Dr. A. Smith showed myomatous uterus showing large abscess cavity
removed by panhysterectomy. This specimen was removed from a
woman aged forty, five years married, during which she had given
birth to two stillborn children and an instrumentally-delivered full
term child last December. The tumour was then a little larger than
a four months pregnant uterus, and had since then grown rapidly, so
that in the April of this year it filled up the entire abdomen. It
was diagnosticated as a fibro-myoma of a cystic nature. He (Dr.
Smith) attempted to do the operation of primary ligation of both
the ovarian and uterine arteries, and found no difficulty in ligating
the ovarian artery, but could not do so in the case of the uterine
artery, owing to the weight of the tumour (2J stone) fatiguing his
assistant. He, therefore, decided to split the peritoneum in front
high up, and to separate the bladder with a sponge. The bladder
was so soft that in doing this he perforated it. He then dis¬
covered that the common iliac artery seemed to take the place of
the uterine artery, and on separating it there was some haemorrhage,
which was checked by compression of the aorta. He amputated
the uterus, and, while removing the tumour, damaged the ureter,
which he clamped temporarily. The bladder was afterwards
stitched with fine interrupted silk sutures, and the ureter treated
in the same manner, the peritoneum being finally stitched over it.
A large clot of blood which had collected in the bladder was
washed out with a Bozeman’s catheter, and the patient made a
good recovery. The cystic contents of the tumour were found
to be an abscess, which had started from the last confinement, the
woman having then had septic troubles.
The President (Dr. F. W. Kidd) observed that complete re¬
covery after one of the most dangerous complications — namely,
injury to the bladder and ureter, with haemorrhage— was gratifying.
Dr. Purefoy asked if there was anv marked alteration in the
size of the tumour during the few weeks succeeding the confine¬
ment.
454 Royal Academy of Medicine in Ireland.
Dr. Smith, in replying, said the patient a few years ago had
been in a Dublin hospital, where a diagnosis was made by making
an abdominal incision, but they did not operate, the patient then
becoming pregnant again. So rapidly did the tumour grow that it
gave the impression of an ovarian tumour.
Tuberculous Ovary removed by Abdominal Section.
Dr. Smyly showed a specimen of tubercle of the ovary, also a
microscopic section of the same. Until quite recently such a con¬
dition was unknown, but Martin, in his recent work on diseases of
the ovaries, states that 184 cases have been recorded in recent
years, so that the disease is not so rare as had been supposed. As
a primary affection, however, it is extremely rare, three cases only
having been recorded by Edmonds, Jacobs, and v. Franke, but even
these are doubtful. The patient was aged twenty-eight, and had
been married two years. She enjoyed good health until shortly
before marriage, when she had influenza, from which, however,
she completely recovered. About Christmas, 1897, she began to
feel ill, and had gradually got worse. I first saw her in April,
1899. She complained of always feeling tired, and seldom left
her bed before mid-day, had profuse night sweats, and had steadily
lost weight — 18 lbs. in the last twelve months. She was greatly
emaciated, had the appearance of a person in advanced phthisis,
and had not menstruated for seven months. She had no cough,
nor any physical signs of pulmonary disease. The abdomen was
somewhat distended, and a small tumour could be detected in the
left inguinal region, which, upon bimanual examination, proved to
be the uterine adnexa of that side. The uterus and right append¬
ages appeared to be normal.
Diagnosis.- — Tubercular disease of left uterine adnexa, probably
the tube, and tubercular peritonitis.
Operation. — On opening the abdomen no general tubercular
disease was found. There were, however, dense pelvic adhesions,
but no visible tubercles. Both tubes were found diseased, the
right being about as thick as an ordinary pencil ; the left, some¬
what larger, lying upon an ill-defined mass about the size of an
orange. When freeing the right tube it burst, and some pus
escaped, but it was removed, with the accompanying ovary, with¬
out difficulty. The tumour on the left side had developed in the
meso-recium, which was intimately connected with it, passing over
it from left to right, and then down behind it. The peritoneum
was opened in front of the rectum, and about a quarter of an inch
455
Section of Obstetrics.
from it, but in attempting to detach the latter, though the greatest
care and gentleness were used, the finger penetrated the gut.
Keeping the huger ends in contact with the tumour, it was
enucleated without difficulty, brought up out of the pelvis, and
removed with the tube in the ordinary manner. Upon examining
the cavity left, however, it was discovered that the entire anterior
wTall of the rectum was wanting as far down as the reflexion of the
peritoneum. After consultation with Dr. Gordon, who assisted at
the operation, it was decided that an ordinary enterorrhaphy offered
small prospect of success, not only because of the extent of the
injury, but also because of the condition of the surrounding struc¬
tures. It was, therefore, determined to resect the injured portion
of bowel, and about two inches having been removed, two ligatures
w7ere inserted, one on either side of the lower end of the upper
portion of the bowel, and by means of these it was drawn down
into the lower portion, and secured there by a double row of
sutures. Having sponged out the pelvic cavity, and packed the
sutured portion around with iodoform, gauze, the ends were brought
out at the lower angle of the abdominal incision, the rest of which
■was closed in the usual manner.
The patient suffered severely from shock, but improved some¬
what towards evening. Next day, however, she was not so well ;
the pulse was very rapid and weak, and the surface bedewed with
cold, clammy sweat. During the night vomiting set in, with
violent abdominal pains, and Dr. Smyly was summoned to her
early in the morning. She had then violent abdominal pains, with
evident peristaltic movements of the intestines, but no flatus had
escaped. There was constant vomiting, no radial pulse could be
felt, and her arms were cold up to the elbows. An endeavour to
reach the constrictor per anurn failed. Dr. Gordon saw her in
consultation at 9 a.m., but as the wound presented an unhealthy
appearance, and could not be used to form an artificial anus, and
as it was evident that to have opened the abdomen in another
position it would have proved immediately fatal, it was decided
that nothing further could be attempted. During the day she
gradually became worse, and the vomit assumed a faecal character.
Shortly after midnight, however, she took a turn for the better,
passed flatus, and shortly after a faecal motion ; pains and vomiting
ceased, and she took and retained nourishment. Since then she
has steadily improved, takes her food well, and is putting on flesh.
A considerable but steadily decreasing quantity of faeces, however,
escapes from the abdominal wound. The specimen under the
microscope shows giant cells and caseation.
456 Royal Academy of Medicine in Ireland .
Dr. Kidd exhibited a small ovarian papillomatous cyst, with the
following interesting history : — Patient, T. C., unmarried, aged
thirty-five, was admitted to the Coombe Hospital on the 5th of
May. She had been treated about a fortnight previously in the
country for obstruction of the bowels and peritonitis ; this had
yielded to treatment. After arrival she was examined, and a small
ovarian tumour diagnosed. Operation on the 13th. Tumour was
adherent to everything — omentum, peritoneum, and intestines, but
the adhesions were comparatively recent, and could be separated
with a little care. Part of cyst wall looked gangrenous, and when
the adhesions were all separated it was found that there was a
twist on the pedicle ; it required two half turns to put the tumour
in its proper place. Patient made a very rapid recovery. Tem¬
perature only on one occasion touched 99° F., and stitches were
removed on the eighth day. Union was perfect.
Myomatous Uterus removed by Abdominal Hysterectomy ■ Doyens
Method.
Dr. Smyly said this was the first time he had resorted to this
method of operation, which, he believed, had never before been
attempted in this country. The operation wras performed for pain,
and on opening the abdomen he found adhesions to the omentum
and small intestines, in separating which there were a large
number of bleeding points to control. This portion of the opera¬
tion occupied three quarters of an hour. Doyen’s part, which took
seven minutes, commenced with pulling the tumour out of the
abdomen over the pubes. He then opened the posterior cul-de-sac ,
reached hold of the cervix with a vulsellum forceps, and decorti¬
cated it with his finger, afterwards reflecting the peritoneum from
the uterus, and finishing the operation in the ordinary way. He
had no hesitation in saying this w7as by far the best method.
Besides rapidity it had other advantages, for in the older method
they cut the arteries where they are largest, thereby running the
risk of death from embolism or haemorrhage. As a matter of fact
he did not see a big vessel at all during the operation.
The President said he had seen the cinematographic representa¬
tion of the operation in Edinburgh, and he w7as amazed at the
celerity with which an operation of such magnitude could be per¬
formed.
Dr. Tweedy asked if the operation were applicable to every
form of myomatous uterus. Was it applicable where the myoma
grows behind or in intra-ligamentous tumours ?
Section of Obstetrics. 457
Dr. Smyly, in reply, said that Doyen specially recommended this
operation because he believed it to be applicable to all cases.
Polycystic Ovarian Tumour.
Dr. Kinkead read a paper on the above disease.
Dr. Smyly expressed surprise that tapping should have been re¬
sorted to by those having charge of the case before Dr. Kinkead.
He was of opinion that any medical man who tapped an ovarian
cyst should be liable to prosecution for malpractice. The Spencer
Wells trocar was one of those instruments which were quite use¬
less, and it was impossible to keep it aseptic. The muscular coat
which covered the front of the tumour, he thought, might have been
the broad ligament.
Dr. Knott related the case of a young woman suffering from a
rapidly growing tumour. She was tapped, as they were very chary
of performing ovariotomy in those days. The patient died finally
of slow suffocation, and the necropsy, at which he was present, re¬
vealed a polycystic ovarian tumour extending up into the thorax.
