EDINBURGH

"I

MEDICAL JOURNAL,

COHBININQ

THE MONTHLY JOURNAL OF MEDICINE

AM)

THE EDINBURGH MEDICAL AND SURGICAL JOURNAL.

VOL. XXXIV.— PART II.

JANUARY TO JUNE 1889.

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EDINBURGH: ^^

OLIVER AND BOYD, TWEEDDALE COURT. LONDON: SIMPKIN, MARSHALL, AND CO.

MDCCCLXXXIX.

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ORIGINAL COMMUNICATIONS.

I.— AN EXAMINATION OF THE PHENOMENA IN CHEYNE- STOKES RESPIRATION.

By G. A. Gibson, M.D.

Few symptoms have within an equally brief space of time excited so much discussion as that peculiar modification of the respiratory rhythm which in every language bears the names of Cheyne and Stokes, and, as so much has already been written on the subject, there cannot fail to be some hesitation before adding another to the many contributions towards its elucidation. In our own country, however, the symptoms which frequently accompany the type of breathing in question are but imperfectly known, while of the many explanations that have been advanced to account for its appearance, very few have been seriously considered, and it therefore seems unnecessary to give any reasons for bringing the matter forward once more. During the last four years several excellent examples of this type of breatliing have been under my observation, and these have led me to study the phenomena which are linked with it, as well as to criticise the theories that have been formed to explain its mode of origin. In the following pages the results of these investigations are fully embodied, and as they naturally fall into three classes, it will be of advantage to group them in three divisions : historical, clinical, and critical.

Historical.

The type of breathing which forms the subject of the present remarks has aroused a great amount of interest and produced a corresponding number of contributions to medical science. Occurring as it does, moreover, in the course of very various affec- tions, the symptom is, as might be expected, referred to in works on many different diseases. The literature of the subject has therefore assumed large proportions. Many of the writings which have been devoted to it are of but little value, and yet they have served a useful purpose by throwing light upon some of its phases, or by recording its presence in conditions where it had not been observed before. Others again are remarkable at once for their

EDIXBURGH MED. JOURN., VOL. XXXIV. — XO. VII. 4 E

586 DR G. A. GIBSON ON THE [jAN.

clinical acumen and critical insight. Many even of the most important are utterly unknown to the literature of this country, and it seems to be my duty, even at the risk of being here and there somewhat tedious, to mention, to an extent proportionate to their value, the different writings on the subject.

Hippocrates, like many other writers of antiquity, has suffered at the hands of his admirers, and his works have so often been wrested to suit the individual views of subsequent authors, that his name is only mentioned here with a certain degree of reluctance. It seems almost beyond doubt, however, that in the First Book of the Epidemics he makes reference eitlicr to the type of breathing about to be considered or to some nearly allied form of respiration. In describing the case of Philiscus, who died of an acute disease of a somewhat indefinite kind, accompanied by an enlargement of the spleen, he remarks^: — " Tovrew Tri/eviua Sia reXeo?, cocnre? avaKoXovimeuw apaiov, jmeya. In this case, the respiration until the end, like that of some one recollecting himself, was infrequent and deep;" or, as it has been rendered by Adams,^ "The respiration througliout, like that of a person recollecting himself, was rare and large." The last-named author remarks in a footnote, — " The modern reader will be struck with the description of the respira- tion, namely, that the patient seemed like a person who forgot for a time the besoin de respirer, and then, as it were, suddenly recollected himself. Such is the meaning of the expression as explained by Galen in his Commentary, and in his work On Difficulty of Breathing."

In his learned address on Medicine, delivered before the Edin- burgh meeting of the British Medical Association, Warburton Begbie^ called attention to this observation of Hippocrates, and the matter is put so clearly that it will be well to quote his words : — " It is, however, in respect to tlie peculiar character of the breathing that the case of Pliiliscus acquires its chief interest, and it is in this particular that a resemblance is to be found between the ancient and the modern examples now quoted. The attention of Hippocrates had been arrested by the peculiar char- acter of the breathing which existed throughout the fatal illness of Philiscus. Surely it is matter of interest and for reflection that the respiration described by Hippocrates as apaiou /neya, 'rare and large,' and to which Galen has attached the meaning, ' like a person who forgot for a time the need of breathing, and then suddenly remembered,' or 'the respiration throughout, like that of a person recollecting himself, was rare and large,' has attracted great attention in quite recent times. The expression used by French writers, * besoin de respirer,' corresponds in some measure to the meaning which is sought to be conveyed by the Greek

1 (Euvres completes d'Eippocrate, par E. Littre, tome ii. p. 684. Paris, 1840.

2 The Genuine Works of Hippocrates, vol. i. p. 371. London, 1849.

3 British Medial Journal, vol. ii. for 1875, p. 164.

1889.] PHENOMENA IN CHEYNE-STOKES RESPIRATION. 587

words. In Latin the rendering is, ' Spiratio huic perpetuo rara et magna fuit.' Daremberg, the learned French editor of Hippo- crates, thus translates the passage : ' La respiration fiit constam- ment grande, rare comme chez quelqu'un qui ne respire que par souvenir.' "

With the exception of this observation made by the Father of Medicine, the peculiar form of breathing which we are about to consider remained unnoticed until Cheyne, who carried the torch of medical science from our own shores to those of the sister island, observed it anew. In reporting' a case of fatty degeneration of the heart, he thus describes the type of the respiration : — " The only peculiarity in the last period of his illness, which lasted only eight or nine days, was in the state of the respiration. For several days his breathing was irregular ; it would entirely cease for a quarter of a minute, then it would become perceptible, though very low, then by degrees it became heaving and quick, and then it would gradually cease again : this revolution in the state of his breathing occupied about a minute, during which there were about thirty acts of respiration." In the description of the dissection, it is noted that there were between three and four ounces of fluid in the ventricles of the brain. A very interesting observation, which has most frequently escaped the notice of subsequent writers, is contained in a footnote, where Ciieyne remaiks:^ — "The same description of breathing was observed by me in a relative of the subject of this case, who also died of a disease of the heart, the exact nature of which, however, I am ignorant of, not having been permitted to examine the body after death."

Berton^ mentions changes in respiratory rhythm as being a common symptom in cerebral inflammations, and quotes some remarks by Dance, in which breathing, not very unlike that under consideration, is described. Subsequent French writers on children's diseases follow in the same path.

It has been stated that Flourens, in the course of his celebrated experiments, observed the occurrence of periodic breathing as the result of injury to the nerve centres. But in the first edition of his work^ there is no reference to such a phenomenon, while in the second edition the exact condition which is mentioned admits of considerable doubt. In the second edition, when criticising the observations of Marshall Hall, and describing the results of some experiments on the medulla oblongata,^ he says: — "Je r(5petai cette experience, sur un lapin. L' animal surv^cut h. Toperation

1 Dublin Hospital Reports, vol. ii. p. 216, 1818.

2 Ihid., p. 222.

3 Traite des Maladies des Enfants, p. 67. Paris, 1837.

* Recherches Exp^rimentales sur les Proprid/s et les Fondions du Systevie Nerveux, dans les Animaux Vertibi-es, p. 168 et seq. Paris 1824. " Ibid., Deuxieme edition, p. 206, 1842.

588 I)K G. A. GIBSON ON THE [jAN.

pendant a pen pr^s vingt-deux minutes : sa respiration n'etait plus, k la v^rite, continue ; mais elle se reproduisait de temps en temps, et surtout quand on irritait Tanimal." Such arrests of the respiration, as will be seen later, are regarded by some authors as belonging to the same series as Cheyne-Stolves respiration ; they are looked upon as essentially different by others.

West^ briefly refers to irregularity of breathing as frequently occurring in inflammations of the brain and meninges, and later authors in this country also do so,

Stokes, whose name, as well as Cheyne's, is now indissolubly bound up with the peculiarity of breathing in question, made it pathognomonic of fatty degeneration of the heart. Speaking of the symptoms of this condition he says:^ — " But there is a symptom which appears to belong to a weakened state of the heart, and which, therefore, may be looked for in many cases of the fatty degeneration. I have never seen it except in examples of that disease. The symptom in question was observed by Dr Cheyne, although he did not connect it with the special lesion of the heart. It consists in the occurrence of a series of inspirations, increasing to a maximum, and then declining in force and length, until a state of apparent apncea is established. In this condition the patient may remain for such a length of time as to make his attendants believe that he is dead, when a low inspiration, followed by one more decided, marks the commencement of a new ascending and then descending series of inspirations. This symptom, as occurring in its highest degree, I have only seen during a few weeks previous to the death of the patient, I do not know any more characteristic phenomena than those presented in this condition, whether we view the long continued cessation of breathing, yet without any suffering on the part of the patient, or the maximum point of the series of inspirations, when the head is thrown back, the shoulders raised, and every muscle of inspiration thrown into the most violent action ; yet all this without rale or any sign of mechanical obstruction. The vesicular murmur becomes gradually louder, and at the height of the paroxysm is intensely puerile.

" The decline in the length and force of the respirations is as regular and remarkable as their progressive increase. The inspira- tions become each one less deep than the preceding, until they are all but imperceptible, and then the state of apparent apnoea occurs. This is at last broken by the faintest possible inspiration ; the next effort is a little stronger, until, so to speak, the paroxysm of breath- ing is at its height, again to subside by a descending scale."

Hasse,^ writing a year later than Stokes, observes, in describing the symptoms of tubercular meningitis, that " long pauses occur

^ Lectures on the Diseases of Infancy and Childhood, p. 16. London, 1848. ' The Diseases of the Heart and of the Aorta, p. 324. Dublin, 1854, 3 Handhuch der speciellen Pathologie und Therapie, redigirt von Eudolf Virchow, iv. Band, i. Abtheilung, S. 473. Erlangen, 1855.

1889.] PIIEXOMEKA IN CHEYNE-STOKES IIESPIKATION. 589

now and then, as if the patients had for tlie time forgotten inspira- tion." This may, however, have been an allied type of intermittent respiration.

Schweig,^ writing in ignorance of previous observations, brings forward periodic breathing as a new symptom, and it is clear from his remarks that he had the true plienomenon of Cheyne and Stokes before him. He records several cases. In all there was a comatose tendency preceding or accompanying the onset of the symptom in question. After death, one was found to have thickening of the skull, several ounces of fluid in the left ventricle, a flabby, but otherwise healthy, heart, old tubercular masses in the pulmonary apices, and abdominal adhesions. No notice is taken of the state of the kidneys. The second, in which the author states there was no change in the pulse during the phases of the breathing, had thickening of the skull, dropsy of the ventricles, old tubercular lesions in the lungs, and atheroma with cardiac hyper- trophy. The state of the kidneys is not mentioned. The tliird was a case of renal disease with hypertrophy of the heart, dropsy of the pleurse, and oedema of tlie legs. Here again it is noted tliat neither phase of the respiration had any influence on the pulse. The head was not examined after death. In the fourth case there was atheroma of the vessels with fatty degeneration of the heart, thickening of the skull, and a considerable quantity of fluid in the left ventricle of the brain. The kidneys receive no notice. He lays stress in all these cases on the comatose tendency, and in the three whose heads were examined on the sclerosis of the skull, and the chronic hydrocephalus, but especially emphasizes the fact that on the left side in these three cases the foramen jugulare was greatly narrowed, and thus caused pressure on the vagus and accessorius nerves. After these remarks he describes another case in which, after various affections especially connected with the brain, pneumonia ensued, and was followed, after severe mental troubles, by periodic respiration with gradual development of coma. The author diagnosed thickening of the skull, narrowing of the left cranial cavity, left-sided hydrocephalus, and stenosis of the left fora- men lacerum. The necropsy revealed thickening of the skull with osseous deposits, oedema of the pia mater, bleeding points throughout the brain substance, distention of the left ventricle by fluid and some also of the right, atheroma of the basilar-artery, and great stenosis of the left jugular foramen, which was only one-third of the size of the opposite one. The heart was adherent to the pericardium and enormously hypertrophied, with atheroma of the mitral and aortic valves, great dilatation of the right side of the heart, a considerable amount of fluid in the pleurse, which were adherent in great part, and tubercular lesions in the lungs. Tlie kidneys escape observa- tion. A sixth case is mentioned, still alive when the paper was

^ Aerztliche Mittheilungen aus Baden, xi. Jahr{:;ang, S. 49, 1857.

590 DR G. A. GIBSON ON THE [jAN.

published, in which cardiac disease was followed by mental affections accompanied by periodic breathing.

Soon afterwards similar phenomena were produced experi- mentally, for we find that Schiff^ observed the characteristic breathing as the result of haemorrhages involving the medulla oblongata, but not directly affecting the vital spot. He says :• — " Injury of other parts of the medulla oblongata than that described above permit indeed life and breathing to go on, but probably through the accompanying haemorrhage, which influences the respiratory centre, it may modify the respiration in two ways.

" a. Every sliglit hoemorrhage upon the medulla oblongata, and every pressure upon it, makes the breathing less frequent and more laboured.

" h. If the haemorrhage be larger or the pressure greater, a peculiar symptom is observed in different mammals, the like of which I have as yet sought in vain for in human pathology, and to which I may direct the attention of physicians. The respirations entirely cease for a quarter of a minute or half a minute, then begin gradually, increase their rate, and afterwards wane, until a new pause occurs. This appears to be caused by variations in the amount of the pressure, which is of necessity dependent on the power of the heart beat." From this it is evident that Schiffs attention had never been called to the observations of Cheyne, Stokes, or Schweig.

Eeid,^ in reporting two cases of aneurism with this symptom, one of a man aged 60, the other that of a woman aged 59, notes that the pulse was periodically irregular, becoming less frequent during the respiratory distress, and more so when the distress was lessened.

In another paper^ the same author describes a case of aortic and mitral disease, without any change in the texture of the muscular walls on dissection, and from a study of it he concludes " that the symptoms of respiratory distress must henceforth cease to be looked upon by me as pathognomonic of fatty degeneration of that organ." He observes that in this patient " the pulse becariie invariably slow when the distress was greatest, and as invariably quick when it was subsiding, or whilst the patient had ceased to breathe." He is inclined to think that this change in the pulse is not a mere coincidence, " but that it and the distress stand towards each other in the relation of cause and effect ; " he does not, however, venture upon any theory.

Trousseau^ mentions, as characteristic of cerebral inflammations, a symptom, which, if not exactly the same as Cheyne-Stokes respiration, has a great resemblance to some forms of that type of

^ Cyclus organisch verhundener Lehrbiicher sdmmtlicher medicinischen Wissen- schaften, herausgegeben von Dr C. H. Schauenburg, ix. Theil, i. Band, S. 324. Lohr, 1858-59.

2 The Dublin Hospital Gazette, vol. vi. p. 308, 1859.

3 Ibid., vol. vii. p. 133, 1860.

* Clinique ATedicale de I'Hotel-Dieu de Paris, tome ii. p. 318. Pans, 1862.

1889.] PHENOMENA IN CHEYNE-ST0KE3 RESPIKATION. 591

breathing, as it has not only the cessation of respiration, but also the ascending and descending phases.

Eeferring to this subject in the third edition of his treatise, Walshe' remarks : — " I cannot avoid inferring that the proximate cause lies in a failure of the special nervous excitant of the respiratory act — in ana3Sthesia either of the vagus or of the medulla oblongata itself." This opinion is simply adhered to in the last edition of the work.^

In a lecture by Laycock, reported by Ropes,^ there is a descrip- tion of the peculiar breathing, and it is stated that the most probable explanation of the phenomena " is that a sentient palsy of the respiratory centre occurs, or a paresis of reflex sensibility of the mucous membrane of the lung."

hi a research undertaken with a view to solve some physio- logical and pathological questions connected with the brain, Leyden* notes that when the pressure is abnormally raised in animals there are changes in the respiration,^ The breathing became irregular, long pauses separating periods, during which respirations rapidly succeeded eacii other, so that, as the author states, there was a similarity to Cheyne-Stokes respiration ; there was never such a regular periodicity of the events or transition from the breathing to the pause. It is of interest to observe that in this contribution, in addition to changes of sensibility, mobility, and intelligence, the author noted' alterations in the pupils.

Head '^ recorded a case which presented this symptom, and in which fatty degeneration of the diaphragm was found after death, with atheromatous degeneration and dilatation of the aorta, and aortic incompetence. In this paper is a full notice of the condition of the pulse during the two stages of apnoea and dyspnoea ; from tracings taken by Grimshaw it was observed that the pulse was as strong during the former as the latter phase, wdiile tracings obtained from another case under the care of Little showed stronger pulsations during the cessation of respiration.

This type of respiration is said by von Dusch** to occur in affections of the brain, and in uraemic coma, and he also states that he has observed it in one severe case of pericarditis.

Little^ published a few cases in which the symptom was prominent, one being an example of fatty degeneration of the heart, another of aortic stenosis and hypertrophy of the left

^ A Practical Treatise on the Diseases of the Heart and Great Vessels. Third edition, p. 345. London, 1862.

2 Ibid. Fourth edition, p. 407. London, 1873.

3 The Medical Journal for 1864, p. 116.

* Archiv fiir pathologische Anatomie und Physiologie und fiir Klinische Medicin, xxxvii. Band, S. 519, 1866. 6 Op. cit., S. 553 und S. 554. 6 Op. cit, S. 549 und S. 550. '^ Dublin Quarterly Journal of Medical Science, vol. xliv. p. 405, 1867.

8 Lehrbuch der Herzkrankheiten, S. 153. Leipzig, 1868.

9 Dublin Quarterly Journal of Medical Science, vol. xlvi. p. 46, 1868.

592 DR G. A. GIBSON ON THE [jAN.

ventricle, and a third of renal disease with atheromatous degenera- tion and dilatation of the aorta, and thickening of the aortic valves. The author of this contribution ingeniously argues that the cause of the peculiar respiration is a loss of balance between the two sides of the heart, either tlirough diminished force of the left ventricle, as in fatty degeneration, or when some abnormal burden has been imposed on the left ventricle, under whicli it is unable to get rid of blood as quickly as it is supplied to it, and the blood accumulates in the left auricle and the pulmonary veins and capillaries. Being fully oxygenated, this blood fails to excite the terminal filaments of the vagus, as venous blood does, and the respiration ceases. A few pulsations then displace this blood, and the venous blood streaming in excites the respiration anew. He also states his belief that the altered rhythm of the respiration is only found when the lesion which has destroyed the balance between the two ventricles has been rapidly produced ; that when this is not the case the ventricles adapt themselves to the changed conditions.

Benson^ describes a case of mitral disease in which cerebral haemorrhage occurred followed by the type of respiration which we are considering, and he gives expression to his opinion that the theory propounded by Little is a " true account of the essential mechanism of the phenomenon," but adds that he thinks " a certain nervous complication is necessary to determine the accession of this peculiar form of respiration, and without which it would not occur." He also notes, in the description of his case, that it was only while the patient was allowed to remain in the semi-comatose state that the peculiar respiratory rhythm showed itself; when roused up, the respiration became almost normal, and assumed the ascending and descending character when the condition of stupor was permitted to return. He distinctly states liis belief that the nervous centres were incapacitated for work by the cerebral lesion ; that this produced arrest of the respiration, that the centres after a certain time regained their excitability sufficiently to reflect a motor impulse, thus re-establishing respiration, but that being weak, the centres could not sustain the effort and apnoea again occurred, and so on. He therefore concludes that there must in every case be a diseased condition of the circulatory and of the nervous mechanism, a double pathological condition, which he states as follows : —

" 1. A certain diseased state of the heart, by reason of which, indirectly, the excito-motor impulse upon the nervous centres, conveyed through the pulmonary branches of the pneumogastric, is diminished.

" 2. A certain weakened state of those nervous centres, by reason of which the reflecto-motor impulse is diminished,"

1 Dublin Quarterly Journal of Medical Science, vol. xlviii. p. 12V, 1869.

1889.] PHENOMENA IN CHEYNE-STOKES RESPIRATION. 593

This brings us to the period of the classical clinique, in which Traube expounded his theory, published by Frautzel/ and re- printed in his collected works.^ Describing a ca.se of aortic and mitral disease, with hypertrophy of the left and dilatation of the right ventricle, in which the phenomenon appeared after a sub- cutaneous dose of morphine, he takes the opportunity to mention the first case in which he had met with this symptom — one of cerebral haemorrhage — and refers to other instances of cerebral hemorrhage, as well as cerebral tumours, tubercular meningitis, and ursemic coma, which presented it. He concludes, therefore, that the peculiar type of respiration may occur in two classes of patients : 1. Those with healthy hearts, but diseased contents of the cranial cavity ; 2. Those with healthy contents of the cranial cavity, but diseased hearts. He further observes that the duration of the periods may be so short, and the pauses so inappreciable, that the phenomenon may escape notice ; that, towards the end of long pauses, muscular twitchings may occur closely resembling those seen when the artificial respiration is suspended in slightly curarised animals ; and that sometimes during long pauses the tension of the arteries rises, while the pulse-rate diminishes. He proceeds to point out that all the cases in which the pheno- menon is present have one characteristic — they have all a diminu- tion of the supply of arterialized blood to the medulla, where the respiratory centre is situated. There is thus a smaller supi)ly of oxygen, of which we know that it, in a higher degree, influences the irritability of the cellular nervous elements. Through this lessened amount of oxygen the irritability of the nerve cells l)ecomes so much lowered that a larger quantity of carbonic acid is required to cause an inspiration, and therefore the time within which the carbonic acid will accumulate in sufficient quantity is lengthened. This is similar to the effects of section of the vagi, in which long pauses occur in the respiration, attended by dyspnoea. The respiration may be excited in two ways : 1. By the pulmonary fibres of the vagus, whose peripheral terminations are probably washed by the blood, and whose central ends are connected with the respiratory centre ; and 2. By the aff'erent nerves coming from all parts of the body, which are able to send a sufficient stimulus to the medulla, as in the case of dashing cold water on the skin, and the well-known effect of the gastric portion of the vagus on the respiration. The diff'erence between these two is this, that the pulmonary endings of the vagi are bathed in blood containing much carbonic acid, while the others have a supply of blood which contains but little. If both be equally irritable, then in health only the pulmonic vagi will be called into action. If the vagi be cut the respiratory centre can only be excited by the other nerves,

^ Berliner klinische JVochenscJirift, vi. Jahrgang, S. 277, 1869. 2 Gesammelte Beitraye zur Fathologie und Physiologie, ii. Band, S. 882. Berlin, 1871.

EDINBURGH MED. JOURN., VOL, XXXIV. — NO. VII. 4 F

594 DR G. A. GIBSON ON THE [jAN.

and this can only happen when the blood circulating throughout the body is as rich in carbonic acid as that normally passing into the lungs. It must be borne in mind that tlie number of the vagus fibres is incomparably smaller than that of the other nerves ; when these latter act, therefore, the effect is correspondingly greater, and simple respiration becomes dyspnoea. Applying this reasoning to the phenomenon in question, we find that the lessened irritability of the respiratory centre, caused by the cerebral pressure, or uroemic blood, or deficient arterial supply, requires a larger amount of carbonic acid as a stimulus, and thus there is a long pause. When this gas has accumulated in sufficient quantity it first stimulates the pulmonary terminations of the vagi, but, as was shown long before by Traube, the strongest stimuli applied to the vagi never cause dyspnoea, and this only causes the shallow breathing which appears first after the pause. The amount of carbonic acid meantime increases sufficiently to cause stimulation of the nerves coming from the skin and other parts of the body, and hence the dyspnoea sets in. The quantity of the gas is greatly diminished by the forcible breathing, and the excitement of the other nerves ceases, so with the action of the vagi alone shallow breathing again occurs, until there is not enough carbonic acid gas to excite the pulmonary endings of the vagi, and a pause sets in anew, Traube ends by calling attention to the fact that the morphine directly induced the peculiar respiratory rhythm by reducing the irritability of the respiratory centre in a case where it was already at a low ebb.

Mader^ describes five cases in which Cheyne-Stokes respiration was present ; an extravasation into the floor of the fourth ventricle ; a tumour between the medulla, pons, and cerebellum ; an extra- vasation reaching from the right optic thalamus to the medulla ; an enlargement of the vertebral artery compressing the medulla ; and, lastly, renal disease with a tumour of the pons. He main- tains that the cause of the phenomenon must be sought in anatomical changes in the medulla oblongata, and opposes the view of Traube that the respiratory change can take place, without any palpable changes in its structure, through alterations in the circulation.

Hesky, ^ observed the occurrence of Cheyne-Stokes breathing during the course of a fatal case of enteric fever. The chief point of interest in his description is the fact that the pulse almost ceased during the long pauses ; the pulsation, indeed, appeared to become less before the respiration began to diminish. The section gave evidence, in addition to the characteristic abdominal lesions, of congestion of the brain and medulla, particularly of the floor of the fourth ventricle, and more especially of the points of origin of the vagus and hypoglossus. The author is of opinion

1 Wiener medicinische Wochenscrift, Band xix. S. 1447 und 1464 1869.

2 Wiener medicinische Presse, x. Jahrgang, S. 1107 und 1133, 1669.

I

1889.] PHENOMENA IN CHEYNE-STOKES KESPIEATION. 595

that the cause of the symptom is a smaller access of oxygenated blood to the centres, produced by the lessened activity of the circulation.

Esenbeck^ describes the case of a man, aged 62, belonging to an apoplectic family, and subject to no affection beyond nervous palpita- tion, who had about a year and a half before been attacked by apoplexy, which passed away without leaving any distinct sequelse in its train. He was again suddenly seized with unconsciousness accompanied by convulsive twitchings of the face and right arm, which became absolutely paralysed. Seven days after the attack the patient died in a comatose state. Thirty-six hours before death the rhythm of Cheyne-Stokes breatliing appeared, and continued until death occurred. On section, fatty degeneration of the heart was found. The skull was very thick, the meninges and ventricles of the brain contained a considerable amount of exudation, the vessels were turgid, and the brain substance showed " capillary apoplexy," but no patch of cerebral haemorrhage. The medulla was quite normal in appearance. The author points out tliat the result of the post-mortem examination agrees with what has been described by Stokes and Traube, and gives his adhesion to the theory advanced by the latter.

Leube,^ mentions three cases which he observed in von Ziemssen's clinique presenting this syn)ptom, one being an instance of fatty degeneration of tlie heart, anotlier of cerebral haemorrliage, and a third, which he narrates at length, of mitral stenosis with dilatation of the right ventricle, venous pulsation, hydrothorax, ascites, and albuminuria, in which the characteristic rhythm of the respiration came on after a subcutaneous injection of morphine. He remarks that at the beginning of the pause the pupils were contracted and underwent no change in size with alteration of liglit, and continued in this state throughout the pause. With the first returning breath, or, rarely, immediately before it, they dilated again. With the movement of the pupils there was a peculiar lateral deviation of the globes of the eyes, which M'as repeated with each change of the size of the pupils. With the commencement of respiration the globes became still, and during the respiratory period they performed the usual movements in every direction. He also observes that consciousness was entirely lost during the pauses, and further notes that during this phase the pulse was always smaller and more irregular than during the periods, but that the rate was unaltered or slightly increased. He attributes the pupillary changes to the action of the excess of carbonic acid in the blood on the oculo- pupillary centre, and refers to the observations of Vigouroux on the action of the iris in inspiration and expiration, and to the researches of Kiissmaul on the influence of the circulation on it, as well as to the investigations of Adamtik on stimulation of the

* Aerzliches hitelligemblatt, S. 253, 1870.

2 Berliner Klinische Wochenschrift, \u. Jalirgang, S. 177, 1870.

596 THKNOMENA IN CIIEYNE-STOKES RESPIEATION. [jAN.

corpora quadrigemina. Lastly, he mentions that in spite of deep inspirations produced by electric stimulation of the phrenic nerves, the onset and course of the period of breathing were unaffected. He notes that each deep inspiration thus produced by artificial stimuli was accompanied by dilatation of the pupils ; this, however, he says may be due to stimulation of the sympathetic in the neck by the current.

{To he continued.)

II.— THE INFLUENCE OF CERTAIN MEDICINAL AGENTS UPON THE BACILLUS OF TUBERCLE IN MAN.^

By G. Hunter Mackenzie, M.D. Edin. ; Vice-President for Scotland, British Laryngological and Rhinological Association.

The subject of this paper is one of great interest alike to the general physician and to the laryngologist. To the latter it is particularly so, as to him it pertains more especially to treat those tubercular lesions which, from being situated in the upper respira- tory regions, are, or ought to be, more amenable to local medica- tion than such as are located in the lungs.

Before proceeding to my subject proper, it may be as well to glance briefly at the conditions which accompany the presence of tubercle-bacilli in the respii'atory organs and tract, and in the sputum.

What are the prospects of an individual with tubercle-bacillary development and tubercle-bacillary sputum ? ^ M. Germain See^ says, "It is the bacillus which, a priori, should <''^ decide the lot of the patient. Theoretically this may be true. I am convinced, however, from numerous observations that, so far as life is concerned, the outlook in such cases is frequently not so gloomy as the acceptance of this dictum would lead one to infer. Thus a patient in whose expectoration I found these bacilli for the first time, nearly six years ago, while repeated examinations every year since then have continued to reveal their presence in numbers varying from about 150 to 300 (x 450), has had scarcely any fever, and has markedly increased in weight during this period. The remarkable thing is that for all these years she has hardly ever felt indisposed. In another patient I found them plentiful in the expectoration five years ago. I continued to make examina- tions of the sputum for about three years — bacilli were always present. Neither during that time, nor since, has the patient felt more than very slightly indisposed, and that very occasionally. In another case I found them in the sputum four years ago : the

^ Read before the British Laryngological and Rhinological Association, London, l4th November 1888. 2 Bacillary Phthisis, English Translation, p. 228.

1889.] BACILLUS OF TUBEKCLE IN MAN. 597

patient has had one or two attacks of what was described as "catarrhal pneumonia" since, but is now in tolerable health.

I might enumerate many similar cases which have come under my notice, but those referred to will, 1 think, justify us in as- suming that the presence of tubercle-bacilli in the sputum is not, per se, a grave indication so far as life, and even tolerably fair health are concerned. They do not in any way decide the lot of I the patient.

Nor do the numbers in which these organisms are present iu the sputum necessarily add to the gravity of the case. I except from this rule, however, those instances in which they are so persistently abundant as to be beyond power of enumeration, and especially when singly, or combined in twos or threes, they present comma-shaped outlines. But, speaking generally, I concur with* Germain Se(5^ when he says that "the multiplicity of these para- sites does not in any way indicate the gravity of the lesion."

There are, however, certain symptoms and collateral conditions which, plus the bacillus, may materially aid us in forecasting the lot of the patient.

The most important symptoms are fever, and consequent loss of body-weight. Tubercle-bacilli within the organism are not necessarily productive of fever. The evening temperature in many cases ranges from 98° to 98°*5, or at most to 99°; the body- weight may increase, and all the while bacilli may be found per- sistently present in fair average numbers in the sputum. What- ever may be the immediate cause of the phthisical pyrexia, it is certainly not due to the mere presence of the bacilli. On the other hand, I have seen comparatively few bacilli accompanied by a marked state of fever : this is a most ominous combination — a great deal more so than many bacilli and slight or no fever. I shall not now attempt an elucidation of these points, but content myself with stating the simple facts.

The principal collateral condition which materially contributes towards deciding the lot of the patient is, the locality of the tubercular lesions.

I have already brought under your notice the cases of several individuals who have led tolerably comfortable lives for years with tubercle-bacillary sputa persistently present throughout the period of observation. In all these cases the seat of the lesions was the lungs. When the larynx or pharynx has been the locality, or one of the localities, of the lesions, the course of the case has been very different, for I have rarely witnessed a case of genuine tubercle-bacillary disease of the larynx or pharynx with-, out its undergoing rapid deterioration. Bacilli, plus laryngeal or pharyngeal lesions, do decide the lot of the patient : there is no mistake about this. They may be said simply to swarm in the acute variety of laryngeal phthisis. ^^

^ Bacillary Phthisis, English Translation, p. 233.