Dr. F. W. Kidd said he was called into consultation in a case of
a very large ovarian cyst, and to relieve dyspnoea and to benefit
the puerperium, the patient having been recently delivered, he
advocated tapping, cautioning, however, the medical man in attend¬
ance that this was only a palliative measure. Over 30 pints of fluid
characteristic of an ovarian cyst were withdrawn. He was able to
state that the cyst did not fill again, and that the patient had com¬
pletely reeovered.
Notes on a Successful Case of C cesarean Section.
Dr. F. W. Kidd (President) read notes on this subject. The
case presented many points of interest. It was not done for
contracted pelvis, but for a large growth which sprang from the
posterior portion of the cervix. When seen at first this tumour
was drawn up to such an extent that at first it seemed possible to
push up the cervix ; however, this method proved quite ineffectual.
Patient was aged thirty-two, and was a primipara; was visited at
her house on the 3rd December. Tumour was then diagnosticated,
and patient brought into hospital. A thorough examination was
made, and as the patient had had labour pains it was determined
to operate at 1 a.m. on the morning of Sunday, the 4th December.
Every antiseptic precaution was taken, and on Dr. Stevens
devolved the duty of attending to the child when born. I was
assisted by Drs. Heuston, Cole-Baker, and Scully. Incision was
458 Royal Academy of Medicine in Ireland.
about 2 inches above and 4 below umbilicus, placenta, which was
huge (11 inches by 7), was on anterior wall of uterus, and to
right, and directly under incision in wall of uterus, so that it had
to be dissected off towards left side for an inch or two. Then
there was difficulty in getting lower extremities of child. Finally
one was extracted before the other, with the result that the incision
in uterine wall was ruptured at top end for a further two inches
in an oblique direction. Membranes were unruptured at time of
operation. The uterus did not immediately contract, and the
bleeding was very considerable. Uterus was sutured with deep,
strong silk sutures, going down to but not involving mucous mem¬
brane, with alternate superficial sutures of a finer silk drawing
peritoneum well over line of incision, parietal peritoneum drawn
together with continuous suture of fine silk, and abdominal incision
closed with silk-worm gut sutures. Convalescence was somewhat
protracted on account of an attack of bronchitis and the severe
haemorrhage ; however, the temperature never reached 100° F.,
and the patient made a remarkably good recovery. The child,
which was a male, was born partly asphyxiated, but under the
care of Dr. Stevens, who Schultzed him, he came to, but never
cried lustily. He died on the third day ; had had a slight convul¬
sion the preceding day ; his muscles had seemed continually to be
tense, and he had vomited coffee-ground vomit. There was an
autopsy, which only revealed some intussusceptions of small
intestine, probably caused during the death agony, and some
haemorrhage at lower end of the oesophagus. This gave rise to the
interesting question as to whether this could have been done by
the Schultzing, even when in experienced hands. The stitches
were removed on the eighth day, when the incision was found
perfectly healed. Before the patient let t the hospital a careful
examination of the tumour was made. It had come down into the
pelvis, and seemed so near that one was tempted to remove it by
morcellement through the vagina. However, it was found that
the uterus was adherent to the anterior abdominal wall, and this
procedure was thrown aside owing to the expressed opinion of Dr.
Smyly that if it were done, and haemorrhage should occur, one
could not check it by drawing down the uterus due to its adhesions.
It was decided that the operation should be done from abdomen ;
however, the patient refused operation. Her present condition is
splendid, she suffers in no way, and the line of the incision is
perfectly even and firm.
Dr. Smyly remarked that every step of the operation, though
459
Section of Obstetrics.
apparently a simple one, was the subject of controversy. Professor
Murdoch Cameron, of Glasgow, has said that the position of the
child depended on the placenta, and he would like to know if this
opinion was borne out in this case, and if the abdomen of the child
was turned towards the placenta.
Dr. Purefoy said that, though a recent writer had advocated
the low incision in preference to the fundal incision, his own ex¬
perience had led him to think that the high incision was certainly
the better. He thought that the careful application of the sutures
and adjustment of the peritoneum had a great deal to do with the
success of a case. He had always regarded Schultzing with mis¬
givings, owing to the possibility of injury to the soft parts of the
child.
Dr. Tweedy did not see the necessity of avoiding insertion of
the ligatures right through the endometrium if the uterus were
aseptic, and this method gave a firmer union in his opinion. Lusk
says that an incision is made low down in the uterus in order to
avoid haemorrhage, whereas it has been recently claimed that an
incision through the fundus, the most muscular portion of the
uterus, obviates much haemorrhage.
Dr. Kidd, in reply, said the child was very nearly in the left
occipito-anterior position, and the placenta was more over to the
right of the mother. He was not opposed to Schultzing, and he
thought that Sylvester’s method was far more likely to cause
haemorrhages. With regard to the question of suturing, he had
no guarantee that the uterus was aseptic in this case.
The Section then adjourned.
460
Royal Academy of Medicine in Ireland.
SESSION 1899-1900.
SECTION OF PATHOLOGY.
President — A. C. O’Sullivan, M.D.
Sectional Secretary — E. J. McWeeney, M.D.
Friday, November 3, 1899.
Dr. E. H. Bennett, President of the Academy, in the Chair.
Pathological Eyes.
Mr. Arthur H. Benson and Dr. H. C. Earl exhibited a series
of Pathological Eyes, Half Globes (mounted in formalin), and
Microscopic Sections.
(a) . Glioma was the only tumour originating in the retina. It was,
perhaps, the most malignant growth occurring in the human body,
and the prognosis was favourable only when removal was carried out
early. It was essentially a disease of infancy and early life, and
might even be congenital. It was usually monocular, and never
pigmented. The specimen was from a child aged four months.
It was now seven months since the operation, and so far no re¬
currence had taken place.
( b ) . The second case (sarcoma of choroid) was that of a boy
aged three years. On admission a fungating mass, the size of a
duck’s egg, was protruding from the right orbit. This contained
the remains of the globe, and filled the orbit. Removal of the
whole contents of the orbit was performed, but it was found that
the orbit back to the posterior foramen was completely filled witli
the growth, and the optic nerve was so disintegrated that no trace
of it was visible to the naked eye. As the growth could not be
entirely removed the prognosis was bad, and recurrence did
actually take place a month after the child’s return home.
(c) . The third specimen (epithelioma of cornea and conjunctiva)
was taken from a man aged sixty-nine. The whole cornea and
part of the ocular conjunctiva were covered by the growth, which
was so extensive, and seemed to penetrate so deeply into the sub¬
jacent tissue that he (Dr. Benson) felt sure it could not with safety
be excised, and that enucleation gave the man the only chance.
The tumour was unpigmented, flat, and sessile, with a veiy bioad
base, and had ulcerated.
(cT). Bony degeneration of choroid in a woman aged fifty. She
had had a diabetic cataract removed from one eye in 1898. The
other eye was collapsed and blind since childhood, the lesult of an
461
Section of Pathology .
accident. It was irritable and painful to the touch, and, as it was
believed to be the source of irritation in consequence of possessing
a bony choroid, it was removed. The choroid was found converted
in its whole extent into a layer of true bone. The lens was calcified,
not ossified.
(c.) Intra-ocular haemorrhage. Patient, aged forty-five, gave
history of cataract of right eye of four years’ duration. During
the last three months the pain in the eye had been very severe, and
one month ago a large haemorrhage occurred, which filled the
anterior chamber, and the pain became constant and intolerable.
The tension was about — 1, and the globe had the appearance of a
shrinking one. Enucleation was performed. No cause for the
haemorrhage (which probably came from the iris) was found.
(/). Collapsed globe, after cataract removal, in a woman on
whose left eye a combined extraction of an opaque lens was per¬
formed. An asthenic suppurative cyclitis resulted, the globe
shrank, and vision was lost in the eye. Seven and a half months
after the globe was collapsed, and the right eye had a condition
very suggestive of sympathetic ophthalmitis — serous iritis, keratitis
punctata, pupil fixed, tension normal, and slight circumcornale
vascularity. The lens was opaque, and no illumination of the
fundus could be obtained. There was no pain. As the shrunken
left globe was believed to be the cause of the trouble in the right
eye enucleation was performed. Four days later the patient
became delirious. She continued in a low state, and thirteen days
after operation refused food altogether, and the bowels acted
involuntarily. No organic lesion could be found, and she died
sixteen days after operation.
Mr. Henry Gray Croly said he thought that one could not be
certain that sarcoma would not return until a period of ten or,
perhaps, eighteen months had elapsed. He thought that in the
fatal case the woman’s death was due to septicmmia.
Mr. Benson, replying, said he did not mean to convey that a
case of sarcoma would be safe at the end of seven months. He
had merely said that his case of glioma of the retina was safe up
to the present — seven months after the operation. With regard
to the other case, it was quite conceivable that the wom^p died
of sepsis, but at the time he did not think it at all probable.
Exhibitions.
Mr. Henry Gray Croly exhibited (1) fracture of the base of
the skull ; (2) sarcoma of testis. The fracture of the base of the
skull was the most perfect he had ever seen. It extended through
462 Royal Academy of Medicine in Ireland.
the petrous bone, body of sphenoid, and ethmoid. The man was
found on the road in a pool of blood, and was carried to hospital
in a collapsed state. There was great haemorrhage from both ears.
He recovered consciousness sufficiently to say that he felt himself
better. He lived for three days. There was no lesion of the
brain, and no haemorrhage into the brain. There was no fracture
of the vault of the skull.
The President remembered a case of fracture of the skull in
which the occipital and frontal regions could be moved on each
other. The man recovered completely.
Mr. Croly, in reply, thought the case mentioned by the Presi¬
dent was one of fracture of the vault of the skull. Men recover
occasionally from fracture of the base of the skull. In this case
the remarkable fact was that the man lived so long.