598 DR G. HUNTER MACKENZIE ON THE [jAN.

I am unable to assign a definite reason why these bacilli be- come engrafted upon a case of chronic laryngitis, or lay hold of the larynges of certain subjects of pulmonary tubercle-bacillary disease and not of others. I do not believe that they come from the pulmonary expectoration in transit, for I have never yet been able to detect them in the secretion of the non-tubercular larynx in cases of pulmonary tubercle-bacillary disease. If in such cases one could find them in the secretion of the larynx hefore structural evidences of their presence were visible, one might assume that they were derived from the pulmonary expectoration. But such is not the case.

Whilst tubercle-bacilli, as already stated, may persist in the expectoration of certain subjects of tubercle-bacillary disease for years with no, or slight apparent results upon the general economy, and without inducing pyrexia or appreciable progressive local changes, still, in view of the fact that they are now considered by most competent authorities the essential factor in the pro- duction of tubercular disease, the most important indications of treatment is to get rid of them. How is this to be accomplished? My paper this evening is a short summary of many therapeutic observations made in this direction.

It may be assumed that there are three principal methods by which we may endeavour to influence the bacillus of tubercle, namely, by climate, by general, or by local remedies. Combina- tions of tliese may, of course, also be essayed.

In watching and estimating the effects of different climates upon these organisms one cannot help being impressed with two facts, — the obstinate persistence of the bacillus, and the remark- ably small amount of difference between the anti-bacillary virtues of the most diverse climates. Thus I have several times sent patients round the world, sometimes with a short sojourn in Aus- tralia, and they have uniformly returned in much the same con- dition as when they set out, so far at least as the bacilli were concerned. I have during successive seasons sent the same patient to Switzerland, the Riviera, and Algeria, without appar- ently influencing the numbers of bacilli in the sputum. In one case, the bacilli appeared to increase after leaving this country for the Riviera, and in another the same thing happened after going to Algeria. In one patient I found that almost continuous resi- dence for nearly three years in the Upper Engadine, whilst pro- ductive of great benefit to the patient's general health, and followed by a gain of 34 lbs. in thirty months, failed to drive the bacilli from the expectoration. I have compared the effects of residence on the sea (yachting) with residence on shore, and have been un- able to detect any difference in the result so far as the bacillary character of the sputum was concerned.

I may summarize on this point by setting forth the statement, based on a fair number of observations, continued in some instances

1889.] BACILLUS OF TUBERCLE IN MAN. 599

for years, that I have never yet witnessed the complete disappear- [ ance of tubercle-bacilli from the sputum follow on, or be induced i by climatic changes. The climate which has given most promise — certainly not marked — of proving inimical to their growth is one which is dry, with the minimum variation of temperature, wliich ought to be rather low than high. One beneficial aspect of a low temperature is its tendency to diminish the amount of expectoration, a result which almost always accords with a diminu- tion in numbers of the bacilli. If the hygrometric conditions are too low (air too dry), there is a risk of increased irritation of the bronchial mucous membrane and ensuing difficulty in expec- toration.

So far as general remedies are concerned I have little to say. I have frequently examined tlie sputa of patients before, during, and after courses of treatment by almost all the vaunted remedies and ( specifics, and am quite certain that not the slightest effect was I produced by any of tliem. To those who are desirous of investi- ' gating this part of the subject, I may direct attention to the state- ment of Leyden, that alcohol, by internal administration, has an antiseptic action on the pulmonary secretions, and that potash is abundantly present in catarrhal (bacillary) sputum,^ whilst soda is sparingly found. Alcohol should in this view be administered to, / whilst potash ought to be witheld from tubercle-bacillary cases. I cannot as yet speak as to the results of this treatment on the bacilli.

The subject of local medication will probalily be tlie most interesting to the members of this Association. What is the value, apart from soothing or sedative effects, and judged by the bacillary test, of the topical medicinal treatment, antiseptic or other, of tubercular lesions ? It ought to be borne in mind that an efficient antiseptic must possess both positive and negative qualities — it must be destructive to the bacillus and innocuous to/ its host. Were it not for the latter essential quality, it would not/ be difficult to select a host of bacilli destroyers.

I think I can affirm that bacilli may be found in the secretion of the tubercular larynx befoi'e ulceration has taken place, that is to say, in the stage of infiltration or thickening, — a period of the disease which it is occasionally difficult to distinguish from simple chronic laryngitis. In fact, I have not unfrequently made use of the bacillary test to distinguish between these two conditions, more especially when the former has supervened upon the latter, — a process which I have had the opportunity of carefully observing in a few cases, and of the existence of which I am therefore thoroughly convinced.

Whether, then, the condition of the tubercular larynx be one of infiltration, or of infiltration plus ulceration, the bacillus is there. It is unnecessary for me to eimmerate the methods by which local ^ Bamberger, quoted by Riegel, Ziemssen's Cydopcedia, vol. iv. j). 343.

i

600 Dll G. HUNTER MACKENZIE ON THE [jAN.

medication may be carried on. I would merely remark, that, in order to allow the medicament to act upon the diseased parts, it is necessary in all cases, before attempting topical medication, to effect ja. preliminary cleansing of the affected areas from all mucus or pus.

Probably no drug has, for its supposed aseptic properties, been more employed in the local treatment of tubercle-bacillary lesions than iodoform. For many years it was the remedy par excellence, and records of cases were not wanting in which its marvellous powers in this class of disease were apparently placed beyond doubt. As I have used the drug very largely, and made very many obser- vations on its effects upon the bacilli of tubercle, I select it prin- cipally as an example of remedies administered by insufflation. Though insufflation has been the principal mode in which I have employed it, I have occasionally aided this by internal administra- tion and by inunction.

I may refer to a case published by me in the Lancet,^ in whicli the bacillary results of application of iodoform to the larynx, its internal administration and inunction, all combined, are recorded in great detail. I there say that " treatment by iodoform was pushed as far as was considered judicious (iodic intoxication), but without effecting any reduction in the number of the bacilli, although it diminished the putrefactive odour of the sputum."

The same results have been obtained by me in many other cases of laryngeal phthisis, and I cannot but conclude that iodoform is an inert drug in this complaint.

Heyn and Eovsing^ distinctly assert that inoculation of a certain quantity of tuberculous material, accompanied by a relatively large quantity of iodoform is, in all cases, follow^ed by local, and subsequently by general tuberculosis. Not only so, but they affirm that iodoform appears to exercise an irritant action on the tissues, more especially upon delicate tissues such as the iris, and this irritation seems to render such tissue a favourable soil for the development of tuberculosis. Jeffries,^ as the result of a careful experimental inquiry, came to the conclusion that iod^j'orm js.jQOt a germicide; it has a decided tendency to stop serous oozing, and is therefore indicated in wounds where the moisture threatens the integrity of the aseptic and antiseptic dressing. It has further been found that, when to a virulent culture of the bacillus a strong jdose of iodoformized ether is added, the culture is arrested although !a temperature favourable to its growth is maintained. It even seems ito fade away, and yet a month afterwards, the induction of tuber- 'culosis is as readily as ever effected by it.*

I have for some time back entirely discarded iodoform in the treatment of tubercle-bacillary disease.

1 Lancet, 1885, vol. i. p. 187.

2 Quoted by MM. Filleau and Leon- Petit, Curabilitede laphtisie, May 1887. ^International Journal of the Medical Sciences, January 1888.

* Bulletin du laboratoire des docteurs, A. Filleau et Leon-Petit, May 1887.

1889.] BACILLUS OF TUBERCLE IN MAN. 601

Tlie method of spraying may be employed for the application of antiseptic medicaments to tubercle-bacillary lesions, as, for instance, to those of the larynx. By this metliod I have made use of carbolic acid, iodine, corrosive sublimate, and other antiseptics. The mode of operating- has been for the patient to use a Siegel's steam spray four or five times daily, from two to five minutes at a time. This is to be continued from one to three months, and the sputum to be examined twice weekly. The result, even with the bichloride of mercury (1 in 2500), has been the same as with iodoforn), absolutely nil. These sprayings, it may be remarked, if used too frequently or for too prolonged a period, tend to induce nausea and vomiting, and the bichloride of mercury blackens the teeth and tongue.

I consider dry inhalations as distinctly contraindicated in t\ laryngeal disease, on account of their desiccating and irritating ] effect upon the laryngeal mucous membrane. I have accordingly for years given up their use in tubercle-bacillary disease of the larynx, but have made a number of prolonged observations of their effects in the pulmonary variety of the disease. In this way I have used carbolic-acid, creasote, eucalyptus, iodine, and bromine, putting a few drops of one or otlier of these medicaments upon the S[)onge of an oro-nasal respirator, and causing the patient to breathe i the same for eight to ten hours daily for periods varying from six \ weeks to twenty months. In no single instance have i been able to satisfy myself that they influenced in the slightest degree the bacilli of tubercle. In one case already recorded by me with illustrative charts,^ and treated by this system for a period of twenty months, the bacilli actually increased in numbers during a most conscientious carrying out of this treatment.

The problem of affecting the germ of tubercle by either general or local medicinal agents has not yet been solved. The character of this organism has been fully and, I am afraid, accurately described by MM. Filleau and L^on-Petit^ as follows: — 'The bacillus of tubercle is, of all micro-organisms, one of the most refractory to the action of the most destructive agencies. It maintains its virulence after lying for forty days in putrid sputum, and for one hundred and eighty six days away from contact with air. It can live at temperatures between 86° and 104° F. The most unfavourable conditions, though affecting its activity, do not compromise its existence, for it resumes its virulence whenever its surroundings become suitable. To render it inactive, it is necessary to have recourse to violent means, such as ebullition, steaming, or prolonged contact with antiseptic substances, such as ammonia, concentrated salicylic acid, absolute alcohol, or a strong solution of carbolic acid. Corrosive sublimate itself is powerless to disinfect the sputum (Schill and Fischer).

^ A Practical Treatise on the Sputum, 1886, p. 78.

^ Le Crachat, by Hunter Mackenzie and Leon-Petit. Footnote, p. 133.

EDINBURGH MED. JOURN., VOL. XXXIV. — NO. VII. 4 0

'/

602 BACILLUS OF TUBERCLE IN MAN. [jAN.

" The bacillus acclimatizes itself amid the most unfavourable surroundings. It complies with the exigencies of its conditiou, and even alters its shape, but without losing any of its virulence, of which it gives ample evidence whenever fortune favours it. Its poly- morphism is not the least curious point in the life-history of this organism. Thus it is sometimes a short rod, sometimes a line — occasionally it splits, and forms spores — but it always returns to the bacillus in its complete form with its virulence intact, whenever circumstances become favourable. ' It knows how to suffer, but it never loses sight of its claims.' "

Gentlemen, in view of the above facts I am a sceptic in regard to the curability, by medicinal agents, of tubercular lesions, i.e., lesions due to the bacilli of tubercle, and in which their presence can be demonstrated. (This assertion does not, of course, embrace what are essentially surgical measures, such as scraping, galvano- or thermo-cauterizations, and tracheotomy.) Antiseptics in bacil- licidary strength as regards concentration and period of application cannot be borne by man, and what result can be expected from the application of a few grains of a powder, the intermittent use of a spray, or a short residence in a southern clime, or on an Alpine height, in the case of an organism which is not only extremely tenacious of life, but when unfavourably suited for growth, is always prepared to " bide its time," and bud and blossom afresh whenever it returns to favourable conditions ?

\

III.— CASE OF GANGRENE OF THE TRANSVERSE COLON IN AN UMBILICAL HERNIA ; REMOVAL OF 22 INCHES OF GUT; SUTURE OF THE INTESTINE: RECOVERY.

By J, M. CoTTERiLL, Assistant Surgeon, Edinburgh Royal Infirmary.

{Read before the Medico- Chirurgical Society of Edinburgh, 5th December 1888.)

In the spring of the present year, I mentioned at one of the meetings of the Medico -Chirurgical Society the case of a patient from whom I had removed a large piece of gangrenous transverse colon. The patient recovered from that operation with an artificial anus at the umbilicus, and I said that I hoped to complete the cure by some further operation, and report the case more fully at a later date. Accordingly, this evening I propose to read a short history of the case from its commencement, and to discuss briefly such points of interest as suggest themselves.

Mrs R., aged 38, was admitted from the Maternity Hospital into Ward VIII. of the Royal Infirmary on 14th April suffering from umbilical hernia. The previous history of the case was to the effect that the patient had suffered for seven years from an umbilical hernia of large size, which, however, had never given any

1889.] GANGRENE OF THE TKANSVERSE COLON. 603

trouble till ten days before admission. At that time the patient reports that she took a long walk, that the streets were slippery, and that she fancied she had strained herself by recovering herself in slipping. When she reached home the rupture was swollen and painful. Fomentations were applied, but as in a week's time she was no better she sent for her medical attendant. At this time Mrs R. was seven months pregnant, and as no success followed the attempts at taxis, a firm binder, which the patient was in the habit of wearing, was reapplied, and she was sent to the Maternity Hospital, as it was feared she was about to miscarry. The patient herself was under the impression that the cliild had been dead three or four days. At the Maternity Hospital no improvement took place, so she was transferred to Professor Annandale's Wards in the Infirmary, of which I happened to be in charge at the time.

On admission the following notes were taken : — The patient is a strong-looking woman, but enormously fat, being some eighteen stone weight. At the summit of a large fat abdomen, distended by a uterus seven months pregnant, is a bright-red, angry looking, brawny swelling about fourteen inches in diameter, and projecting some four inches from tlie general outline of the abdominal profile. The patient is anxious and in pain, and the face is pinched. Pulse, 110; temperature, 100''*2. No vomiting had taken place before her admission to the Infirmary, but as it came on a few hours afterwards, I was sent for. I found that she had vomited about six ounces of a coffee-coloured fluid containing blood; her pulse and temperature were rapidly rising, and she was evidently getting much worse.

I accortlingly determined to operate at once, and with the assistance of Dr Hodsdon and Dr George Keith I freely opened up the swelling by an incision some ten inches in length. When the sac was opened it was found to contain a large coil of gangrenous transverse colon, several large masses of omentum adherent to the sac and also gangrenous, and fluid fteculent matter which had escaped from the ruptured gut.

There appeared to be no strangulation at all at the umbilical opening, and the gangrene seems to have been caused by the pressure brought to bear on the contents of the hernia between the firm binder above and the pregnant uterus below.

We proceeded to cut away fifteen inches of colon which was absolutely gangrenous or beyo'ud recovery, cleared out the putrid omentum and most of the sac, and having washed the wound out thoroughly with sublimate lotion, stitched the cut ends of the gut to the edges of the skin wound, and got the patient back to bed in an apparently dying condition.

I will not detain you by a detailed account of the fight between life and death for the few days following the operation ; how a condition of profound collapse, as evidenced by a fluttering pulse of 160, Cheyne-Stokes respiration, and delirium, gradually gave

604 Mil J. M. COTTERILL's case of gangrene of the [JAN.

way before assiduous treatment. On the second day after the opera- tion tlie bowels moved through the wound for the first time. On the day following, i.e., 17th April, the patient miscarried. A seven months' child was born alive with one pain, the whole labour being over in the course of three minutes. The child survived about two days. The bowels were again freely moved during the labour, and there was considerable post-partum lunemovrhage.

The patient seemed to be considerably relieved by getting lier labour over, and all went well with her till 20th April, when, after a severe rigor and rise of temperature, she developed an attack of phlegmasia dolens, first in the left leg, and, a few days subsequently, in the right. This, however, ultimately cleared up, and she left the Hospital on 23rd June with the wound well contracted and healed round the artificial anus. The bowels at this time were acting loosely about six times a day, and she was in very good health.