Dr. Knott showed some specimens of fractured humeri. In
connection with one showing fracture of the lower end of the bone,
he drew attention to the fact that the epiphyseal line of the lower
articular surface of the humerus does not involve the condyles.
The President concurred in the diagnosis of one of the speci¬
mens as a fracture passing obliquely through the elbow-joint, as it
had none of the features of an epiphysary displacement.
Mr. Croly, referring to one of the specimens, pointed out a
fact which he thought a great many did not know, and which
Robert Smith had drawn particular attention to — namely, that
epiphysary fracture of the upper end of the humerus included the
tuberosities. He (Mr. Croly) in teaching fractures of the upper
end of the humerus impresses on his pupils that there are two
fractures of the surgical neck, one being epiphysary below the
tuberosities, one lower down in the surgical neck. The line of
fracture through the anatomical neck is above the tuberosities.
Speaking of the specimen to which Dr. Bennett had drawn attention
he would certainly say it was not an epiphysary fracture, since
the condyles here were carried forwards instead of backwards,
which they knew was distinctive of epiphysary disjunction.
Dr. Knott, in reply, said that the epiphysary line at the upper
end of the humerus was always exactly horizontal. In addition
to the observation Mr. Croly had made that from the action of the
tricep? it would be almost necessary that there should be a back¬
ward displacement in epiphysary disjunction of the lower end of
the humerus, there was also the point that his specimen involved
the external condyle, which it would not do if it were an epiphy¬
sary disjunction, as the external condyle did not belong to the
epiphyses, but to the shaft.
The Section then adjourned.
Section of Medicine .
463
SECTION OF MEDICINE.
President— John W. Moore, M.D., President of the Royal
College of Physicians of Ireland.
Sectional Secretary — R. Travers Smith, M.D.
Friday , November 17, 1899.
The President in the Chair.
A Case of Cerebrospinal Disseminated Sclerosis (Patient exhibited)..
Dr. Craig- exhibited a man, aged thirty-four, suffering from
insular sclerosis, and demonstrated as far as possible the classical
symptoms of that disease as first described by Charcot — (1) There
was defective vision, o.d. T6^, o.s. -fg ; the field of vision was not
contracted ; the optic papillae had a dirty white complexion ;
there was nystagmus and defective power of consensual, lateral,
and upward motion of the eyeballs. (2) Intention tremors were
very evident. (3) Scanning speech was fairly characteristic.
(4) A spastic condition of the lower extremities existed, with
increased knee-jerks, rectus and ankle-clonus, weakness and
rigidity of the muscles, and the “toe phenomenon ” of Babinski.
(5) Considerable delay precedes the act of micturition.
The next case referred to was a boy, who, at the age of nine,
was found to be blind of the right eye, with atrophy of the disc, *
which seemed to Dr. C. E. Fitzgerald to be congenital. Right
eye was normal. Three years after the lower extremities became
spastic, tenotomy was performed in London to correct the talipes
equino-varus, and shortly afterwards the sight was lost in the
right eye. Nystagmus, intention tremors, and slow, monotonous
speech had all developed. A probably specific origin, the youth of
the patient, the completeness of the optic atrophy, and the surgical
interference were the points of interest.
The third case mentioned was that of a young lady who, at the
age of seventeen, developed symptoms of an apparently hysterical
character.
In 1882 there was transient blurring, defective vision, with
hazy disc in the right eye, and recovery in a month.
In 1884 left optic neuritis, with right hemiparesis, occurred,
followed by recovery within a few weeks.
464 Royal Academy of Medicine in Ireland.
In 1885 there was again transient dimness of the right eye.
In 1888 there was transient blurring in both eyes, but discs
were normal.
In 1889 there was transitory blurring in left eye, with vision
and discs normal.
In 1890 there was numbness in right leg, weakness in both, giddi¬
ness, diplopia, blurred vision, defective lateral movement, and, for the
first time, nystagmus in the left eye. Delay preceding micturition,
with excessive secretion of urine, was noted.
In 1891 there was apparently complete recovery from all the
symptoms, save very slight nystagmus. Patient felt quite strong
and well.
In 1896 patient became unsteady in walking, and was easily
fatigued; knee-jerks were increased, but no ankle-clonus and no
tremors existed. Diplopia, blurred vision, and nystagmus were
present. Physical disturbances and slight blunting of mental
faculties were observed.
In 1898 intention tremors first appeared; legs became quite
rigid ; ankle and rectus-clonus and toe phenomenon were present ;
loss of muscular sense in both upper and lower extremities was
very manifest ; control of bladder was weak ; vision o.d. -^g-?
o.s. _6_ . hazy discs and nystagmus, but no distinctive syllabic
speech.
If only the class ical symptoms were to be relied upon in forming
a diagnosis the facility for making mistakes becomes very evident.
In this case — 1. Nystagmus did not manifest itself for 6 years after
the initial symptoms. 2. A spastic condition of the extremities
was 14 years in making an appearance. o. Intention tremors
appeared after the lapse of 16 years. 4. Syllabic speech cannot be
said to exist at all. The difficulty in arriving at a diagnosis was,
therefore, chiefly limited to the earlier years where the transient,
ocular, and paretic symptoms might have been considered to be of
a functional nature. Dr. Craig then contrasted in detail the differ¬
ential diagnosis between organic disease and functional disturbance
of the central nervous system.
The President (Dr. J. W. Moore) said Dr. Craig had laid
before them a very classical paper, which, since this disease was
so liable to be confounded with another important disease — -namely,
hysteria — was worthy of the attention of all clinical and practical
physicians.
Dr. J. B. Coleman said that the disease was not very uncom¬
mon. A case which he had under observation at present did not
differ very much from the case exhibited.
465
Section of Medicine.
Dr. Finny took exception to one of the diagnostic points Dr.
Craig had mentioned as distinguishing this disease from hysteria.
The statement he referred to was that ankle-clonus was not present
in hysteria. Tie had a clear recollection of ankle-clonus occurring
distinctly in a case of pure hysteria, and ankle-clonus, which was
once thought of great value as pointing to structural changes in
the pyramidal tract and cord, was not now considered so reliable.
In many cases of typhoid fever ankle-clonus could be found where
there was no evidence of hysteria or structural disease of the
spinal cord.
Sir George Duffey said he could corroborate what Dr. Finny
had said about the presence of ankle-clonus in hysteria. He re¬
membered a case in the City of Dublin Hospital which presented
peculiar nervous symptoms, and about which there was great
doubt as to the diagnosis.
Dr. Knott said that Sharpe’s great test was to ask the patient
to shake hands. In cases of chorea the patient made a series of
jerky movements, whereas in disseminated sclerosis the patient
always went in a curved line. He was struck with the extra¬
ordinary similarity in the way patients suffering from this disease
carried their heads. He noticed that the pupils of the patient
exhibited were a good deal larger than normal. He suggested
that the peculiar monotone of the speech could have been better
demonstrated by getting the patient to recite prose rather than
poetry.
Dr. R. Travers Smith .mentioned a case of a girl, aged about
twenty-two, who presented the clinical group of symptoms known
as spastic paraplegia. The diagnosis between insular sclerosis and
primary lateral sclerosis was at first doubtful, but the question was
finally settled at the end of a few months by the patient developing
an external strabismus, which he considered was an important
sign in the diagnosis of insular sclerosis. After that other
symptoms of the disease had set in.
The President (Dr. J. W. Moore), referring to Dr. Finny’s
remark, suggested that at a certain period in typhoid fever there
might be structural changes in the spinal cord. Such changes
are, however, of a transitory nature, for just as the heart suffers
in zymotic diseases so also the spinal cord may suffer from a
purely temporary organic change.
Dr. Craig, in reply, said that, with reference to Dr. Finny’s
remarks, he agreed that in severe illness, and, indeed, in many
chronic diseases, structural changes might take place in the cord
and ankle-clonus and other symptoms be evinced. In answer to
2 G
466
Royal Academy of Medicine in Ireland .
Sir George Duffey, the third case he (Dr. Craig) had referred to
often got perfectly well for two years, and it was 16 years before
they knew she was not suffering from hysteria.
Senile Dementia.
Dr. Conolly Norman read a paper on senile dementia. He
dwelt on certain points of clinical interest, emphasising the fact,
which he held is too often forgotten, that this form of mental
trouble may appear with apparent rapidity, and often seems to
develop after an attack of acute physical illness — influenza or the
like. Dr. Norman pointed out that the most typical mental
condition in senile dementia was characterised not only by a forget¬
fulness of recent events, but also by an abnormal acuteness of
recollection of events long past. He, therefore, thought that mere
amnesia did not cover the field. He gave a somewhat detailed
description of the conditions of aphasia, paraphasia, and alexia,
which are sometimes met with in cases of senile dementia.
Dr. Ninian Falkiner inquired if there was generally albu¬
minuria in cases of senile dementia, and asked if it was a fact that
there was a train of mental symptoms in chronic Bright’s disease
closely resembling those of senile dementia.
Dr. Law said he had a little experience of asylum work in
England and afterwards in British Guiana, and a point that struck
him when in the latter place was the large number of cases of
senile dementia in comparatively young subjects, where in this
country they would expect an attack of more active mental disease.
He also noticed that cases of that kind were commonest in the
lowest races in the colony.