During the three montlis that she was out of the Infirmary slie was confined a good deal to bed, for there was considerable prolapse of the intestine and discharge of faeces whenever she walked about much. Her discomfort was so great that she expressed a very strong wish to come back and have tlie artificial anus cured at any price, for, as she expressed it, "she would much rather die than go on as she was."

J had thought of trying to close the artificial anus by some modification of Dupuytren's operation, but was dissuaded from this by finding that fiuids injected from the umbilical opening into the lower segment of gut would not pass per anum, but regurgitated alongside of the syringe. This appeared to be due to a kink in the gut at the splenic flexion about eight inches from the cut end, which kink was presumably caused by the dragging of the gut downwards towards the umbilicus. The patient was accordingly prepared for the operation of resection of the gut and suturing of its free ends. For ten days previous to operation she was directed to be fed entirely on peptonized fluids, partly by the mouth and partly by the bowel, and the intestines were still further emptied by castor oil and several enemata both from the umbilical opening and from the anus proper. This last proceeding resulted in the passage of a scybalous mass of large size per anum.

The operation was performed on 30th Sept., and again I had the assistance of Drs Hodsdon and Keith. Having carefully cleansed the skin around the opening and having washed out the two cut ends of intestine, I put a ligature round the upper one to prevent faeces escaping into the wound, and then I freed them both from the adhesions which bound them to the umbilical ring and surround- ing parts. Gentle traction was then made upon the two ends until normal gut covered by peritoneum protruded sufficiently for my purpose. Instead of using a clamp I passed a piece of thin india- rubber tubing through a small hole in the mesentery and round the gut, fixing it there with a pair of catcli forceps; I then cut away

1889.] TIIANSVERSE COLON IN AN UMBILICAL IIEIINIA. 605

four inches of the upper segment of colon and three inches of the lower, with portions of mesentery attached. The two pieces of intestine were, as usual under such circumstances, found of very unequal size, the upper segment admitting four fingers, while the lower, in which function had been in abeyance for five months, would only just admit the forefinger. Though I succeeded in dilating it a little, this inequality in the two ends added very greatly to the difficulty of the operation. Tins difficulty has been got over in one or two cases by cutting the lower bowel away obliquely from its mesenteric attachment so as to increase the area to be sutured. By the very careful passage of over a hundred stitches I was able to get the ends satisfactorily together.

I used fine curved needles, round like a dressmaker's needle, and threaded witli the finest Chinese twisted silk. The method used was the modification of the Lerabert suture by Czerny, i.e., a double row of interrupted sutures, which lie completely outside tlie bowel, and are passed through the serous and muscular coats of the intestine alone. The outer row is about one-third of an inch out- side the inner row, and the stitches of one row are about a line distant from one another.

The cut edges of the mesentery were then sutured together, and the gut was returned into the abdomen. The large umbilical open- ing was brought together by deep silk stitches, and a firm pad and binder applied. A hypodermic injection of ;^th of a grain of morphia was given, and the patient was put back into bed, having been just three hours on the table.

During the first twenty-four hours after the operation there was a little fever and restlessness, the tempei'ature once rising as high as 102°, but in a day or two it became practically normal, and has remained so ever since. Wind passed freely the day after the operation, and the day following there was a free liquid movement of the bowels. From that time she has made an uninterrupted recovery, the bowels moving about every other day. She was fed exclusively on peptonized fluids for three weeks after the operation, but for the last six weeks has taken soup, porridge, minced chicken, etc., and is now taking ordinary diet. There has never been any pain beyond a little occasional griping from the passage of wind along the bowel ; but that has now quite ceased. A little compound liquorice powder is taken every two or three days to keep the stools soft.

She was discharged from the Infirmary on 25th November in excellent health.

Without attempting to generalize from so small an experience, there are certain convictions which have forced themselves upon me in connexion with this case.

Firstly, that it is of the utmost importance, even in the case of a surgeon who is frequently operating, that this operation should be practised on the dead body before trying it on the living. The

606 MR J. M. COTTElilLL's CASE OF GANGRENE OF THE [jAN.

confidence that one lias really closed the gut, and the celerity in operating which are obtained by such practice, cannot be too highly valued, for one cannot test by any means on the living body whether the sutures liave been applied in such a way as to render the gut water-tight before it is returned into the abdomen ; and it is most important not to waste any time in the performance of an operation which is very tedious at the best.

Again, judging from several hours' practice of the operation, I cannot say that I see the necessity for the introduction into the lumen of gut of any of those materials, such as india-rubber collap- sible bags, lumps of cocoa-butter, etc., which have been used for the purpose for dilating the gut during the process of suture. As a matter of fact, I believe that most surgeons who have had any experience of the operation are now coming to this opinion.

With regard to the clamps which are recommended for this operation, though I liad the two most frequently used (Bishop's and Treves') by my side, I used neither of them, as they appeared to hamper one's movements very considerably, and neither of them were long enough in the blade to efficiently clamp the large intestine. The piece of india-rubber tubing, applied as I have described, acted adnurably. The best form of clamp appears to be that of Mr Makins of St Thomas's Hospital. It is less complicated and cumbersome than the others, and has the advantage botli over the method I used and over Treves' clamp, that no wounding of the mesentery is necessary for its application. Tliis is somewhat important, as the experiments of Eydygier and Madelung go to show that separation of the gut from its mesentery is apt to he followed by gangrene of the bowel at the denuded part.

The idea that an assistant's fingers should take the place of a clamp does not commend itself, for neither would the control of the gut during a long operation be so reliable, nor does this plan leave the operator so mucli room to work in, unless more healthy intestine is pulled out of the abdomen than would be necessary if a clamp were used.

I was prevented upon the occasion of the first operation, by the extreme prostration of the patient and the intense putridity of the parts concerned, from suturing the gut and returning it into the abdomen at once.

It has been established, chiefly by statistics drawn up by Mr Makins, that the best results after resection of intestine are obtained in cases of operation for the cure of artificial anus (the mortality in this class being 38 per cent, as contrasted with a mortality of about 50 per cent, when all cases are taken together). In other words, it appears less hazardous to do the operation in two stages rather than complete the operation at the time of the removal of a gangrenous portion, when the patient is frequently in an unsatisfactory condition, both locally and generally, for such a serious proceeding. It is, of course, undeniable that the patient

1889.] TRANSVERSE COLON IN AN UMBILICAL HERNIA. 607

lias in the former case to undergo two operations instead of one in the latter ; but it seems probable that this apparent disadvantage is in some instances, at any rate, more than counterbalanced by the lessening of tlie mortality after the operation when it is done at the later stage. Upon the other side must be borne in mind the increased difficulty in the secondary operation due to shrinking of the lower disused portion of intestine.

Of the thirty-three different methods of suture which have been recommended for the purpose, the one I employed, namely, Czerny's modification of Lembert's, is most in favour. It cer- tainly appears to fulfil the chief requirement of bringing two broad surfaces of the peritoneal aspect of each segment in good apposition with one another; and judging from experiment on the dead body, the double row of sutures is evidently of service in preventing the immediate escape of fluids from the sutured bowel.

A study of the reported cases of resection and suture of intestine shows that, while a certain number of successful operations have been performed on the small intestine, chiefly by German surgeons (and amongst others by the late Dr Angus Macdouald, who, in the course of an operation for ectopic gestation, removed some six inches of small intestine), tiie large intestine has very seldom been successfully dealt with in like manner.

Mr Hardie {Medical Chronicle, Jan., 1885) reports a case where he resected three inches of colon for artificial anus with a successful result. Mr Kendal Franks has within the last few days published a case in wliich he successfully removed a large epithelioma with six inches of colon ; and Professor Weir of Xew York informed me a few weeks ago that he had in one case resected six inches of colon with a good result.

In the case I have brought before you, no less than twenty- two inches of large intestine were removed in the course of the two operations.

IV.-PERSONAL EXPERIENCES OF A WINTER IN THE CANARY ISLANDS.

By H. CouPLAND Taylor, M.D., F.R. Metl. Soc.

As so many members of the medical profession, as well as of the general public, are seemingly anxious to know what the prospects are of these favoured islands affording a desirable winter resort for those who require a warmer and more equable climate tlian that of the Riviera, and yet a drier one than that of Madeira, the following personal experiences of a medical invalid, who spent last winter in them, may not be devoid of interest to those inquiring as to their suitability for invalids.

The island of Teneriffe may be most quickly reached and with the greatest comfort by the fine ocean steamers of either Messrs Shaw,

608 DK II. C. TAYLOK's experiences of a [JAN.

Savill, & Co., or of the New Zealand Shipping Company, both of which sail monthly from London, and calling at Plymouth, from which they take only four and a half to five days. The Castle Line of packets to the Cape call at Las Palmas, Grand Canary, once a month. Tiie British and African Company's ships sail weekly from Liverpool, calling both at Teneriffe and Grand Canary, and take about nine days on the voyage. They are smaller, slower, and cheaper boats than the above-mentioned, and vary very nmch in their accommodation, some being clean and good, others dirty and uncomfortable.

Las Palmas, the capital of Grand Canary, faces nearly due east, and is built on a flat strip of land at the base of some barren hills, and lies between them and the sea. The town has a very Moorish appearance, nearly all the roofs of the houses being flat, and many only one story high. I landed at the port, which is about four miles from the town, about the middle of October, with several other invalids, and we then drove along a very dusty bare road to the English hotel, which is situated in the town of Las Palmas itself. Even at that time of the year we found the heat greatly too oppressive and debilitating for those who are not strong, and it was much complained of by those both there and at Orotava. The beginning of November is therefore as early as invalids should arrive, unless they go direct to either of the two high stations in Teneriffe, viz., Laguna, 2000 feet, or Villa Orotava, 1200 feet, at both of which there are now very good English hotels, and at both of which, indeed, the entire summer may be spent without incur- ring any great heat, — a great convenience to those invalids who dare not return to England during the summer. Many of the residents in Orotava and Santa Cruz go up to these places with their families in May and remain till October, during which period, Dr G. Victor Perez of Orotava informs me, the weather is most pleasant.

The general accommodation and food in the hotels at Las Palmas are fair, though invalids have not hitherto been much considered, in fact, have rather been thought de trop. But the great complaint against them is that they are all essentially badly situated for in- valids, being placed more or less in the streets of a particularly noisy, dirty, and odorous town ; neither is it possible within an easy walk to get out of these narrow streets for fresh, pure air and the gentle exercise which are so essential for the phthisical. The invalids had, therefore, to drive daily to the fine sandy beach about a mile and a half off, a quite unattainable distance on foot for invalids in the hot sun experienced there, and spend the morning on the shore. Often, however, as there was no shelter of any kind to be obtained, the more susceptible of the invalids found the strong and cool north-east trade wind too much for them, and they had to return to the close atmosphere of the town and hotel rooms. There being no villas to be obtained, every one is forced to take up their quarters in the town hotels. Until, tliere- fore, there is accommodation with good sanitary arrangements

1889.] WINTER IN THE CANARY ISLANDS. 609

provided away from the streets of the town, with gardens, shel- tered balconies, and such like conveniences for the delicate, so that invalids can obtain fresh air without constantly inhaling the foul odours of the streets of a drainless town, Las Pal mas does not seem to fulfil the elementary requirements of a health resort. Indeed, from the amount of illness there last season amongst the visitors, especially diarrhoea and typhoid fever, the former of which almost universally attacks all new-comers, whether healthy or delicate, whether they are indiscreet in their use of fruit or never touch it, it appears scarcely a satisfactory winter resort for any one, and many and great have been the disappointments of those who have gone there with expectation of spending a pleasant winter, and of returning home in improved health.

Leaving Grand Canary at the end of November, I spent the re- mainder of the winter in the island of Teneriffe. The steamers take about six hours, or frequently a night, in going from Las Palmas to Santa Cruz, the chief town and port of Teneriffe. There is a fair English hotel at Santa Cruz, but it labours under the same disad- vantages as those at Las Palmas, and few persons stay there more than a day or two, though I hear an English boarding-house has been opened this season, under the superintendence of an English medical man. Though at present neglected, it seems probable that for tlie months of January, Eebruary, and March, Santa Cruz has the best climate in the islands, for, as it has a southern aspect, the clouds which so constantly gather in these islands and Madeira around the high mountains and extend up to the zenith, do not inter- cept so much of the sunshine as in those places, such as Orotava, which are situated on the north or east sides of the islands. Again, it is more protected from the cool north-east winds to which those places lie exposed, and which are grateful enough later on in the spring, but are rather trying to many invalids during the earlier months of the year.

From Santa Cruz to Orotava is a long six or seven hours' drive, the road passing through Laguna, above referred to, at a height of nearly 2000 feet. Many find this drive very trying, not only from its tediousness and the nature of the carriages employed, but also on account of the cold winds, fog, and wet frequently experienced during the winter months at that elevation. It is most injudicious, therefore, for persons to throw aside their wraps and put on light underclothing, as they are so apt to do on arriving at Santa Cruz, for several cases of serious chill and illness were caused thereby during last season.

On arriving at Orotava, I found that the Grand Hotel itself, which had been so highly praised, could only entertain about twenty persons ; so, like the vast majority of visitors, I was placed in one of the more or less unhygienic dependencies, situated in the centre of the town, and devoid of gardens, etc., which make so much difference in the value and pleasantness of a place for invalids.

EDINBURGH MED. JOURN., VOL. XXXIV. — NO. VII. 4 H

610

DU H, C. TAYLORS EXPERIENCES OF A

[JAN.

One soon found, however, that Orotava had many advantages over Las Palmas, even in its present condition; but not only so, its pos- sibilities were much greater. To begin with, the town is far smaller, and within a very few minutes' walk of any part of it there is a fine sea-beach bounded by a nice level road, which could very easily be made into a splendid promenade. Again, though the town is placed on a low peninsula of land and very little raised above the sea-level, the ground rises very rapidly, almost pre- cipitously, at the back of the town to a sloping plateau with an elevation of about 300 feet, thus affording splendid sites for the future building of villas. Here the new hotel company have already commenced to build a fine hotel, which, it is hoped, will obviate many of the disadvantages of position, arrangement, and manage- ment so bitterly complained of by many visitors during last season.

Though Orotava is situated on the north side of the island, it does not experience the cool north-east trade winds in such force during the winter months as Las Palmas, for the island of Teneritfe is not then so directly in the track of these winds as that of Grand Canary, though it has the advantage of experiencing them as con- tinuously during the summer months, when they exercise a grateful and cooling influence on the climate. Vegetation is decidedly more prolific than around Las Palmas — a very barren place — thus rendering the country far more beautiful and pleasant, though indicating a rather damper climate. The rainfall is, however, only about 14 inches in the year, and the ground being composed of volcanic scoriae and rock, is very porous and quickly dries.

My meteorological observations taken at Orotava for the past season were as follows {vide Table), by which it will be seen that 50° F. was the lowest temperature recorded, and that the mean temperature of the five winter mouths, 62°"8 F., is almost identical with the mean summer temperature of London, i.e., 62°'3 F.

Becord of Temperatibre taken at Port Orotava, Winter 1887-8.

Mean for month, .	November. Fahr. . 65-7	December. Fahr. 64-6	January. Fahr. 62-2	February. Fahr. 60-4	March, Fahr. 61-5
Mean maximum, .	. 71-6	70-2	67-8	66-5	67-5
Mean minimum, .	. 59-8	59	57-6	54-4	55-6
Mean range, . .	. 11-8	11-2	11-2	121	11-9
Highest maximum,	. 77	821	74-5	73	761
Lowest minimum, .	. 53	56	50	50	53
Approximate amount ) of sunshine, . . . j	Hours. 180	Hours. 1791	Hours. 163	Hours. 234
Rainy days (daylio only), ....	;ht) _	3	5	8	5

^ Hot (S.E.) wind, occasionally experienced from Africa, and corresponding to the Leste of Madeira. The obsei-vations for November were taken by a friend.

1889.] WINTER IN THE CANARY ISLANDS. 611

Note. — Thermometers with full northern exposure, no Stevenson's screen, which probably renders the result rather lower than if one had been used.