Dr. Norman, in reply, said that albuminuria and bad kidney
disease associated with senile dementia was only what they might
expect. He could not, however, subscribe to the theory of some
nervous pathologists that senile dementia depended upon arterio¬
sclerotic conditions in the brain, although it was undoubtedly true
that gouty kidney and extensive arterio-sclerosis was common in
persons dying of senile dementia. Consequently the two con¬
ditions — mental disturbance and albuminuria — co-existing would
not surprise him. He had heard of various conditions of mental
disturbance being described as the insanity of Bright’s disease.
With regard to the racial question, Dr. Law’s remarks bore out
his statement that the more the brain was used the less the proba¬
bility of the occurrence of senile dementia.
The Section then adjourned.
SANITARY AND METEOROLOGICAL NOTES.
Compiled by J. W. Moore, B.A., M.D. Univ. Dubl. ;
P.R.C.P.I.; F. R. Met. Soc.;
Diplomate in State Medicine and ex-Sch. Trin. Coll. Dubl.
Vital Statistics
Foi foui 11 ee/cs ending Saturday , -November 4, 1899.
I he deaths registered in each of the four weeks in the twenty-
three principal Town Districts of Ireland, alphabetically arranged,
coi responded to the following annual rates per 1,000 : —
Week ending
Aver-
1
Week ending
Aver-
Towns,
age
Towns,
<&c.
&c.
Oct.
14
Oct.
21
1
Oct.
28
1 KT
i Nov.
4
Rate
for 4
weeks
Oct.
14
Oct.
21
Oct.
28
Nov.
4
age
Rate
for 4
weeks
23 Town
Districts
252
26-8
26-5
23-2
25-4
Limerick
16-8
23-9
9-8
18-2
17*2
Armagh -
14 3
74
28-5
14-3
164
Lisburn
17-0
257
12-8
2L3
19*2
Ballymena
5-6
5-6
28-2
11-3
12-7
Londonderry
29-8
23-6
254
17-3
24-0
Belfast
22-3
21-3
244
19-5
21-9
Lurgan
36-5
414
94
18*2
26-2
Carrickfer-
11-7
o-o
234
11-7
117
Newry
204
164
84
84
134
gus
Clonmel
43-8
243
o-o
97
19-5
Newtown-
22 ‘7
34-0
11-3
5*7
184
Cork
ards
284
2/-0
21-5
25-6
25-6
Portadown -
6-2
247
18-6
6-2
13-9
Drogheda -
19-0
3-8
114
304
16-2
Queenstown
~ .h'
O 1
o-o
287
11*5
11*5
Dublin
(Reg. Area)
31*3
35'3
35-9
31-3
334
Sligo
10-2
254
15-2
254
194
Dundalk -
12-6
84
29;3
20-9
17*8
Tralee
39-2
44-8
224
11-2
294
Galway
18-9
11-3
264
18-9
18-9
Waterford -
17-9
39-8
239
27-9
274
Kilkenny -
18-9
14-2
37-8
14-2
21-3
W exford
22-6
54-2
13-5
4-5
237
In the week ending Saturday, November 4, 1899, the mortality
m thirty-three large English towns, including London (in which the
rate was 18*6), was equal to an average annual death-rate of 18*8
per 1,000 persons living. The average rate for eight principal
towns of Scotland was 18*8 per 1,000. In Glasgow the rate was
20T. In Edinburgh it was 18T.
468 Sanitary and Meteorological Notes.
The average annual death-rate represented by the deaths legis-
tered during the same week in the Dublin Registration Area and
in the twenty-two principal provincial Urban Districts of Ii eland
was 23*2 per 1,000 of their aggregate population, which, for the
purpose of this return, is estimated at l,0o3,188.
The deaths from the principal zymotic diseases in the twenty-
three districts were equal to an annual rate of o'3 per 1,000, the
rates varying from 0’0 in thirteen of the distiicts to 7 3 in the
Dublin Registration Area. Among the 131 deaths from all causes
registered in Belfast are one from whooping-cough, one from
simple continued fever, and 3 from enteric fever. The 37 deaths
in Cork comprise one from diphtheria, and 2 from diarlicea. ihe
11 deaths in Londonderry comprise one from enteric fever and 2
from diarrhoea.
In the Dublin Registration Area the births registered during
the week amounted to 225 — 104 boys and 121 girls ; and the deaths
to 21G — 112 males and 104 females.
The deaths, which are 38 over the average number for the
corresponding week of the last ten years, represent an annual rate
of mortality of 32*2 in every 1,000 of the population. Omitting
the deaths (numbering 6) of persons admitted into public institu¬
tions from localities outside the area, the rate was 3 Do per 1,000.
During the forty-four weeks ending with Saturday, November 4, the
death-rate averaged 29'4, and was 2*7 over the mean rate for the
corresponding portions of the ten years 1880—1898.
The number of deaths from zymotic diseases registered during
the week was 53, being 31 over the average for the corresponding
week of the last ten years, but 15 under the number for the
previous week. The 53 deaths comprise 38 from measles— being
6 under the number registered from that cause in the preceding
week and 14 under that for the week ended October 21 — one from
influenza, 2 from whooping-cough, 3 from diphtheria, 2 from enteric
fever, and 6 from diarrhoea. Forty-four of the 53 deaths from
zymotic diseases occurred among children under 5 years of age.
The number of cases of measles admitted to hospital during the
week was 56, being 4 under the admissions in the preceding week,
and equal to the number admitted in the week ended October 21.
Forty-two measles patients were discharged, 4 died, and 1/2
remained under treatment on Saturday, November 4, being 10 ovei
the number in hospital on that day week.
Nineteen cases of scailatina were admitted to hospital, against
11 admissions in the preceding week and 10 in that ended Octobei
21. Nine patients were discharged, and 62 remained undei tieat-
Sanitary and Meteorological Notes. 469
ment on Saturday, November 4, being 10 over the number in
hospital at the close of the preceding week.
The number of cases of enteric fever admitted to hospital was
40, being 4 under the admissions in the preceding week, and one
under the number admitted in the week ended October 21 . Thirty-
eight patients were discharged during the week, 3 died, and 273
remained under treatment on Saturday, November 4, being one
under the number in hospital on the previous Saturday.
The hospital admissions for the week included, also, 3 cases of
diphtheria ; 9 cases of this disease remained under treatment in
hospital on Saturday.
ihe deaths from diseases of the respiratory system amounted to
53, being 20 in excess of the average for the corresponding week of
the last ten years, and 13 over the number for the previous week.
4 hey comprise 36 from bronchitis and 16 from pneumonia.
Meteorology.
Abstract of Observations made in the City of Dublin , hat. 53° 20'
2V, Long. 6° 15' W., for the Month of October , 1899.
Mean Height of Barometer, - 3T022 inches.
Maximal Height of Barometer (on 8th, at 9 a.m.), 30-378 „
Minimal Height of Barometer (on 1st, at 9 a.m.), 29-333 „
Mean Dry-bulb Temperature, - - 48’5°.
Mean Wet-bulb Temperature, - - 46'8°.
Mean Dew-point Temperature. - - 45-1°.
Mean Elastic Force (Tension) of Aqueous Vapour, *304 inch.
Mean Humidity, - 88*7 per cent.
Highest Temperature in Shade (on 18th), - 65- 1°.
Lowest Temperature in Shade (on 6th), - 32-9°.
Lowest Temperature on Grass (Radiation) (on
6 th) -
Mean Amount of Cloud,
Rainfall (on 11 days),
Greatest Daily Rainfall (on 11th),
General Directions of Wind,
29*0°.
43*6 per cent.
1*538 inches.
•263 inch.
S.W., w.
Remarks.
October, 1899, was a quiet, foggy, but withal fine month.
Anticyclonic systems tended to prevail in the British Islands, and
go there was a large diurnal range of temperature, cold foggy
nights alternating with sunny, warm days. The weather broke
470
Sanitary and Meteorological Notes.
upon the 24th, and from that date to the end of the month cyclonic
conditions prevailed and rain fell frequently though not heavily,
except in the South of England on the 26th and 27th, when 1*32
inches was the measurement in London.
In Dublin the arithmetical mean temperature (50*2°) was
slightly above the average (49*7°) ; the mean dry-bulb readings
at 9 a.m. and 9 p.m. were 48*5°. In the thirty-four years ending
with 1898, October was coldest in 1892 (M. T.=44*8°), and in
1896 (M. T. = 45*0°). It was warmest in 1876 (M. T.=53T°).
The M. T. in 1898 was 52*8.
The mean height of the barometer was 30*022 inches, or 0*182
inch above the corrected average value for October — namely,
29*840 inches. The mercury rose to 30*378 inches at 9 a.m. of
the 8th, having fallen to 29*333 inches at 9 a.m. of the 1st. The
observed range of atmospheric pressure was, therefore, 1*045 inches.
The mean temperature deduced from daily readings of the dry-
bulb thermometer at 9 a.m. and 9 p.m. was 48*5°, or 6*4C below
the value for September, 18-99. The arithmetical mean of the
maximal and minimal readings was 50*2°, compared with a twenty-
five years’ average of 49*7°. Using the formula, Mean Temp. = Min.
-f- (max. — min. X *485), the mean temperature was 49*9°, or 0*4°
above the average mean temperature for October, calculated in
the same way, in the twenty-five years, 1865-89, inclusive (49*5°).
On the 18th the thermometer in the screen rose to 65*1° — wind, S.E. ;
on the 6th the temperature fell to 32*9° — wind, W.S.W. The
minimum on the grass was 29*0°, also on the 6th. The thermometer
did not sink to 32° in the screen, but frost occurred on the grass .
on 6 nights.
The rainfall was 1*538 inches, distributed over 11 days — the
rainfall and the rainy days were decidedly below the average. The
average rainfall for October in the twenty-five years, 1865-89,
inclusive, was 3*106 inches, and the average number of rainy days
was 17*6. In 1880 the rainfall in October was very large — 7*358
inches on 15 days. In 1875, also, 7*049 inches fell on 26 days.
On the other hand, in 1890, only *639 inch fell on but 11 days;
in 1884, only *834 inch on but 14 days; and in 1868 only *856 inch
on 15 days. In 1898, the October rainfall was 3*579 inches on
19 days.
Lightning was seen on the night of the 29th. High winds were
noted on 8 days, but attained the force of a gale on only one occa¬
sion — the 29th. The atmosphere was more or less foggy in
Dublin on the 6th, 7th, 8th, 9th, 14th, 17th, 18th, 19th, 20th, 21st,
471
Sanitary and Meteorological Notes.
2.2nd, 23rd, and 24th. A solar halo appeared on the 18th. Lunar
halos were seen on the 17th and 18th. Hail fell on the 12th.
I he rainfall in Dublin during the ten months ending October
olst amounted to 22*486 inches on 149 days, compared with 12*366
inches on 123 days during the same period in 1887 (the dry year),
22*052 inches on 165 days in 1896, 24*081 inches on 179 days in
1897, 21*547 inches on 156 days in 1898, and a twenty-five years’
average of 22*840 inches on 160*4 days.
At Ivnockdolian, Greystones, Co. Wicklow, the rainfall in October
amounted to 1*560 inches on 11 days. Of this quantity *520 inch
fell on the 1st. From January 1st, 1899, up to October 31st, rain
fell at Jvnockdolian on 1 50 days to the total amount of exactly 30
inches. In 1893 the rainfall in the corresponding ten months was
F*801 inches on 133 days; in 1894, 32*221 inches on 154 days;
in 1897, 32*730 inches on 171 days; and in 1898, 24*177 inches
on 140 days.
At Cloneevin, Killiney, Co. Dublin, the rainfall in October was
1*24 inches on 12 days, compared with *710 inch on 14 days in
1893, 6*460 inches on 17 days in 1894, 2*280 inches on 11 days in
1897, 3*530 inches on 18 days in 1898, and a fourteen years’
average (1885-1898) of 3*319 inches on 16 days. On the 1st,
*30 inch fell. Since January 1, 1899, 24*99 inches of rain have
fallen at this station on 151 days.
At the National Hospital for Consumption, Newcastle, Co.
Wicklow, the rainfall in October was 1*484 inches on 11 days,
compared with 3*175 inches on 13 days in 1897, and 4*385 inches
on 17 days in 1898. Of this quantity, *521 inch was recorded on
the 1st. The highest temperature in the screen was 63*0° on the
18th, the lowest was 35*2° on the 15th. At this Second Order
Station the rainfall from Januarv 1 to October 31, inclusive,
amounted to 27*643 inches on 140 days, compared with 26*479
inches on 139 days in the corresponding 10 months of 1898.
At Recess, Co. Galway, the rainfall was 3*261 inches on 17
days, *620 inch being registered on the 11th, and *609 inch on
the 28th. On the 30th a hailstorm occurred in the morning and
a thunderstorm in the evening.
PERISCOPE.
THE INFECTIOUSNESS OF RHEUMATISM AND CHOREA, AND THE
RELATION BETWEEN THEM.
It is pretty generally believed that acute rheumatic polyar¬
thritis is an infectious disease, even if of multiple origin.
472
Periscope.
Numerous observers have found micro-organisms in the
lesions of the disease and of its complications, but these have
differed among themselves, and it has not, . heretofore, been
possible to cultivate the micro-organisms artificially, and with
them again to generate acute polyarthritis. For a long time
some relation has been thought to exist between acute rheu¬
matism and chorea, the latter affection not rarely following the
former, both prevailing at corresponding seasons, and both
being often complicated by endocarditis. Chorea also is
coming gradually to be looked upon as an infectious disease,
but concerning its bacteriology little is as yet known. Whether
chorea is dependent upon, the same causes as acute rheumatism
or upon allied causes must be considered as yet merely a matter
for speculation. An important contribution to this most in¬
teresting subject has recently been made by Westphal, Wassei-
man and Atalkoff in the Berliner hlinische W ochenschrift , No. 29,
1899. These observers report a case of acute articular rheu¬
matism followed by chorea and complicated by endocarditis
and nephritis, in which they succeeded in isolating from the
blood, the brain, and the endocarditic vegetations a micrococcus
susceptible of culture and capable of inducing polyarthritis
when inoculated into lower animals. The patient was a girl,
nineteen years old, who in the sequence of an attack of acme
articular rheumatism, developed chorea, with general move¬
ments, delirium, elevation of temperature, acceleration of pulse,
and collapse, followed by death. Post-mortem examination dis¬
closed the presence of fine, delicate endocarditic vegetations-
upon the mitral leaflets, as well as recent parenchy¬
matous nephritis. From the blood, the biain, and the
valve-leaflets was isolated a micro-organism, injection
of which in small quantities into the blood-vessels was
followed in animals by the development of high fever and
multiple neuritis, usually terminating fatally. The affected
joints presented evidences of inflammation, and in the exudate
was found the micro-organism already mentioned. Injection
of this after culture again induced acute multiple arthritis. The
micro-organism is a streptococcus, although in the tissues and
in the blood it may appear as a diplococcus, and it may be the
same as that found by other observers in the vegetations of
endocarditis, but not subjected to culture and inoculation. Its
growth requires a higher degree of alkalinity of the culture
medium than usual and a larger amount of peptone. New
York Med. Record , Nov. 18, 1899.
INDEX
TO THE ONE HUNDRED AND EIGHTH VOLUME.
- ^ -
Abdominal wall, vascular tumour of,
Mr. R. C. Maunsell on, 286.
Academy of Medicine in Ireland, Royal,
63, 139, 219, 283, 384, 451.
Address, introductory — by Di\ J. W.
Moore, 372 ; by Dr. More Madden,
430.
Africa, Guide to South, Rev., 370.
African, South, Health Resorts, Rev.,
426.
Air bath, hot, Dr. M. Altdorfer on, 87.
Albumen, egg, in illness, 236.
Alcoholism, six cases of, Dr. James R.
Wallace on, 443.
Allbutt, Dr. T. Clifford, a system of
medicine, vol. vii., Rev., 354.
Altdorfer, Dr. M., the hot-air bath, 87.
Alvarenga Prize of the College of
Physicians of Philadelphia, 442.
American text-book of diseases of chil¬
dren, Rev., 42 ; Orthopaedic Associa¬
tion, transactions of the, Rev., 43 ;
Pediatric Society, transactions of the,
Rev., 128; text-book of medicine and
surgery, Rev., 365.
Anatomical proportions of different races,
62.
Anatomy and Physiology, Section of,
in the Royal Academy of Medicine in
Ireland, 387.
Aneurysm, innominate, by Dr. James
Craig, 416.
Apothecaries’ Hall in Ireland, regula¬
tions of the, 305.
Apple-tart, the microbe and the, 78.
Appendix, vermiform, Dr. D. J. Coffey
on the, 388,
Archives of Pediatrics, Rev., 45, 128.
Archives of the Rontgen Ray, Rev., 276.
Army Medical Corps, Royal, examina¬
tion papers, 314 ; pass list, 287.
Aseptic Surgical Dressing Company,
399.
Ashby, Dr. H., and Mr. Wright, Diseases
of Children, Rev., 423.
Aspirin, 160.
Asthma, treatment of, 450.
Astragalus, dislocations and fractures of
the, Mr. H. G. Croly on, 241.
Autopsy, right to perform an, 348.
Bacillus of Eberth, transmission of the
agglutinative substance of, MM. Paul
Commont and Coll on, 278.
Bacon, Dr. Graham, a manual of Otology,
Rev., 427.
Bacteriology and clinical medicine, 203.
Ball, Dr. C. B., gastro-enterostomy,
3S4.
Bath, hot-air, Dr. M. Altdorfer on, 87.
Bayer, Messrs. E., heroin hydrochloride,
79 ; aspirin, 160.
Beatty, Dr. Wallace, mercury in heart
diseases, 257.
Belfast, Queen’s College, regulations,
298.
Belfast, Samaritan Hospital for Women,
Dr. John Campbell on, 214.
Bell, Dr. Joseph, surgery for nurses,
Rev., 122.
Bennett, Prof. E. H., dislocations of
the metatarsus on the tarsus, 284.
Benson, Mr. A. H.. specimens, 460.
Bewley, Dr. H. T., report on practice
of medicine, 201.
Bibliographical notices, 40, 102, 188,
268, 349, 421.
Birch, Dr. de Burgh, practical physio¬
logy, Rev., 199.
Birmingham, Prof., formalin specimen
of the abdomen, 390.
Blake, Dr. Clarence John, and Dr.
Bacon, manual of Otology, Rev., 427.
Blake, Dr. Edward, study of the hand,
Rev., 366.
Bone, central sarcoma of, Mr. W. I.
Wheeler on, 284.
Bradshaw’s dictionary of bathing places,
Rev., 134.
Breast containing new growth, Mr. G. J.
Johnston on, 70.
Brodie’s abscess of tibia, Mr. H. G.
Croly od, 140.
Brown, Dr. A. M., elements of alkaloidal
{etiology, Rev., 50.
Brown, Messrs., Guide to South Africa,
Rev., 370.
Burdett, Sir Henry, Burdett’s Hospitals
and Charities, 1899, Rev., 275.