The mortality from plithisis is small, though the natives are by no means exempt; and the death-rate per 1000 at Orotava for the following years was as follows :— 1875, 0-94; 1876, 047; 1877, 1-0 ; 1878, 1-62 ; and in 1879, 1-41. The general death-rate varies from about 14 to 22 per 1000.

Before closing, I cannot refrain from adding a few words on Madeira. Though this island is far better known both to the profession and to the public than the Canaries, and has been much frequented by invalids for the last forty years, yet it has lately to a certain extent gone out of fashion since the rigorous treatment of phthisis by wintering in Alpine regions came into vogue. The disadvantage urged against the climate is its humidity, which, however, is by no means excessive, the relative humidity being almost identical with that of Cannes (which Dr Marcet gives as 73 per cent.), though undoubtedly the rainfall and number of rainy days are greater. Madeira has, however, no mean advantages in other respects, — firstly, in the good food obtainable (in striking contrast to the Canaries) ; secondly, in the entire absence of dust ; thirdly, in the hotel comforts, and the unusual way in which the proprietors lay themselves out to meet the wants and requirements of invalids. Indeed, it is very rare to find in any of the hotels of the many health resorts of the Continent (and I speak from expe- rience) such consideration and attention paid to the invalid as is done here. It has suffered, however, in the past from the position of the hotels, for I feel convinced, if they had been more judiciously placed in the outskirts of the town (as, for instance, the excellent situation of Mr Card well's new hotel, which is on high ground facing the sea, with ample space around it, so that the bracing sea breezes are constantly felt), so many complaints of the climate being enervating, oppressive, and relaxing would never have been heard.

Teneriffe has great capabilities for a health resort in its dry and equable climate, but labours under many disadvantages through its lack of development, which, however, are mostly removable by time and good management. Madeira, on the other hand, has scarcely such a good climate, being certainly damper, but it has at present the advantages pertaining to a well-developed health resort.

612 MR T. ARTHUR HELME ON THE [jAN.

v.— THE PHYSIOLOGY OF THE THIRD STAGE OF LABOUR: A CLINICAL CONTRIBUTION.

By T. Arthur Helme, M.B., Physician to the Women's Dispensary, Edin- burgh ; formerly Buchanan Scholar and Clinical Assistant in the Gyne- cological Department, Royal Infirmary, Edinburgh.

{Read before the Edinburgh Obstetrical Society, lUh Nov. 1888.)

The following account of a labour, which I have the honour of presenting to the Fellows of this Society, possesses a special interest, inasmuch as its facts seem to have a clear bearing on the now much-debated question of the Separation of the Placenta. In regard to this we have at present two main ideas, the one directly opposed to the other : according to tliose who hold by the one, the placenta is separated during the time when the area of the uterine wall is becoming smaller; while according to those who hold by the other, the placenta is separated during the time when the area of the uterine wall is becoming larger. The following case (in addition to other points of interest) presented an almost unique opportunity for observing the clinical aspect of this question, and it is to this portion of the history — dealing with the Third Stage — that I w^ould particularly draw attention.

I was asked by Dr M'Call, to whose kindness I am indebted for the following particulars, to see Mrs T., aged 35, an viii.-para. Labour had set in early in the day, but pains continued very slight till nearly 5 o'clock. The child was born at 5.15 P.M., the doctor arriving immediately thereafter. Finding the abdomen still of large size, he examined the patient, and found the os cervix occupied by a bag of membranes, but no part of a foetus was palpable, nor were any heart-sounds audible with the stethoscope. At 7 o'clock, as pains did not return, I was asked to see the patient. On examination the following condition presented itself: — Abdomen immensely dis- tended and almost globular, the superficial veins very striking. The size of the abdomen would have been remarkable even in an ordinary single pregnancy, and of its appearance before the expulsion of the first child it would be difficult to form any conception. On palpation the walls of the abdomen were exceedingly tense and elastic ; the uterus could not be recognised as a distinct sac, and no foetal parts could be felt within ; while on percussion a fluid thrill was most markedly given as one is accustomed to feel it in an ovarian cyst, showing the extreme distension and thinness of the uterine wall. Auscultation revealed no foetal heart.

Per vaginam, the cervix was widely dilated, the bag of mem- branes presenting; on pushing this upwards, while the patient was lying on her back or side, no foetus could be felt, but on placing her in a half-sitting posture, one felt a small hard body,

1889,] PHYSIOLOGY OF THE THIRD STAGE OF LABOUR. 613

resembling a knee, fall upon the examining finger, immediately receding on exercising the slightest pressure from below. There was evidently a very considerable amount of liquor amnii. As two hours and a half had elapsed since the birth of the first child (and no placenta had escaped), I ruptured the membranes, and after the escape of a large quantity of fluid, I passed my hand away up into the uterus, and found that, situated on the dorsum of the child in the cervical region there was a cystic body, very thin walled, and about the size of a large orange, evidently a spina bifida. It was impossible to deliver the head and this together safely, and during its passage through the pelvis, the thin cyst wall ruptured. The cord, in which no pulsation could be detected by the time the child was delivered, was ligatured and divided. (Two ligatures were used, and the cord divided between them.) No inspiration was made by the child, though movements of the lips occurred, and after the cord had been cut, a few feeble trials were attempted, though never sufficiently deep to draw air into the chest.

The fundus of the uterus was grasped by the liand, but re- traction was very slight, probably owing to the previous over-dis- tension, and contractions were almost absent — in fact, the uterus remained in a flabby condition, feeling like a piece of bowel rather than anything else. By steady kneading and friction (owing to the now laxness of the abdominal walls, one had perfect control over the uterus) an occasional contraction was called forth, the uterus making a fairly respectable imitation cricket or prefer- ably football, to be again succeeded by a rapid relaxation of the uterine wall, so that the fundus reached above the umbilicus, about half-way between it and the xiphoid cartilage. This went on for half an hour with slight hnemorrhage. As tlie latter seemed to become rather freer, eight minims of ergotinin were injected hypodermically, and a vaginal douche of hot water administered, but this only called forth a weak response on the part of the uterus ; the haemorrhage, however, was reduced. On passing my fingers into the interior of the uterus, both placentae were found to be still attached to the uterine wall; 1 therefore grasped the uterus externally between my hands, and gently compressed it; this provoked a strong contraction, the uterus becoming firm, and as it was felt becoming smaller and smaller, the patient called out that something was coming away — it was a placenta which had separated while my hands were grasping the uterus ; it escaped into the vagina, whence it was expressed, being born edge first, and folded as Matthews Duncan has described. This was the placenta belonging to the child last born. The uterus immediately again became flabby, reaching up above the umbilicus; and now bleeding had become more active — instead of a faint dribbling it began to trickle away. On passing the hand into the interior of the uterus I found that partial separation had taken place, the placenta being

614 Mil T. ARTHUR IIELME ON THE [jAN.

detached at its lower extremity. By kneading and pressure one or two very faint contractions were aroused, followed by full relaxation, tlie uterus extending up above the umbilicus, and feeling like a piece of bowel in which the blood could be felt crackling. I decided to prevent any further loss of blood by removing this second placenta by the hand. This was done without "any difficulty, the placenta leaving the uterine wall easily and cleanly : the points that struck me most forcibly being the extreme tenuity of the uterine wall — it seemed to be like two or three sheets of writing paper between the fingers of the two hands — and the looseness of the placental attachment to the uterine wall.

I have reported this case fully because of its not uninteresting relation to the important subject of the phenomena of the Third Stage. Of late this subject has been prominently brought under the notice of this Society in its anatomical and purely physio- lof^ical aspects, but clinical observations are much needed, for, although anatomical study will, and must, take a necessarily important part in helping to build up the foundation of its explanation, it is to clinical study that the chief part belongs ; with it, indeed, lies the final accepting or rejecting of the results obtained by other methods, according as they agree or disagree with clinical experience.

Dr Berry Hart has lately propounded an entirely novel view of these phenomena ; he suggests that the separation of the placenta is brought about, not, as usually supposed, by the diminution in area of the uterine wall, but by an increase, i.e., the placenta separates during relaxation of the uterus, not during its contrac- tion. Hart's words are : — " Placenta and membranes separate when there is a disproportion at the plane of separation between their area and their site of attachment. This disproportion is only slight, as the trabeculse are microscopic. This disproportion happens during the Third Stage in the relaxation following a pain, and^ therefore, separation occurs after the pain. The gist of the view advocated is that the placenta separates in the Third Stage after the pains, and is expelled, when separated, by the pains." ^

The facts of the case above related bearing on this problem may be thus summarized : —

1. Here is a uterus at the conclusion of the Second Stage containing two placentae, both attached to the uterine wall.

2. Placenta No. 1 is that belonging to the first child, born three and a half hours before the second child. The first child breathed and cried loudly before its cord was ligatured, so that all con- ditions were fulfilled to make this placenta what Dr Hart calls " practically a bloodless structure." On Dr Hart's relaxation theory, therefore, this placenta is favourably placed for separa- tion.

1 " On the Third Stage of Labour," Edin. Med. Joiirn., Oct. 1888.

1889.] PHYSIOLOGY OF THE THIKD STAGE OF LABOUR. 615

3. Placenta No. 2 is that of the second born child. This child did not breathe before the cord was tied, so that the placenta was not aspirated, hence its foetal half is not a " bloodless structure," and on Hart's theory this placenta is unfavourably placed for separation.

4. While contractions and retractions were only slight, relaxation was extreme, the fundus receding to a point above the umbilicus after expulsion of the second child.

Here, then, is a relaxed uterus, containing on the one hand Hart's bloodless placenta, and on the other hand a bloodful placenta. If the uterus could be made to contract and relax, we should naturally expect the aspirated placenta to separate first. But what really happens ? In the first place neither placenta is separated during relaxation ; and afterwards that placenta is the first to separate whose foetal blood has not been aspirated ; while the other placenta remains attached to the uterus, though its blood has been aspirated.

But, further, as to the time and method of separation. The placenta which came away first (namely, that belonging to the second cliild), \\as sejMvated not during relaxation, hut during a pain. During the relaxed condition of the uterus, I ascertained, by passing my hand into the uterus, that both placentte were attached (No. 1, the larger, over the posterior, right, and upper portion of the uterus, extending over the fundus ; No. 2, the smaller, to the left and front and below), and after one or two slight contractions, brought about by kneading and friction, with subsequent extreme relaxa- tion. On renewed examination I again found hoth placeiitoi still attached to the uterine wall. It was immediately after this last examination that I compressed the uterus (gently, not violently), and -was relieved to feel a response, the uterus becoming firmer or harder — in fact, contracting well, and then suddenly becoming smaller, a placental mass being extruded with its lower edge first. There was no doubt at all that this placenta No. 2 separated during a genuine uterine contraction, brought about by a stimulus applied externally. It was not artifically driven out, nor forcibly torn away, but separated naturally during a uterine pain.

After this the uterus again became distended, so that the fundus came to be at a higher level than the umbilicus, and yet this extreme relaxation did not detach the remaining placenta though it was " practically bloodless."

Stimulation had the effect of setting up one or two slight contractions, but neither these nor the subsequent relaxations detached the placenta. It was therefore artificially detached; separation presented no difficulty ; there was no special bleeding (in fact, circulation seemed to have almost stopped in the maternal as well as foetal part of placenta), nor were there any points of morbid adhesion, the finger passing along the plane of separation between the layers almost as easily as through butter. Its com- plete non-separation seemed to me to be entirely owing to want of

616 MR T. ARTHUR HELME ON THE [jAN.

uterine contractions. The points then that these observations sliow are that —

1. Of the two placentae, that whose foetal blood was not as- pirated was separated and expelled, while the placenta whose foetal blood had been fully aspirated was not separated.

2. With regard to the placenta spontaneously detached, its separation occurred during a pain, alter complete relaxation had failed to detach it.

3. With regard to the placenta artificially detached, complete relaxation of uterus failed to detach it, and, owing to the non- occurrence of contraction, it remained unseparated.

These facts may be shown as follows : —

Non-aspirated Placenta.	Aspirated Placenta.
Was spontaneously detached. Relaxation failed. Contraction succeeded.	Was not spontaneously detached. Relaxation failed. Contraction separated lower bor- der and then was absent.

Appendix.

The question may be raised. Why the placenta of the first child did not separate along with the placenta of the second child, since they were subjected to the same contraction ? It seems to me that there were three factors which influenced this —

1. The Mass in the Uterus. — When both placentae were present there was a large mass on which the weak uterine power could act. This power was not able to separate both. It separated the one and not the other, because of 2 and 3.

2. Tlie Condition of the Bloodvessels. — The one placenta was emptied of blood, and the other full of blood. As the uterus becomes smaller, a placenta full of blood will not follow the diminution in area of its site to the same degree as a placenta which contained little or no blood, and so will come to be stripped of.

3. The Relative Positions of the Two Placentce. — That situated lowermost separated first. During separation it has been noted that the placenta in some cases is detached first at its lower margin,^ so here the placenta situated lowermost was first separated.

Another question arises as to whether there was any morbid adhesion of the last separated placenta. I think certainly not, on the following grounds: — 1. No adhesions were felt; 2. The separated placenta had a normal and healthy appearance ; 3. The child was healthy, and born at full time ; 4. The other placenta

1 " The Third Stage of Labour : A Criticism of papers by Cohn, Champneys, and Berry Hart," by A. H. F. Barbour, M.A., M.D., F.R.C.P.E., ^f?. Med. Jour., August 1888.

1889.] PHYSIOLOGY OF THE THIRD STAGE OF LABOUR. 617

was healthy, and separated of itself, and what reason is there that this uterus should develop in its interior a healthy and an unhealthy placenta at the same time ? 5. The placenta was partially separated at its lower margin, and if the contractions had been powerful enough it would probably have been entirely separated.

But the essential point is that relaxation failed to separate both the placentae, so that, even if the second placenta were "adherent," the fact still remains that relaxation failed to detach the first.

VL— NOTES ON REPORT OF THE DEPARTMENTAL COM- MITTEE APPOINTED TO INQUIRE INTO PLEURO-PNEU- MONIA AND TUBERCULOSIS IN THE UNITED KINGDOM.

By Dr Peel Ritchie, Vice-Pres. Med.-Chirurg. Society, Pres. R.C.P. Ed., etc.,

F.R.S.E.

{Read before the Medico- Chirurgical Society of Edinburgh, 7th November 1888.)

In submitting to your consideration the following notes on the Report of the Departmental Committee appointed to Inquire into Pleuro-Pueumonia and Taberculosis, it may be well, first, to briefly recall the association of this Society with this most important inquiry, especially as no reference to the Society's action appears in published Transactions. On the 15th of February 1888, Prin- cipal Thomas Walley, M.R.C.V.S., in an elaborate paper on Animal Tuberculosis in relation to Consumption in Man, directed our attention to the relation existing between animal and human tuberculosis. After a very full discussion of the pathological and scientific aspects of the subject, I moved that, as a practical result, it be remitted to the Council to take steps to carry out some of the author's suggestions, by approaching by memorial, on the one hand the legislative authorities, and on the other the municipal, for improved and extended legal enactment was not only necessary, but the local enforcement of such powers as were already possessed called for more rigorous application. Accord- ingly, a memorial in the following terms was presented by the President in name of this Society to the Marquis of Lothian, Secretary for Scotland, on the 23rd of March 1888 : —

" My Lord Marquis, — The Medico-Chirurgical Society of Edinburgh having had the subject of animal tuberculosis in its relation to man under con- sideration and discussion along with that of other bovine diseases alleged to be prejudicial to the safety of the community, would most respectfully approach your Lordship, in order to express their sense of the serioiis nature and momentous importance of these matters. The Medico-Chirurgical Society is composed of the medical practitioners of Edinburgh, as well as of other non- resident medical men, and numbers among its members many who are cognisant not only of the evil which has been clearly traced to these sources, but deeply impressed with the necessity for some active measures being

EDINBURGH MED. JOURN., VOL. XXXIV. — NO. VII. 4 I

618 DK PEEL RITCHIE ON [jAN.

adopted for their prevention. The Society would therefore earnestly pray your Lordship to use your influence and the powers with which you are invested to bring into operation the statutes and enactments of the Govern- ment towards the prevention of those evils, and, if necessary, for the introduction of additional means for the regulation and supervision of the whole traffic in milk and in butcher's meat supplied to the inhabitants. I have, with the authority of the Medico-Chirurgical Society, the honour to address you, my Lord, on the subject, and in its name to subscribe myself, — Your Lordship's obedient, humble servant, John Smith, President."