Burr, Dr. C. B., primer of psychology
and mental disease, Rev. , 122.
474
Index .
Burroughs, Wellcome & Co., Messrs. —
new preparations, 80, 158, 159, 398,
400.
■Caesarean section, Dr. F. W. Kidd’s case
of, 457.
Callosities, trade, Dr. H. S. Purdon on,
173.
Cameron, Sir C. A., typhoid ferer due
to milk, 330.
Campbell, Dr. John, exhibits, 224; ten
years’ work at the Samaritan Hospital,
Belfast, 224.
Cancer — uterine, and its treatment, Dr.
More Madden on, 224 ; in Ireland, Dr.
Martley on, 452.
Cape Calony, the Rinderpest of 1897 in,
by Mr. James Harpur, 53.
Carbolic dressing poisoning, 282.
Cascara sagrada tabloids, 398.
Cat, hysteria in a, 371.
Cerebellum, lecture on the, by Dr. Risien
Russell, 27.
Cerebro-spinal disseminated sclerosis,
Dr. Craig on, 463.
Charles, Prof. J. J., reaction of the
intestinal contents in man, 265.
Chemistry, elementary, 79.
Children, recent works on diseases of,
Rev., 40, 126, 428.
Chorea, 234; infectiousness of, 471.
Church Lads’ Brigade Medical Corps,
manual for, Rev., 424,
Churchill, Messrs. J. & A., new publica¬
tions, 73.
Clarke, Dr. J. C., the corpus luteum,
Rev., 124.
Clavicles, pathological, Dr. Knott on,
283. .
Clinical investigations on W idal’s reaction
by Dr. H. E. Littledale, 18 ; reports
of the Rotunda Hospital, 161, 334.
Clinical Records, 443.
Coffey, Dr. D. J., glands in the human
oesophagus, 387 ; vermiform appendix,
388.
Cole-Baker, Dr., melanotic sarcoma of
choroid, 73 ; treatment of the third
stage of labour, 407.
Coleman, Dr. J. B., Hodgkin’s disease,
68 ; diseases of the suprarenal capsules,
219.
Commont (Paul), and Coll, transmission
of the agglutinative substance of
Eberth’s bacillus by the mother’s milk,
278.
Congress, International Tuberculosis,
239.
Cork, Queen’s College, regulations, 298.
Coryza, treatment of, 212.
Craig, Dr. James, innominate aneurysm,
416 ; cerebro-spinal disseminated scler¬
osis, 463.
Croly, Mr. H. G., Brodie’s abscess of
tibia, 140 ; dislocations and fractures
of the astragalus, 241 ; specimens, 461.
Cuming, Dr. James, obituary of, 316.
Da Costa, Dr., phlegmasia dolens in
typhoid fever, 155.
Day, Dr. John Marshall, diphtheria, 81.
Deep reflexes of the lower extremities,
237
Delepine, Mr. A. S., Rieder’s Atlas of
urinary sediments, Rev., 191.
Dementia, senile, Dr. C. Norman on,
466.
Dental education and examinations in
Ireland, 307.
Dercum, Dr. E. X., mental disturbance
following typhoid fever. Rev., 357.
Diabetes insipidus, Dr. J.Lumsden on, 13.
Diarrhoea, precautions against summer,
238.
Dickson, Dr. E. Winifred, specimens, 63.
Diphtheria, Dr. Day on, 81.
Diplomas — in State Medicine, Public
Health, or. Sanitary Science, 294, 297,
304 ; mental diseases, 298.
Diseases of the foot, Mr. Wheeler on, 65.
Disinfection by formic aldehyde, Drs.
Littledale and Kirkpatrick on, 451.
Dislocation of both hips, 287.
Dislocations and fractures of the astra¬
galus, by Mr. H. G. Croly, 241 ; of
the metatarsus on the tarsus, Dr.
Bennett on, 284.
Douglas, Dr. C., chemical and micro¬
scopical aids to diagnosis, Rev., 272.
Dowse, Dr. T. Stretch, treatment of
disease by physical methods, Rev., 121.
Doyen’s operation, Dr. W. J. Smyly on,
456.
Drugs, enteroliths formed by, IS 7.
Dublin, the water supply of, Dr. J. W.
Moore on, 176.
Dublin, University of, regulations of
the, 290.
Dysentery, magnesium sulphate in, 207.
Ear disease, chronic, operation for, by
Dr. J. R. Wallace, 447.
Earl, Dr. H. C., specimens, 460.
Earth, smell of the, 240.
Edinburgh Medical Journal, Rev., 116 ;
Royal College of Surgeons, 371.
Education and examinations in Ireland,
medical, 288.
Egg albumen in illness, 236.
Elementary chemistry, 79.
Elder, Dr. George, diseases of children,
Rev., 126.
Index.
475
Endocarditis, infective, from the pneumo¬
coccus, Dr. McWeeney on, 283.
Enteric fever — embolic hemiplegia in,
Dr. J. W. Moore on, 142 ; due to milk,
Sir C. A. Cameron on, 330.
Enteroliths formed by drugs, 1S7.
Epistaxis, peculiar clot from, Dr. Ninian
Falkiner on, 145.
Epithelioma of lip, Mr. G. Jameson
Johnston on, 70.
Erysipelatous pneumonia, 397.
Evans, Dr. A. H., Golden Rules of medi¬
cal practice, Rev., 422.
Examination papers for the Army and
Indian Medical Services, 314.
Eyeball, advancement of the recti
muscles of the, Mr. J. B. Story on,
222.
Facial nerve, topography of the, Mr.
Joyce on, 327.
Fagan, Mr., pathological conditions of
the tunica vag-inalis testis, 286.
Falkiner, Dr. Ninian, peculiar clot from
epistaxis, 145.
Fatal wasp sting, 397.
Feeding bottles, sanitary, 240.
Fere, Dr. Ch., the pathology of the
emotions, Rev., 349.
Fever, typhoid — Widal’s reaction in, Dr.
H. E. Littledale on, 18 ; hemiplegia
in, 142 ; phlegmasia dolens in, 155 ; due
to milk, Sir C. A. Cameron on, 330.
Fibulae and patellae, pathological, Dr.
Knott on, 73.
Finny, Dr. J. M., cases of tachycardia, 1;
sarcoma of suprarenals and lung’, 71’
321.
Foot, diseases of the, Mr. Wheeler on,
65.
Formalin specimen of the abdomen,
Prof. Birmingham on, 390.
Formic aldehyde, Drs. Littledale and
Kirkpatrick on, disinfection with, 451.
Foy, Dr. George M., translation, 278.
Fractures of the astragalus, Mr. H. G.
Croly on, 241.
Fraser, Professor Alec, serial sections of
the bod}', 389.
Galway, Queen’s College, regulations,
299.
Gargles, uselessness of, 157.
Gastric ulcer, perforating, Mr. T. Myles
on, 66.
Gastro-enterostomy, Dr. C. B. Ball on,
384.
Geophagy, 420.
Gibson, Dr. G. A., The Edinburgh
Medical Journal, Rev., 116.
Giffen, Grace Haxton, students’ prac¬
tical materia medica, Rev., 199.
Glands in the human oesophagus, Dr. D.
J. Coffey on, 387.
Glasgow Hospital Reports, Rev., 361.
Glenn, Dr., specimens, 63, 224.
Gonorrhoea, 238.
Goodhart, Dr. James F., diseases of
children, Rev., 40.
Gould, Dr. George M., American text¬
book of medicine and surgery, Rev.,
365.
Gowers, Sir W. R., diseases of the
nervous system, Rev., 129.
Great Eastern Railway’s tourist guide
to the Continent, Rev., 128.
Grafstrom, Alex, von, Medical Gymnas¬
tics, Rev., 425.
Greenish, Mr. Henry G., materia medica,
Rev., 108.
Griffith, Dr. J. P. Crozier, the care of
the baby, Rev., 127.
Guaiacol-camphorate, 159.
Guaiacol, local application of, 208.
Hale-White, Dr. W., materia medica,
Rev., 198.
Halliburton, Dr. W. D., chemical physi¬
ology, Rev., 46 ; handbook of physi¬
ology, Rev., 47.
Hare, Dr. Hobart A., medical complica¬
tions of typhoid or enteric fever, Rev.,
357.
Hare, Dr. Hobart Amory, progressive
medicine, Rev., 117.
Harpur, Mr. James, the Rinderpest of
1897 in Cape Colony, 53.
Heart diseases, mercury in, Dr. Wallace
Beatty on, 257.
Hemiplegia fatal in enteric fever, Dr.
J. W. Moore on, 142.
Hereditary syphilis cured by mercury,
Dr. J. R. Wallace on, 448.
Heroin hydrochloride, 79.
Hey’s internal derangement of the knee-
joint, Dr. Knott on, 221.
Hill, Mr. Leonard, manual of human
physiology, Rev., 197.
Hime, Dr. Maurice C., schoolboys’ special
immorality, Rev., 50 ; an apology for
the intermediates, Rev., 117.
Hips, dislocation of both, 287.
Hirst, Dr. Barton Cooke, text-book of
obstetrics, Rev., 360.
Hoblyn, Mr. Richard D., dictionary of
terms used in medicine, Rev., 277.
Hodgkin’s disease, Dr. J. B. Coleman
on, 68.
Hospitals, Rotunda, Clinical Reports of
the, 161, 334; discussion on the
Reports of the, 63.
Hot-air bath, Dr. Altdorfer on, 87.
Hydrochloric acid in digestive disorders,
209.
476
Index.
Hymen, imperforate, Dr. It. J. Kinkead
on, 174.
Hysteria in a cat, 871.
Imperforate hymen, Dr. It. J. Kinkead
on, 174.
Incontinence of urine, nocturnal, 238.
Infectiousness of rheumatism and chorea,
471.
Infective endocarditis from the pneumo¬
coccus, Dr. McWeeney on, 283.
Influenzal change of type of acute
pneumonia, 138.
Index Catalogue of the Library of the
Surgeon- General’s Office, U. S. Army,
Rev., 429.
Indian Medical Service, 308.
Indicators for chemical tests, 400.
Injection of saline solutions in collapse,
154.
Innominate aneurysm, by Dr. James
Craig, 416.
International Tuberculosis Congress,
239.
“ In Memoriam ” — Dr. James Cuming,
316.
Intestinal contents in man, reaction of
the, Dr. J. J. Charles on, 265.
Intestine, rupture of the small, Mr.
ISfash on, 135.
Ireland, Apothecaries’ Hall in, regula¬
tion of the, 305.
Ireland— Royal Academy of Medicine in,
63, 139, 219, 283, 384, 451 ; medical
education and examinations in 1899-
1900, 288 ; Royal University of, regula¬
tions, 295 ; cancer in, Dr. Martley on,
452.
Jellett, Dr. Henry, short practice of
midwifery, Rev., 361 ; gynaecology,
383.
Jenks, the William F., memorial prize,
146.
Jewett, Dr. Charles, practice of obstet¬
rics, Rev., 360.
Johnston, Mr. G. Jameson, epithelioma
of lip, 70 ; breast containing new
growth, 70.
Joyce, Mr. Robert Dwyer, topography
of the facial nerve, 327.
Kelynack, Dr. T. N., the pathologist’s
handbook, Rev., 363.
Kennedy, Messrs., sanitary feeding
bottle, 240.
Kidd, 'Dr. F.W., specimens, 63; Caesarean
section, 457.
King, Dr. A. F. A., manual of obstetrics,
Rev., 188.
Kinkead, Dr. R. J., imperforate hymen,
174 ; polycystic ovarian tumour, 457.
Kirkpatrick, Dr., on disinfection by
formic aldehyde, 451.
Knee-joint, Hey’s internal derangement
of the, Dr. Knott on, 221.
Knott, Dr. J. F., pathological fibulae
and patellae, 73 ; Hey’s internal de¬
rangement of the knee-joint, 221 ;
pathological clavicles, 283.
Koplik’s sign of measles, 397.
Labour, treatment of the third stage of,
Dr. Cole-Baker on, 407.
Las Vegas hot springs, 235.
Lawson, Dr. David, the Nordrach treat¬
ment of phthisis, 324.
Lecture on the cerebellum, by Dr. Risien
Russell, 27.
Lemur, Dr. C. J. Patten on the, 389.
Lentaigne, Mr. John, exhibit, 65.
Lewis, Dr. Percy G., nursing : its theory
and practice, Rev., 368.
Lindley, Mr. Percy, tourist guide to the
Continent, Rev., 128.
Lip, epithelioma of, Mr. G. J. Johnston
on, 70.
Literary intelligence, 73, 383, 429.
Litten’s diaphragm phenomenon, 201.
Littledale, Dr. H. F., Widal’s reaction
in typhoid fever, 18 ; disinfection by
formic aldehyde, 451.
Liver — primary carcinoma of, Dr.
Rambaut on, 143; multiple abscess
of, Prof. McWeeney on, 143.
Lloyd, Dr. H. C., clinical reports of the
Rotunda Hospitals, 161, 334.
Lumleian Lectures, by Sir R. Douglas
Powell, Rev., 421.
Lumsden, Dr. J., diabetes insipidus, 13.
Lung, sarcoma of, Dr. Finny on, 71, 321.
Lyle, Dr. R. P., clinical reports of the
Rotunda Hospitals, 161, 334.
Mackintosh, Dr. Donald J„ skiagraphic
atlas of fractures and dislocations,
Rev., 367.
McWeeney, Dr. E. J., pneumococcal
septicaemia, 67 ; multiple abscess of
liver, 143 ; infective endocarditis from
the pneumococcus, 283.
M‘Caw, Dr. John, diseases of children,
Rev., 127.
Man, reaction of the intestinal contents
in, Prof. J. J. Charles on, 265.
Magnesium sulphate in dysentery, 207.
Manual for Church Lads’ Brigade Medi¬
cal Corps, Rev., 424.
Mater Misericordiae Hospital, introduc¬
tory address at, by Dr. More Madden,
430.
Maunsell, Mr. Charles, vascular tumours
of abdominal wall, 286.
Measles, Koplik’s sign of, 397*
Index. 477
Meatli Hospital, introductory address
at, by Dr. J. W. Moore, 372.
Medical book-keeping without books,
450.
Medical education and examinations in
Ireland, 1899-1900, 288.
Medical Corps, Royal Army, 287 ;
examination papers, 314.
Medical — Miscellany, 53, 135, 213, 278,
372, 430; Service, Indian, 308; ex¬
amination papers, 314 ; School Calen¬
dar for Scotland, Rev., 424 ; Annual
Synoptical Index, Rev., 424.
Medicine — in Ireland, Royal Academy
of, 63, 139, 219, 283, 384, 451 ; Section
of, in the Royal Academy of Medicine
in Ireland, 218, 463 ; Section of State
in the Royal Academy of Medicine in
Ireland, 451 ; report on practice of,
by Dr. H. T. Bewley, 201.
Melanotic sarcoma of choroid, Dr. Cole-
Baker on, 73.
Mercury in diseases of the heart, Dr.
Wallace Beatty on, 257.
Metatarsus on the tarsus, dislocations of
the, by Prof. E. H. Bennett, 284. '
Meteorological notes, 76, 151, 231, 311,
393, 469.
Microbe and the apple-tart, 78.
Middleton, Dr. G-. S., Glasgow Hospital
Reports, Rev., 363.
Moore, Dr. F. C., translation of Rieder’s
Atlas of urinary sediments, Rev., 191.
Moore, Dr. J. W. — sanitary and metero-
logical notes, 76, 147, 229, 309, 391,
467 ; enteric fever fatal through hemi¬
plegia, 142 ; water-supply of Dublin,
176 ; introductory address, 372.
Moore, Mr. Benjamin, elementary physi¬
ology, Rev., 48.
Moore, Mr. Thomas, archives of the
Rontgen Ray, Rev., 276.
More Madden, Dr., uterine cancer and
its treatment, 228 ; address on recent
Medical Progress and Celtic Medicine,
430.
Morison, Dr. Alexander, relation of the
nervous system to visceral disease,
Rev., 194.
Morris, Mr. Henry, treatise on human
anatomy, Rev., 109.
Murphy button, fatal obstruction from
the, 282.
Murray, Dr. Wm., rough notes on
remedies, Rev., 422.
Myles, Mr. Thomas, perforating gastric
ulcer, 66.
Myomatous uterus removed by abdomi¬
nal hysterectomy, Dr. Smyly on, 456.
Nash, Mr. J., accidental rupture of the
small intestine, 135.
Neale, Dr. Richard, the Medical Digest
Appendix, Rev., 426.
Neave’s food for infants and invalids,
399.
New preparations and scientific inven¬
tions, 79, 158, 240, 398.
Nerve, topography of the facial, by Mr.
R. D. Joyce, 327.
Niven, Dr. James, precautions ag’ainst
summer diarrhoea, 238.
Nocturnal incontinence of urine, 238.
Nordrach treatment of phthisis, Dr. D.
Lawson on the, 324.
Norman, Dr. Conolly, senile dementia,
466.
Novy, Dr. Frederick G., laboratory
work in bacteriology, Rev., 112.
Nursing, recent works on, Rev., 368.
Obstetrics, Section of, in the Royal
Academy of Medicine in Ireland, 63,
139, 224, 453.
Obstruction, pyloric, Dr. Parsons on,
223; fatal, from the Murphy button,
282.
Oesophagus, glands in the human, Dr.
D. J. Coffey on, 387.
O’Ferrall, Dr. Lewis More, syringo¬
myelia, 213.
Ogilvie, Mr. George, the exceptions to
Colies’s law, Rev., 268.
Original communications, 1, 81, 161, 241,
321, 401.
Orthopaedic Association, transactions of
the American, Rev., 43.
Ovarian tumour, polycystic, Dr. Kinkead
on, 457.
Ovary, tuberculous, removed by abdomi
nal section, Dr W. J, Smyly on, 454.
Park, Dr. Robert, Ferd’s pathology of
the emotions, Rev., 349.
Parsons, Dr. A. T., pyloric obstruction,
220.
Pathology, Section of, in the Royal
Academy of Medicine in Ireland, 67,
140, 283.
Patellae, pathological fibulae and, Dr.
Knott on, 73.
Patten, Dr. C. J., on the lemur, 389.
Payne, Mr. Ernest, Archives of the
Rontgen Ray, Rev., 276.
Pediatrics, Rev., 44, 128; Archives of.
Rev., 45, 128.
Pediatric Society, transactions of the
American, Rev., 128.
Pedley, Mr. R. Denison, hygiene of the
mouth, Rev., 51.
Perforating gastric ulcer, Mr. T. Myles
on, 66.
Periscope, 78, 154, 235, 314, 396, 471.
478
Index.
Pharyngitis, chronic, Dr. Robert H.
Woods on, 220.
Philadelphia, Alvarenga Prize of the
College of Physicians of, 442.
Phlegmasia dolens in typhoid fever, 155
Phthisis, the Nordrach treatment of.