On receipt of his Lordship's reply of the 16th April, the Secretary, Mr Cathcart, again communicated with him on the 20th. the Departmental Committee of the Privy Council had commenced to take evidence on pleuro-pneumonia and tuberculosis on the 17th April.

"Edinburgh, 20th April 1888.

" My Lord Marquis, — I have the honour to acknowledge, by instruction from the Council of the Medico-Chirurgical Society, the receipt of your Lordship's communication to the Society through their President, Dr John Smith, dated 16th April 1888. I am directed to inform your Lordship that the Council of the Medico-Chirurgical Society beg respectfully to urge, that the object of the inquiry on bovine tuberculosis will be best served by their sending two members to give evidence on the subject. One of them, Dr Henry Littlejohn, 24 Royal Circus, Medical Officer of Health for this city, will be prepared to refer specially to the etiology of the disease, and to its presence in cattle sent for slaughter and kept in dairies. The other, Dr R. Peel Ritchie, 1 Melville Crescent, President R.C.P., a man of wide clinical experience, will be able to give information as to the transmissibility of the disease to the human subject from the lower animals, — I have the honour, etc.,

Chas. M. Cathcart."

To this a reply, of date 24th April, in the following terms was received : —

" Sir, — I am directed by the Marquis of Lothian to acknowledge the receipt of your letter of the 20th inst., proposing that two members of the Medico- Chirurgical Society of Edinburgh should be nominated to give evidence before the Committee now sitting to inquire into the subject of contagious pleuro- pneumonia of cattle, etc. ; and I am to acquaint you that a copy of your com- munication has been laid before the Privy Council for the information of the Committee, — I am, etc., B. W. Cochran Patrick."

In due course the following letter was received by Mr Cathcart from Mr Richard Dawson : —

Agricultural Department, 44 Parliament Street, London, S.W.

Pkivt Council Office. April 26th, 1888.

" Dear Sir, — Your letter of April 20th has been forwarded by the Secretary for Scotland to the Privy Council, and laid before the Departmental Committee on Pleuro-Pneumonia and Tuberculosis. I am desired by the Committee to thank you for this communication, and to say that they will have pleasure in hearing the evidence of Dr Henry Littlejohn and Dr R. Peel Ritchie. The Committee think it advisable to take this evidence towards the termination of the inquiry,— I am, etc. Richard Dawson, Secretary to the Committee."

After my perusal of the foregoing correspondence, it appeared to me to be necessary, as I had been nominated one of the repre- sentatives of the Society, seeing it was the views of the Society I was to state rather than my own as an individual, that the secretary

1889.] PLEURO-PNEUMONIA AND TUBERCULOSIS. 619

should intimate to the Fellows — such Fellows as were thought suit- able— that it was considered advisable, in the interests of the Society, that they should supply me with the facts, so far as they were at liberty to do so, which tended to support the view that bovine tuberculosis was capable of being transmitted to human beings, either by the milk of affected animals, or by the consumption of their flesh, for the experience of one individual at this early stage of this inquiry was not yet sufficient ; and, also, that the combined observation of many was therefore the more necessary, if due effect was to be given to the memorial of the Society. In reply to this appeal, I regret to say there was only the response, that those written to " have no evidence which they are in a position at present to have brought forward."

On 17th May Mr Oath cart intimated he had received a letter from Mr Dawson to the effect, that it had been decided to summon your representatives to give evidence on 29th May. Whilst informing Mr Catlicart that I had written Mr Dawson that I was ready to attend on that day, I requested that a meeting of the Council should be called in order that I might consult as to the evidence it desired to bring before the Departmental Committee. I submitted the views I proposed giving on behalf of the Society. They received the general approval of the Council, and I thereafter wrote Mr Dawson, that " the line of evidence I propose to submit to the Departmental Committee is, 1st, The reasons wliich led the Society to address the Secretary for Scotland upon the subject of bovine tuberculosis ; 2nd, The evidence submitted to the Society ; and, 3rd, The necessity for further experimental inquiry being made into the transmission of bovine tuberculosis to man."

At the meeting of Council it was approved that the points regarding — 1st, the state of cow-houses, dairies, and milk sliops, and the laws concerning tliem ; 2nd, The exposure and seizure of diseased meat in slaughter-houses and markets ; 3rd, The existing powers in dealing with diseased meat or milk; and, 4th, The further extension of these powers by enactment of Privy Council or legislation — should be left for the evidence of the other repre- sentative of the Society, Dr Littlejohn.

It is not necessary that I should further allude to the memorial to the municipal authorities.

Before considering the Committee's Eeport as a whole, it may interest you to learn the terms and nature of the evidence given by your representatives.

As my evidence expressed the views of the Society, it was taken first, but as explanatory of the absence of reference to the Contagious Diseases (Animals) Act, I desire to mention that my evidence was taken as that of a physician, and as approaching the subject from the public health side ; and that, as expressed by one of the Committee, Prof Brown, " an Order emanating from the Privy Council under the Contagious Diseases (Animals) Act, must not have any direct reference to the public health, but must refer

620 DK PEEL KITGHIE ON [jAN.

to the prevention and spreading of the disease amongst the lower animals." It was left, therefore, to Dr Littlejohn to press this point. My examination commenced by the Chairman asking as to the representations made by the Society to the Secretary of State for Scotland upon bovine tuberculosis and the reasons for doing so. In reply, I stated the facts with which you are already familiar, the reading of the paper by Principal Walley, the discussion that ensued, in the course of which it was evident that his statements had made a profound impression, and a motion had been carried unanimously that the Government and the municipality of Edin- buigh should be approached — the latter with regard to the stricter enforcement of legal enactments regarding byres and dairies ; the Government, because the subject was one concerning which there was considerable doubt in the minds of many at present, and it could be better examined into if Government, rather than private investigators or individual members of the profession, were to take it up. I was then asked to give a brief summary of the evidence brought before the Society. In doing so I took the opportunity, first of all, on account of the very great difficulty of diagnosing tubercle in the early stages in cattle, to point out the necessity for skilled inspectors. I then spoke of the bacillus of tubercle as the cause of the disease, and showed that most competent authorities held the doctrine that the tuberculosis of bovines and the tuber- culosis of the human subject were identical, that the apparent differences in the bacilli were accidental, and due to the differences in the media in which they were developed and the rapidity of their growth. We held that the identity of the bacilli being proved showed that, if there was not a probability of communication, we nearly all agreed there was a very great possibility; and I went on to say that the contagiousness of tubercle had already been declared by other societies, mentioning especially the meetings of the National Veterinary Association in London in 1883 and in Man- chester in 1884, and that of the International Medical Congress at Copenhagen in the same year. I further showed that contagion was possible in three ways : first, by the ingestion of tuberculous meat, of wiiich, however, we had as yet no proof; second, by the milk from tuberculous cows; and, third, by inoculation from sores to sores — that was to say, from sores upon the udders to sores upon the hands of those who handled them. In support of these two latter methods I gave particulars of the cases which Principal Walley laid before the Society, in which consumption, tabes raesenterica, and meningitis occurred in persons partaking of the milk of tuberculous cows, aud one in which a boy with sores on his hands was infected from sores on the udder. I also spoke of the impression made on members by Dr Woodhead's observations on the phthisical death-rate in an establishment supplied by a dairy in which he and Professor M'Fadyean found evidence of tuberculosis in the udders of three cows. A question arises as to whether tubercle in the general system of an animal is sufficient to affect the milk.

1889.] PLEUKO-PNEUMONIA AND TUBERCULOSIS. 621

or is it only in cases of tubercular udders that the milk is danger- ous ? Observation points clearly at present to the latter condition only. I then narrated two cases which occurred in my own practice to support the view that tubercle might be conveyed by cow's milk if a like condition occurred in the human subject. These were the cases of two mothers, previously healthy, who be- came affected during the suckling of their infants — the one with her first, the other with her third child. Tlie infants, when respectively

4 months and 7 months, died of tubercular meningitis ; and the mother in one instance died four and a half, and in the other four months afterwards of pulmonary phthisis. The grounds on which I supposed the infants were infected by the mothers' and not by the cow's milk on which they were latterly fed being the subse- quent death of the mothers from tubercular disease. Both mothers, previous to the infants becoming apparently affected, suffered from irritation of the mammary glands ; they never suppurated, but there was nodular inflammation of the glands. I was examined at length upon these cases. I next stated that we also felt, as a Society, that the frequency of tubercular disease in infancy re- quires explanation, and mentioned that in Edinburgh during the last ten years the average death-rate from tuberculosis under

5 years of age has been 6 "8 per cent, of the deaths — that is to say, of 44,616 deaths at all ages, 3054 occurred under 5 years of age from tuberculosis. I also stated we have been in the habit in the past of putting these down to hereditary influences. I here gave in a table prepared for me by Dr Littlejohn, showing the deaths, and pointed out the frequency with which disease of the glands of the abdomen and inflammation of the brain occur in young children. I handed in a table, prepared from a larger one of Dr James's, showing the total deaths in Scotland from tabes mesenterica and tubercular meningitis during ten years, 1876-1885, under 5 years of age, prepared from the Eegistrar- General of Scotland's returns. During that time 7415 deaths occurred from tabes and 13,216 deaths from tubercular menin- gitis ; and " it was found that, with the exception of the first three months at the respective ages, inflammation of the head always caused the larger number of deaths." I continued, — " Now, it occurs to myself that possibly the greater number of inflammations of the brain have been preceded by disease of the glands of the abdomen. One point is this, that in the first three months the tabes is in a larger proportion, but at all other periods between the three months and five years of age tubercular menin- gitis is the largest number. Tubercular meningitis, according to the return, may thus be regarded as one of infection from tuber- culous glands. The glands, therefore, possibly may have become affected from the milk which the children have been fed on (I am merely speaking as a possibility) ; and the secondary disease, inflammation of the brain, may have thus often resulted." In course of further questioning upon this head I observed, — " Men-

622 DK PEEL RITCHIE ON [jAN.

ingitis being much more rapid in its fatal course, presents the more urgent and formidable symptoms, and to it is assigned the cause of' death ; whilst tlie tabes, being less evidently active, may be overlooked, or not mentioned, in the certificate of death." I con- cluded this part of my evidence by stating that, — " So little is the subject known amongst medical men at present, that I interviewed, before coming up to tliis Committee, between forty and fifty of our leading medical men in Edinburgh, and, with the exception of Dr Woodhead, none of them had seen a case in a human subject which they could say resulted from bovine tuberculosis. They had in several instances had suspicions that such a thing might have occurred ; they nearly all agreed as to the possibility of its occurring. Some of them doubted its possibility ; but they were all unanimous in this, that the subject was one of such great importance that they thought an inquiry on the part of the Government was necessary to allay the popuhir mind and the doubts at present existing." I gave it as my opinion that this inquiry should consist of experiments and investigation into the modes of communication of the disease, that it should be extensive in character, and con- ducted by a Board which should not confine its labours to one part of the country. As to the causes, I thought the conditions tlie cows are kept in lead to it, and referred to their insanitary state in Edinburgh. Tlie want of exercise in stall-fed cows aided in pro- ducing a state of health favourable to development of tubercle. Artificial feeding had, I also thought, some influence, the cows being fed on milk-producing foods rather than upon blood and flesh improvers. In-and-in breeding might act by predisposing to hereditary constitution.

In answer to questions by Prof. Horsley, I said the Society had not considered the evidence of the communication of the disease from a husband to a wife ; that though the disease might be intro- duced by inhalation, we thought it was not so in cattle. Possibly the cow got it in the stall or from the insanitary state of its surroundings. Cows were apt to lick what had passed from the mouth of another affected animal if it had dried up on the stall in which it was, and in that way the bacilli might be introduced into the cow's system. I had no figures to show the actual connexion between diseased milk or flesh and tabes mesenterica and meningitis, but that it was on these and such points that we w^ere at present so much in need of enlightenment, and that it would be highly advisable for the general sanitary condition of the nation that an inquiry into them should be instituted; that we desired, if possible, to have a check put on the way in M'hich diseased animals at present are exposed for sale, are slaughtered, and are treated, and so strengthen the hands of the veterinary inspectors in getting these animals properly looked after. I considered that a thorough and regular inspection by skilled men was necessary to prevent the spread of the disease among cattla and its transmission to the human individual, and that such

1889.] PLEUKO-PNEUMONIA AND TUBERCULOSIS. 623

inspectors would require special training in the use of the micro- scope and the detection of the bacilli.

The Chairman and Mr Stirling both put questions as to the phthisical and ordinary death-rates in Edinburgh of late years, to which I replied that tlie ordinary had diminished, and it was not found that the deaths from phthisis were increasing, but it was one of our difficulties that we did not know when or how long this condition that we were now wanting information about may have been continuing or going on. I stated further that the diminution in the death-rate was largely in consequence of the excellent sanitation of the Medical Officer of Health. I was also asked as to the destruction of the bacilli, and said that in milk properly boiled the bacilli were killed, but I could not speak with certainty as to the spores.

Professor Brown then took up the questioning with inquiry as to my views as to skilled inspectors, but I referred him for infor- mation regarding those now engaged at this work to Dr Littlejohn, repeating that they would require to be specially trained in the use of the microscope and the methods of demonstrating bacilli. My examination concluded with questions by the Chairman whether milk should not be supplied from country dairies under proper medical and sanitary conditions rather than from town dairies ; but I held, as the introduction of the late epidemic of scarlet fever had been from the country, that I did not see why our town dairies should not be made perfectly capable of supplying good milk.

Dr Littlejohn was then called and examined. After preliminary questions he informed the Committee that in Edinburgh the carcase of an animal affected with tuberculosis was not allowed to be sold except the disease was limited, the glands unaffected, and the flesh on section sound ; that the authorities had no data to prove that the use of flesh of animals so affected had any effect on the public health (but this was a matter for further investigation and experiment) ; that they had no power to seize tubercular animals in the markets or cowsheds, nor of preventing the milk from such animals being mixed with that from healthy animals. They had powers to seize diseased meat, but they wanted more than that — to take the live animal. He would like that they should have similar powers to those which he believed were enjoyed in England and Ireland, so that their inspectors might take any animals from the public markets which exhibit a sus- picious appearance of emaciation, summoning the veterinary in- spectors of the corporation, and craving powers from the magistrates to have that animal destroyed. He thought the Greenock people had such powers under a clause in their Act of 1877. He was also of opinion that tuberculosis should be included in the Contagious Diseases (Animals) Act, because this would give them power to prevent the milk of suspected animals being mixed with other milk or sold for human food, and would take from local

624 PLEURO-PNEUMONIA AND TUBERCULOSIS. [JAN.

authorities the excuse that they had no power in dealing with this disease, and as public opinion was being so much directed to this point, it would compel these authorities to more stringently enforce the Dairies, Cowsheds, and Milk-shops Order than they do at present. He was under the impression that tuberculosis was on the increase, and gave figures showing that in Edinburgh in 1877, 51 carcases out of 29,665 total cattle, and during the first five months of 1888, 46 carcases out of 10,756 were condemned. Com- pensation he spoke of with diffidence, but would be inclined to grant it only where a mistake had been made. He considered the disease was more common among dairy than among ordinary farm stock, but could not say with certainty that tuberculosis could be communicated from the bovine animal to the human sub- ject. That the disease was more common among dairy stock was due, he thought, to the manner in which their town dairies were managed. The ventilation was usually bad ; everything was kept in a state of constant damp ; the animals tied close up against the wall and close together, without provision for the proper cubic space, and never moved out from the one year's end to the other, until they were taken away for slaughter. He recommended notification, but thought that, having regard to the difficulty of diagnosis, a man should not be punished for not giving notice. He thought it desirable that milk should be examined by the microscope and other means, and would make the examination for the tubercle bacillus a part of the ordinary inspection of the dairy. He did not, however, suggest it as a remedy, unless it was proved to his satisfac- tion that in every case of tuberculosis they could detect the peculiar bacillus in the milk, which he strongly doubted, because, as far as his own experience had gone, he had only found it in cases where the udder had been markedly affected. Asked as to the propor- tionate distribution of the disease in the bodies of animals,he said he had chiefly observed it — first, in the pleura and peritoneum; second, the liver ; and third, the glands generally. The lungs were rarely affected, the animal apparently being killed before they became so. He had never observed deposit of tubercle in the muscle of a bovine animal, but had in that of a pig, and had seen it also in the joints and bones, but usually the animals were killed before the disease had become so extensive. He had no evidence of the spread of the disease from one animal to another.

The remainder of Dr Littlejohn's examination had reference to the carrying out of the Milk-shops Order, the temperature neces- sary for the destruction of the bacillus of tubercle, the status and pay of the inspectors, the necessity for public abattoirs, the inspec- tion of country dairies and the disposal of their milk to middlemen, the dairy companies in England and Edinburgh, and their special private sanitary arrangements. The water supply of Edinburgh dairies was then touched on, and the risk from its not being satis- factory or imperfect in country dairies, concluded his evidence.

{To he continued.)

1889.] INAUGURAL ADDKESS TO THE ROYAL MEDICAL SOCIETY. 625

VIL— INAUGURAL ADDRESS TO THE ROYAL MEDICAL

SOCIETY, 26th October 1888.

By Professor W. S. Greenfield, M.D., F.R.C.P. Lond. and Ed.

Mr Phesident and Gentlemen, — When I was invited to deliver the Inaugural Address on this occasion, both my first and second thoughts were to decline the honourable but arduous task. For not only did I feel myself unequal to it at the best of times, but the an- ticipation of a special pressure of work during the vacation made it certain that I could not do it justice. That I consented was due to the fact that I felt that this Society had a right to command any feeble services which I could render, having conferred upon me what I esteem as one of the greatest honours of my life, that of becoming one of its Honorary Fellows — an lionour which, so far as I am aware, I have never done anything either to deserve or to repay.

The light in which I regard this Society probably differs from that in which it is viewed by most of you ; for in past years I dwelt in a city where this University and Medical School were but little known, and were greatly misconceived. But in the obscurity enshrouding the little known, and so far as known much repro- bated. Medical School of the North, there shone out one bright particular star, one redeeming feature. A graduate in medicine of tliis University, or a licentiate of the Colleges, whatever distinction he might have attained, had as such no honour ; but a man who had been a President of the Royal Medical Society, and still more a Senior President, whatever that mysterious distinction might import, was regarded as of necessity a man of mark, and as one who had a passport to fame. This, and this alone, far outweighed and superseded any other testimonial in competition for an ap- pointment. It is easy, then, to understand how deeply I felt the honour conferred upon me by this Society. Fate had for ever debarred me from the possibility of becoming a president, but such alleviation as was possible you afforded me.

The enormous prestige and world-wide reputation enjoyed by this Society are well grounded. When one glances at tlie roll of past Presidents, and others who have been prominently connected with it, one cannot but be struck with the familiarity of the majority of the names. These men have become known to fame by their discoveries or their writings, and few have failed to justify in after life the opinion formed of them by their fellow-students.

This Society has just completed the 150th year of its more definite existence. Its reputation has become matter of common notoriety. Nowadays, however, antiquity and historical reputation mean little or nothing. We live in an age which is largely de- structive in effect, though constructive in intention. Much that is worn out and useless is destroyed, but much, too, which can never be rebuilt or restored. But as things are it is often safest to say

EDINBURGH MED. JOURN., VOL. XXXIV. — KG. VII. 4 K

626 PROF. W. S. GUEE^TFIELD'S INAUGUR.VL A.DDRESS TO THE [jAN.

little about antiquity, lest the iconoclast's hammer sliould be upon us. Nor in any case is it wise or safe to rely on the past. In a Society like this everything depends on the present. We must ad- vance with the times ; or the times, which after all can get on very well without us, will go on and leave us behind. Adaptation to new circumstances, fresh developments to meet new needs, are essential.

I am not without fear that even the Students' Union, much as we desire its success, may for a time have a prejudicial effect upon this Society. Not that it will at all take its place as a centre of thought or scientific activity, but that some may feel that they cannot give the time or the money to both institutions in their functions as reading-rooms or social resorts. It will, then, be necessary for this Society in every possible way to increase and maintain all the advantages for study and research which it affords, as well as to promote its more special work.

But, after all, what constitutes the strength of a Society like this, and its surest ground of success, lies in the men who have composed and do compose it. It is a human, and therefore a living association, bound to the past by the character and life of those who have lived in it, and to the present by the friendship and co- operation of living members. So long, therefore, as the character and ability of its leading members are such as they have been, it caimot fail. Three of the strongest motive forces to influence the human spirit are united in its support — hero-worship, co-operation, research. Let me say a few words on two of these — hero-worship and research.

It may seem strange to you that I should put hero-worship first. It is so historically, and I believe that it is in fact one of the most powerful motive forces affecting every man's life. In all profes- sions and sciences this is true, and in Medicine — the most human of professions — this most human tendency is seen at its strongest ; and I believe that, if rightly directed and properly restrained, it is one of the most powerful influences for good.

It may be alleged that 1 am mistaken as to its frequency and influence, that nowadays every one thinks and investigates for himself independently, and that the maxim, " Nitlliits in verba magistri jurare," is firmly ingrained in every student from his youth up. It may be perfectly true that there is now little nominal respect for this or that authority. In the old days the pupils of every noted teacher or healer spoke of him as their master, and were proud of tlieir connexion with him. His dicta were quoted and regarded with superstitious reverence. Every one knows how the sayings of Hippocrates, Aristotle, Galen, Avicenna and Averroes, Sydenham, and others, were followed long after their death, and how rival schools under lesser lights waged terrible battles for or against some theory of disease or mode of treatment.

But the historian of the future will find in this present age precisely similar facts, so little does human nature change. He

1889.] ROYAL MEDICAL SOCIETY. 627

will tell of the battles between the schools of Virchow and of Cohnheim ; of the great trio of heroes, Pasteur, Lister, and Koch ; of the long battle waged between the followers and opponents of the antiseptic system, and of its ultimate triumph. Or, going further back into a now remote period, he will tell of the struggle which preceded the abandonment of bleeding as a common means of cure, of the introduction of anaesthetics, and of the discrimina- tion of various forms of continued fevers. And in every case there will be the same tale — the leader or leaders of progress, its opponents, and their respective followers. It is the law of Nature, men must be bound together in progress, and the strongest and tallest will lead, and be acknowledged as leader.

But it is not exactly in this light that I wish to speak of hero- worship ; nor when I use the term do I mean that blind idolatry which is often connoted by the expression. The Darwin cultus, for instance, which consists in intense admiration of his great genius, his earnest, patient, scientific investigations in the midst of suffering, of his acuteness in observation, his skill in planning and carrying out experiments, and his honesty and modesty in regard to his work, is the very opposite of that blind adoration which accepts his speculations as laws of the universe, and his tentative suggestions as infallible dicta,

I believe that every man should have a hero, or more than one. I never met any man who had done anything considerable in life, and who was himself looked up to as a leader, who did not (if one had the opportunity to discover it) reveal the fact that he had at least one hero. For the most part the hero was some one who had, by direct teaching or personal example, communicated some- thing of his own character or vitality. But I have known one whose hero was Hippocrates, and I have heard of another in whose gallery John Hunter was most notably enshrined.

Now, I do not see why hero-worship should not be regulated and cultivated both by the individual and the society. For the indi- vidual it may be that the hero, like the poet, nasciiur, non fit. There must be individual adaptation and recognition. And on this I will only say, be sure that you have at least one hero. You may, indeed, have several — one for your personal life, another for your public life, and yet another for your scientific and medical life. And as the medical hero is especially my subject, let me caution you not too readily to take your professional hero, but to make him first the subject of some study. Be sure that he is taller than yourself. Let him be large enough to appear life size to you when you have put him on a pedestal, and let him be some one whom you will be likely to be able to follow for at least ten years of your professional life. I know, indeed, that one must occasionally revise one's list. 0. Wendell Holmes speaks of dropping a friend over- board every now and then in the course of life, to see how fast one is progressing, just as in heaving the log at sea ; and one may need to drop a hero in the same way, or to take on another. The best

628 PliOF. W. S. GREENFIELD'S INAUGURAL ADDRESS TO THE [jAN.

kind of leading hero is one who combines various qualities, whose character and life are an example and a stimulus, whose scientific energy and method give an impetus to your own, and whose achievements make him respected by others as well as yourself.

I think this Society would do well to cultivate the memory of its heroes. You have here not merely the record of their names, but the beginnings of their work ; you can trace back to the early germs the ideas and methods of work which were fruitful in their after life. In these somewhat forbidding and dull looking volumes of Dissertations you will find the piece of work which, perliaps, was that to which the man ever after looked back as his best, because done with all his youthful freshness and enthusiasm.

I have often thought that on some such opportunity as this I would try to present you with some record of those whom I have known intimately, but who have now passed away, who were in their time Presidents of this Society ; but I will only venture to say a little of one who is especially worthy of record — Charles Murchison. Murchison's name is, indeed, commemorated by his works and by the Scholarship in Clinical Medicine bearing his name, which is annually awarded alternately in Edinburgh and London. But, by some strange mischance, no record of Murchison's life and work has been written beyond the newspaper notices at his death, I desire to do no more than to lay a stone upon the cairn to his memory, all the more as I find that his connexion with this Society is but little recalled.

Twenty years ago, when I was a student in London, there were very few systematic clinical teachers of medicine in London, and of these few four stood out prominently in the estimation of students and of foreigners — Jenner, Gull, Murchison, and Wilson Fox. The teaching methods of Jenner were, I think, the result of his own innate genius and sagacity, and he stood then, as now, facile princeps amongst his compeers as a physician. Murchison and Wilson Fox both followed to a large extent the mode of sys- tematic observation and analysis in clinical teaching which has long been followed in Continental, and especially in the French schools. Both derived it, I believe, immediately from Edinburgh, where it had especially been carried out by Professor Hughes Bennett. My revered master Wilson Fox was for a year Eesident Physician in the Royal Infirmary under Hughes Bennett at the time of the Crimean War. Wilson Fox's mode of teaching was, however, considerably modified by Jenner's influence ; there were the same touches of intuition, of personal experience, of genius, which made Jenner's ward visits impressive for a lifetime.

Murchison's method of teaching was purely logical and de- ductive, his system of diagnosis apparently immutable, and governed by the strictest laws. At first there was to me something un- pleasing in this absolutely dogmatic method, in which everything appeared to be cut and dried. Nor was I for a long time at all impressed with tlie teacher. There was a coldness and a some-

1889.] ROYAL MEDICAL SOCIETY. 629

what sarcastic mode of address which tended rather to repel than to attract, and it was in spite of this that he was followed and admired. It was only as one came to know him better that one saw that this was only manner, and tliat under the cold, critical, logical exterior was one of the truest liearts that ever beat.

Although I had occasionally as a student attended Murchison's cliniques at the Middlesex Hospital, it was not till four or five years later at St Thomas's Hospital, when I was Medical Eegistrar, that I came to see more of him. My first close contact with him arose through a case in which a strong difference in diagnosis happened to arise, and in the discussion of this case and its sequel I learnt both Murchison's tenacity and his generosity. From that time he was my generous and constant friend. In many long con- ferences with him afterwards, I soon discovered both his sagacity and profundity as a physician.

No man whom I have ever known united such keen insight and such minute accuracy of observation. His memory for cases was astounding. He seemed never to forget any noteworthy case he had seen ; he remembered it, too, in every particular, and with the most vivid clearness. In his clinical teaching he would not go a step beyond the point to which he could lead the student. Every possibility must be minutely balanced, and the case decided on the clear laws of evidence. True, the diagnosis might sometimes be wrong, and his insight as a physician might lead him to see that it was probably inaccurate ; but for the student it was safest and surest, and would teach him to diagnose correctly in the great majority of cases, and to recognise more clearly the grounds of error in diagnosis. But take Murchison outside his class, and discuss the same case. No longer the same rigid dogmatic rules, but case after case bearing upon the one in question, a mine of wealth of clinical observation tempered by the soundest judgment. How well I remember the last of those talks when, a day or two before his death, I met him in the corridor at the end of his hospital visit, fagged, depressed, and worn out. Some question on a case in which we had a common interest arose, and for nearly an hour he stood discussing and illustrating it with other cases with the greatest animation, forgetting fatigue in the intensity of thought.

I have mentioned as one of Murchison's characteristics his stead- fastness. If he was outwardly somewhat cold, he was clear and transparent and truthful as the day. The Aberdonian tenacity of character which led him to hold so firmly to what he had observed made him equally certain as a friend. One always knew that one could reckon upon his friendship. In how many ways he helped me I never could tell, for he never, when it could be avoided, let me know that he had any hand in it. But I knew enough to know that he never lost any opportunity of helping me in every way in his power.

But I fear you will think that I am misusing this opportunity to give you too much of my personal experience, although I know

630 PKOF. W. S. GKEENFIELD'S INAUGUKAL address to the [JAN.

not how otherwise to give you an adequate idea of the man. Let nie hasten to tell you something more of Murchison as a student.

Of liis student life I know but little. Many of his fellow- students and friends still living can, if they will, tell of it. Entering the Botany Class in the summer of 1847 at the age of 17, he soon acquired a character as an enthusiastic observer and investigator, and gained the warm friendship of Professor Balfour, who often corresponded with him afterwards on botanical subjects. Apart from his high character and the position he took in classes, he was known chiefly as a quiet student, always studious, always at work at something. Making but few friends, he succeeded in selecting four or five who have since become men of world-wide fame, and who still cherish his friendship as one of the best of their lives. In 1850 he became house-surgeon to Mr Syme, and in 1851 took his M.D. degree, gaining a gold medal for his thesis on Tumours. It was during the session 1850-51 that he was a President of this Society.^

His first paper in this Society, so far as recorded, was read on 14th December 1849 (vol. iii. p. 307), and was on the Bed Cor- puscles of the Blood. The second, read 22nd March and 5th April 1850 (vol. iii. pp. 827 and 957), is a most elaborate monograph of 134 pages, on the Anatomy, Physiology, and Pathology of the Spleen. The latter affords an admirable example of the character of Murchison's mind and the method of his work. It is practically a thorough examination of all that w^as known upon the subject until within a short period before it was written. First we have an admirable bibliography, arranged chronologically, going down to the year 1832, and including 73 papers. Then an exhaustive account, largely compiled, of course, of every point of importance in relation to the anatomy, the pathology, and the functions of the organ. One may especially notice as characteristic the enormous industry, the methodical arrangement, the clearness of thought and expression on every point, so that one can have no doubt as to the writer's meaning. Then one is struck by the fact that, whilst every authority has been studied, and their facts brought forward in due place and order, each has been weighed and judged. And although the paper is largely a compilation, there are few points on which he himself had not by dissections, injections, and micro- scopical examination, made original observations and formed his own judgment.

The same qualities were apparent in a more highly developed degree in his later work. As an example of his industry and method, the record of every case which was under his care at the Fever Hospital was, so to speak, dissected, and every symptom, its order and time of appearance, etc., was recorded by himself in a most elaborate schedule, systematically arranged, so that when one had any unusual complication or condition in a fever case, one

1 I am indebted to Dr Dobie of Chester for much valuable information upon Murchison's early life.

1889.] ROYAL MEDICAL SOCIETY. 631

had only to ask Murcliison if he liad ever seen it, and he could at once put his finger upon the record. No one who has not at- tempted it can tell what labour this involves, when it comes to hundreds of cases recorded as Murchison did them. But it is largely to this that the great value of his classical work on Con- tinued Fevers is due. Yet in this, as in everything, like a calm and deep lake, so pellucid and placid was his mind, that you hardly realized the depth until you tried to fatliom it.