Dr. D. Lawson on, 324.
Physicians and Surgeons, regulations
of the Royal Colleges of, 299.
Physiology, Anatomy and. Section of, in
the Royal Academy of Medicine in
Ireland, 387.
Physiology, works on, Rev., 46, 47, 48.
Pneumococcal septicsemia, Dr. E. J.
McWeeney on, 67.
Pneumonia — influenzal change of type
of acute, 138; erysipelatous, 397.
Pneumothorax from gas-producing bac¬
teria, 450.
Pocket case-book for nurses, Rev., 193.
Polycystic ovarian tumour, Dr. Kinkead
on, 457.
Potassium — chlorate, the use of, 211;
permanganate in coryza, 212.
Powell, Sir R. Douglas, Principles of
treatment of Diseases and Disorders
of the Heart, Rev., 421.
Practice of medicine, report on, by Dr.
Bewley, 201.
Preparations, new, 79, 158, 240, 398.
Price, Hr. John A. P., Hoblvn’s diction¬
ary of medical terms, Rev., 277.
Psoriasis, local treatment of, 158.
Pupil, diagnostic points connected with
the, 205.
Purefoy, Dr., specimens, 63, 224; clinical
reports of the Rotunda Hospitals,
161, 334.
Purdon, Dr. H. S., on warts, 99; trade
callosities, 173.
Pyloric obstruction, Dr. Parsons on, 220.
Queen’s Colleges, regulations of the,
298, 299.
Rambaut, Dr. D. F., primary carcinoma
of liver, 143.
Ramsay, Dr. A. Maitland, Atlas
external diseases of the eye, Rev., 45.
Reaction of the intestinal contents in
man, Prof. J. J. Charles on, 265..
Reflexes, deep, of the lower extremities,
237.
Records. Clinical, 443.
Reports on practice of medicine, by Dr.
Bewley, 201.
Reports of the Rotunda Hospitals,
Clinical, 161 ; discussion on, 63.
Reviews and bibliographical notices, 40,
~ 102, 188, 268, 349.
Rheumatism and chorea, infectiousness
of, 471.
Rieder, Dr. Hermann, Atlas of urinary
sediments, Rev. ,
Right to perform an autopsy, 348.
Rinderpest of 1897 in Cape Colony, Mr.
James Harpur on the, 53.
Rotunda Hospital, Clinical Reports of
the, 161, 334 ; report, discussion on,
63.
Royal— Academy of Medicine in Ireland,
63, 139, 219, 283, 384, 451; University
of Ireland, regulations of the, 295.
Royal Army Medical Corps, examina¬
tion papers, 314 ; pass list, 287.
Royal College of Surgeons, Edinburgh,
371.
Royal Colleges of Physicians and Sur¬
geon, regulations of the, 229.
Rupture of the small intestine, Mr. Nash,
on, 135.
Russell, Dr. Risien, lecture on the
cerebellum, 27.
Rutherfurd, Dr. H., Glasgow Hospital
Reports, Rev., 361
Samaritan Hospital for Women, Belfast,,
ten years’ work at, Dr. John Campbell
on, 224.
Sanitary and meteorological notes, 74,
147, 229,309, 391, 467; feeding bottles,
240.
Sarcoma of bone, central, Mr. Wheeler
on, 284.
Sarcoma— of suprarenals and lung, Dr.
Finny on, 71, 321 ; melanotic of
choroid, Dr. Cole-Baker on, /3.
Scientia, Rev., 195.
Scientific inventions, 79, 158, 240, 39b.
Scotland, Medical School Calendar for.
Rev., 424.
Senile dementia, Dr. C. Norman on, 466.
Septicsemia, pneumococcal, Dr. E. J.
McWeeney on, 65.
Serial sections of the body without
freezing, Professor Eraser on, 389.
Shaw, Dr. James, golden rules of psy¬
chiatry, Rev., 353.
Smell of the earth, 240.
Smith, Dr. Alfred, specimens, 63, 139,
458.
Smith, Dr. Eustace, wasting diseases of
infants and children, Rev., 369.
Smith, Mr. E. Noble, growing children.
Rev., 44.
Smyly, Dr. W. J., specimens, 63; tuber¬
culous ovary, 454 ; myomatous uterus,
removed by Doyen’s method, 456.
Soloid saline solutions, 158.
Soloids, new, 159, 398.
South Africa, Guide to, Rev., 370.
Index.
479
South African Health Resorts, Rev., 426.
Special reports — practice of medicine,
by Dr. Bewley, 201.
Springs, Las Vegas hot, 235.
Stab wound of the thoracic duct, 442.
Starch digestion in the stomach, 234.
Starr, Dr. Louis, American text-book of
diseases of children, Rev., 42.
State Medicine, Section of, in the Royal
Academy of Medicine in Ireland, !
451.
Stedman, Dr. T. L.. Twentieth Century
Practice, Rev., 102.
Still, Dr. George F., diseases of children,
Rev., 40.
Stimson, Dr. Lewis A., fractures and
dislocations, Rev., 131.
Stomach, removal of the, 396.
Story, Mr. J. B., advancement of recti
muscles of the eyeball, 222.
Summer diarrhoea, precautions against,
238.
Suprarenal capsules, diseases of the, Dr.
Finny on, 71 ; Dr. Coleman on, 219.
Suprarenals, sarcoma of, Dr. Finny on,
71, 321.
Surgeons, regulations of the Royal
Colleges of Physicians and, 299.
Surgeons, Royal College of, Edinburgh,
371.
Surgery, Section of, in' the Royal Aca¬
demy of Medicine in Ireland, 65, 221,
384.
Swan, Mr. R. L., venereal diseases and
their therapeutics, 401.
Symes, Dr. Langford, feeding of infants,
Rev., 274.
Syphilis, hereditary, cured by mercury,
Dr. J. R. Wallace on, 448.
Syringo-myelia, Dr. L. M. O’Ferrall
on cases of, 213.
System of medicine by many writers,
vol. vii., Rev., 354.
.Tabloid effervescent medicines, 80.
Tachycardia, Dr. Finny on, 1.
Testicle, tubercle of the, in childhood,
156.
Thoracic duct, stab wound of the, 4 42.
Thorne, Dr. Bezly, Schott methods,
Rev., 356.
Tibia, chronic circumscribed abscess in,
Mr. H. G. Croly on, 140.
Tinnitus aurium, 240.
Topography of the facial nerve, by Mr.
R. D. Joyce, 327.
Trade callosities, Dr. II. S. Purdon on,
173.
Transactions of the — American Ortho¬
paedic Association, Rev., 43 ; American
Pediatric Society, Rev., 128.
Transmission of the agglutinative sub¬
stance of Eberth’s bacillus by the
mother’s milk, 278.
Treatment of the third stage of labour,
Dr. Cole-Baker on, 407.
Tubercle — of the testicle in childhood,
156 ; of the ovary, Dr. W. J. Smyly
on, 45 L
Tuberculosis Congress, International,
239.
Tunica vaginalis testis, pathological con¬
ditions of the, Mr. Fagan on, 286.
Twentieth Century Practice, Rev., 62.
Typhoid fever — Widal’s reaction in, Dr.
H. E. Littledale on, 18 ; hemiplegia
in, 142 ; phlegmasia dolens in, 155 ;
due to infected milk, Sir C. A. Cameron
on, 330.
Ulcer, perforating gastric, Mr. T. Myles
on, 66.
Umbilical cord, poisoning from carbolic
dressing of the, 282.
University — of Dublin, Regulations, 290 ;
Royal, of Ireland, Regulations, 295.
Urinary tract, bacteriological examina¬
tion of the, 210.
Urine, nocturnal incontinence of, 239.
Uterine cancer and its treatment, Dr.
More Madden on, 228.
Uterus, myoma of, Dr. Alfred Smith’s
cases of, 139.
Vascular tumours of abdominal wall,
Mr. Charles Maunsell on, 286.
Venereal diseases and their therapeutics,
by Mr. R. L. Swan, 401.
Vermiform appendix, histology of the,
Dr. D. J. Coffey on, 388.
Verruca, Dr. H. S. Purdon on, 99.
Vital statistics, 74, 147, 229, 309, 391,.
467.
Wallace, Dr. James R., Alcoholism
treated by inhibition of alcohol, mass¬
age and bromides, 443 ; middle ear
diseases, 447; hereditary syphilis cured
by mercury, 448.
Warts, Dr. H. S. Purdon on, 99.
Wasp sting, fatal, 396.
Water-supply of Dublin, Dr. J. W.
Moore on the, 176.
Watson, Dr. J. K., handbook for nurses,
Rev., 368.
Westcott, Dr. T. S., American text-book
of the diseases of children, Rev., 42.
Wheeler, .Mr. W. I. de Courcy, diseases
of the foot, 65 ; central sarcoma of
bone, 284.
Whitelegge, Dr. B. Arthur, hygiene and
public health, Rev., 134.
480
Index.
Widal’s reaction in typhoid fever, Dr.
H. E. Littledale on, 1.8.
Williamson, Dr. R. T., syphilitic diseases
of the spinal cord, Rev., 270.
Woods, Dr. Robert H., chronic pharyn¬
gitis, 220.
Works on — -diseases of children, Rev.,
40, 126, 423; physiology, 46, 47, 43;
nursing, 368.
Wright, Mr. A., and Dr. H. Ashby,
diseases of children, Rev., 423.
Yeai’hook — American, of medicine and
surgery, Rev., 365 ; of treatment for
1899, Rev., 366 ; of the Scientific and
Learned Societies of Great Britain and
Ireland, Rev., 428.
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