Of Murchison's later career in London, his work, his life, and his sudden deatli, I cannot now speak. It ought to be done; but it should be done by some one who knew him better. Apart from his two great works on Continued Fevers and on Diseases of the Liver, his contributions to pathology and medical litera- ture were voluminous. As a pioneer in investigation, and by the encouragement and aid he gave to others, he gave great impetus both to pathology and medicine. But I am not qualified for the task of recording his labours or the ennobling influence of his character and life. The record should be written, and there are friends still living who could do it. Even in what I have said, I know 1 have failed to do him justice, perhaps because he was never my hero, only a kind and generous friend. But in his life and work you have only a sample of the many heroes of this Society. Their early work is not only of intense interest as a study, but of value as a stimulus and an encouragement to your- selves. Cherish, then, their memory, and emulate their labours.

[The following testimony, coming as it does from one who knew Murchison intimately throughout the greater part of his medical career, will carry weight far beyond any words of mine. Professor Gairdner, in a letter in reply to a request for any additional par- ticulars before publishing this address, wrote as follows, and has kindly allowed me to print here some extracts from his letter : —

" There may have been men superior to him in genius and even in dogged laboriousness, but very few men indeed have had the combination of quick and clear insight on the one hand, and exhaustive mastery of details on the other, that was in him. This quality of steadfastness held with him to the very last, and was applied to his own case as much as to the cases of other people. I never knew any one to equal him in his power of reading up and thinking out a subject, and then pigeon-holing everything that he had observed and read and thought, so as to be infallibly in its right place. His book on Fevers is in this respect absolutely unrivalled, and having been accustomed to use it as a handbook off and on ever since its pub- lication, I can scarcely remember an occasion on which I have referred to it in vain, whether I agreed with him or not. Even the slight variations between the first and second editions — at ten years' interval — show the same minute carefulness and, as you have justly called it, steadfastness. One might have thought that

632 PROF. \V. S. GIIEENFIELD'S inaugural address to the [JAN.

between 1863 and 1873 he might have tired of tlie subject of Fever, after having given it so much of his time, which was then becoming more valuable in a pecuniary sense ; but having had a good deal to do with the changes of opinion going on during that interval, I can bear testimony that there is not a change (other- wise than merely verbal or clerical) in the text of the book that is not significant ; and scarcely a point at which changes might have been made at which tliey have not been made, so as to indicate the movement going on in connexion with tlie whole subject. Some of these minutiae of detail will be brought into notice in a volume I have in the press. All of them will show how minutely and steadfastly he did his work up to the very last.

" Mrs Murchison sent me, some time after his death, a number of details about his own illness which he had put on paper. I did not consider them of any great novelty or scientific importance, otherwise I would have published them ere now. But what they do show is that, even when looking illness and death in the face, he was not bereft of his instinct for seeing the truth ; and the personal bias in no way interfered with his desire that everything should be placed exactly in its right position, in estimating the facts with respect to diagnosis and prognosis.

"In the autumn of 1872 he came down to Scotland to consult me as to the aortic lesion which had then become known to him as certainly existing ; and his one anxiety was as to whether I ct)uld throw any light on the very serious issue, How long he might hope to live ? I never was in London after tliis without seeing him ; and only a short time before his death he told me that he liad got through his winter work with more ease than he expected, and had never had so much remunerative work to do.

" You will find some allusions to this in a few remarks made by me, and printed in the British Medical Journal, August 2, 1879, p. 193."]

Another of the functions of this Society of which I wish to speak is, to aid and encourage research. It may be said that in the modern sense in which the term 'encouragement of research' is often used, i.e., the giving of money in aid of or as a prize for research, this Society does nothing. But I hold, and I am sure that those who have seen much of such encouragement will agree with me, that money is that which does least for true research in any branch of science. Money may be needed for apparatus and costly ex- periments, or for leisure and independence, but it rarely supplies the motive force ; indeed, alone it is inert.

The stimulus to research comes first from that innate longing to discover truth, to pry into the secrets of existence, which is as much a part of our nature as love or wonder. The youngest child is endowed with it — in varying degree, if you like, but it is there. Very often it is almost entirely suppressed by bad education, or by other ambitious and interests, but to some degree it lies dormant

1889.] ROYAL MEDICAL SOCIETY. 633

in every man ; and the medical man who is devoid of it is a lusus naturm. In many men it is so strong that it cannot be suppressed, it will out. With Browning's Paracelsus they say, —

" I cannot feed on beauty for the sake Of beauty only, nor can drink in balm From lovely objects for their lovelines.s ; My nature cannot lose her first imprint ; I still must hoard and heap and class all truths With one idterior purpose : I must know ! "

Browning's Paracelsus, p. 95.

ISTone the less is it true that in a great majority of men it needs to be elicited or excited, and in nearly all to be trained and cultivated.

What, then, are the factors which stimulate investigation, apart from the innate desire to discover and know ? One is the pre- sentation and discussion of numerous subjects which afford points of dispute or difficulty. Another is the opportunity of publica- tion, and especially of publication where free discussion and criti- cism are possible. Add to these the influence of example, and you have a very large part of the factors which do practically stimulate research.

But a word more as to money. A man may do anything for money. But, practicall}^, unless a man has all the qualiticatioiis of a researcher, and has already mastered his methods and subject also to a large extent, he can no more do a research for money than the average man could compose a sonata ; or at least it would be of equal value. I know that examples will be cited to the con- trary. M. Pasteur, I believe, made his remarkable investigation on " P(^brine," the disease of silkworms, under the promise of a large reward. But any one who knows anything of Pasteur will know that he was already a master workman, that his immense energy and patience were devoted then, as always, to the solution of the scientific problem, and that the intensity and concentration of his work in that research cost him the use of one arm, and nearly cut short his labours, if not his life ; and, as his subsequent career has shown, he values neither life nor money, except as a means to the promotion of science and the benefit of living beings. Even those discoveries which have been the most profit- able as means of making money have rarely been utilized for money by their discoverers. " Sic vos non vobis mellificatis apes," it is the old story.

In the case of discoveries in relation to medical science it is not expected or desired that money should be the incentive; and where it has been, the supposed discoveries have usually proved to be fallacious and worthless. On the other hand, it is sometimes thought that the sole intended ohjed of medical research is the benefit of humanity. We may, if we please, lay this flattering unction to our bosoms, but it is not strictly true. The idea may encourage and console us, but the stimulus is really much tlie

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634 PROF. W. S. GREENFIELD'S INAUGURAL ADDRESS TO THE [jAN.

same as in all other scientific work. I do not believe that pure benevolence would suffice to sustain any discoverer. The longing to know, the desire of power over tlie forces and secrets of Nature these, too, must co-operate and predominate.

Amongst the functions of this Society in the promotion of research is the bringing forward of subjects which demand inquiry. We are not independent of one another or of external stimulus. Thought is free, but most of it, if not all, is induced — a secondary current. Spontaneity of thought is rare, some would say impos- sible. How few men can pass, say one wet day, in a solitary Alpine hut, alone, without feeling unutterably bored. Even the greatest of men, with many years of experience and thought behind them, often become mentally inert and insipid under such conditions. I remember a learned bisliop, one of the greatest living commentators, who was detained in such a Init during a storm of two or three hours, alone. His sole subject of thought and reflection, as he told us, was found in a scrap of paper with a highly eccentric and truly German spelling-pronunciation of the word "Jane" which he found in the hut. Nor is such mental inertia a rare or morbid phenomenon. It is one of the laws of the mind. I know that it has been said that genius is the faculty of lighting one's own fire, but such genius is rare. Let me give you a little of my own experience. Nothing is commoner than to have inquiries addressed to one as to what subject one would recommend for a research. The usual formula is, " I intend to spend a year in scientific work either here or abroad, and to work up a thesis, will you tell me a good subject ? " Of course one tries, and first one inquires as to any special proclivity for subject or method of research. " Oh, I have no choice whatever ; anything you like." Then one makes an effort to discover what special capacity or training is possessed, and rarely elicits a confession of some peculiar gift. And, lastly, one suggests various subjects, and offers such help as one may be able to give. Bat, as a rule, it ends in nothing. The subject is too difficult ov too long, or the material is not at hand ; in fact, the one vital spark of special interest and desire is wanting, and the molehill becomes a moun- tain. In truth, you cannot manufacture a research — it is a living thing, and must grow.

Gentlemen, far be it from me to ridicule such desire for research. I only point out what is and what is not possible, the right and the wrong method. What I usually say to such men is, — " Well, if you have no desire to investigate :onything in particular, come and learn methods and do some definite piece of work, for which I will find you the material and guidance." Then, if a man has any capacity for research, he will mee^ his subject by the way, and fall in love with it. Matrimonial agencies are as little productive of successful research as they are of happy marriages.

In this Society the constant presentation and discussion of

1889.] EOYAL MEDICAL SOCIETY. 635

various topics brings before the members a succession of moot points, of obscure problems, some one of which must either strike the curiosity or suggest other subjects of inquiry. Even the spirit of opposition to some dogmatic assertion will very frequently serve as the starting-point. Indeed, but for the innate spirit of contra- diction of established dicta, I know not how medical science would progress at all.

I believe it to be also a most valuable training to be compelled to write on some subject selected by others. We never know how little we know, even of a common subject, until we begin to try to present our knowledge to oliiers; and however distasteful or remote the subject may be, it is not lost time. When a man knows a subject thoroughly, and has written all he knows, he should never be allowed to write upon it again. Some of the worst student's manuals are written by great authorities on the subjects of which they treat.

Again, the opportunity of publication, especially where the woi'k can be freely discussed, is a great stimulus to research. Eew men would go on working unless they hoped to make the results of their work known to others. The mere acquisition of know- ledge for one's self is indeed precious, but gold is useless unless coined and spent, and even the miser hopes some day to enjoy his wealth. True, he may and must leave his wealth to others ; but the scientific miser has little such prospect. To begin with, his knowledge will probably not be current or usable in the next generation unless it is circulated in this ; and very few can or do succeed in putting more than a fraction of their work into circula- tion. What piles of manuscript, what stores of knowledge, the fruits of long years of patient observation, thought, and labour, go to the dust bin or wastepaper merchant, or are accumulated to turn yellow and grimy with age and dust, after the death of any man who has been engaged in scientific or medical research ! Earely, indeed, they are rescued by some later worker or bookworm, and used commonly to throw as dirt at some fresh and independent discoverer. Witness the Italian opposition to Harvey. Or, rarely, a man may be his own resurrectionist, like a distinguished opponent of Cohnheim's discoveries on the circulation. Most men leave, for lack of time and energy, much of their best work unpublished; and the best of all, the experience and judgment, ripened by long thought and work, die with them. Now, I do not say this to encourage hasty or premature publication. Young men are often advised to publish something as soon as they can — to bring them into notice. Well, practice and money may be made by adver- tising ; reputation is not, and it may be ruined. But the great advantage of publishing your ideas in a Society like this is that it is free of all suspicion of ulterior object, and that you may bring imperfect and tentative observations forward to the light of sug- gestion and criticism.

636 PROF. w. s. Greenfield's inaugural address to the [jan.

A few words more, gentlemen, on tlie subject of research, and I Lave done. First, every man, even as a student, should have some research on hand, something which he cultivates and speculates and observes upon. It will stinmlate all other work, and afford relaxa- tion and interest outside your regular routine of study — will, indeed, introduce scientific spirit and method into study of every kind.

Let your subject be your own, one which conmiends itself to you as a worthy one, and as one at wliich you can and will do good work. As to its results, be they ever so small or indefinite as bearing upon tlie direct healing of disease, they cannot be value- less as a training ; and if the work is good and the results new, they must be of a value which can only be discovered afterwards. If one traces the progress of any branch of science, one meets with numberless instances of a minute and accurate piece of observation or investigation wliich has been the germ of a revolution. Nature's locks are large and strong, but the keyholes often exceeding small, and the key simple enough to him who can find it.

If you cannot find a new subject, follow some leader, and master his work as far as you can. You will find problems enough to occupy you as you go along, and when you reach the end of his work you can still go on. You \vill have the additional stimulus of the human elements of admiration, of example, and influence, which are, after all, the greatest living forces. Do not be too anxious lest your subject should be one which some one else has already worked out or is engaged upon. It is almost impossible to start an en- tirely new and independent inquiry —

" While you thought 'twas you thinking as newly, As Adam still wet with God's dew, You forgot in your self-pride that truly

The whole past was thinking through you."

Heartsease and Rue, Lowell, p. 134.

The same forces which are working upon your mind are active upon others ; you are being carried forwards by the stream of tendency of thought and by the previous labours of others, and so are many more. You may become topmost on the crest of the wave, but you may chance to see another more fortunate or better endowed by Xature or opportunity above you —

'Tis in the advance of individual minds

That the slow crowd should ground their expectation

Eventually to follow ; as the sea

Waits ages in its bed till some one wave

Out of the multitudinous mass, extends

The empire of the whole, some feet perhaps,

Over the strip of sand which could confine

Its fellows so long time : thenceforth the rest,

Even to the meanest, hurry in at once.

And so much is clear gained.

That is the law of scientific progress. But the majority of investi- gators form the " multitudinous mass."

1889.] KOYAL xMEDICAL SOCIETY. 637

Nor, I think, should you be at first too anxious to find all that has been written upon the subject you select. Literary research is indeed most important, and I would on no account justify its neglect. You must, indeed, study the works of leaders ; and the habit of thorough study and comparison of the A^itten records on any subject is a most valuable one. But there is nothing which more discourages a man, especially at first, when he is seeking direct contact with Nature, than to be sent to wander amongst the tombs of buried researches. In many cases it will suffice, if, before you give your work to the world, you decently exhume them and set their skulls, properly labelled, in decent order in that mortuary, or rather ossuary, which is usually known as a bibliography. 1 know that in saying this I run counter to the fashion and to the strongly-rooted beliefs of many whom I respect; but I can tell you, from my own experience, that the attempt to carry out their precepts rigidly may and does act as an almost absolute barrier to publication. I was educated in the belief that it was one of the seven deadly sins to publish until one had gone over the litera- ture of the subject, and seen all that had been done before. Nor can I, in spite of my acquired belief that it is a venial sin, so far overcome my training or quiet my distorted conscience as to do it in cold blood. On the other hand, when one is occupied in ob- serving, investigating, and recording one's own observations, it becomes more and more impossible to do the work of a gravedigger at the same time. Therefore I am anxious to some extent to free you from this bondage of what is, in great measure, mere literary pedantry. At any rate, carry on your direct questioning of Nature side by side with, or rather in advance of your literary work, and let this serve you as a guide and stimulus and not as a chain. But do not claim priority of discovery until you are sure that no one has preceded you, and for this you must exhaust the records.

Yet another caution as to the spirit of your work. Be content to go by degrees, and if need be slowly. Scientific research is much like Alpine climbing. You see before you a summit which leads to your ultimate destination, and with slow and steady steps you push on till you reach it. Then yet another appears, entirely concealing your peak, and this surmounted, others come, each of which must, still with painful toil, be attained ; and it may be that after all the day is too short, and you find the night fall with the snowy peaks still far above you. But you have so far dis- covered the road, and even if you do not succeed, others will come, and guided by your tracks will get higher and higher. Wait a year or two, and where you had only marshy swamps or dense thicket there will be a carriage road ; where you had loose boulders or slippery moraine, there shall be a good beaten track with steps here and there ; and it may be, that if your mountain is a very special one, it shall be favoured with a railway and a

638 INAL'GUltAL ADDKESS TO THE llOYAL MEDICAL SOCIETY. [jAN.

hydraulic elevator. But you have, at least, made the ascent pos- sible, and the track is certain, easy, passable for all.

Nowadays, however, many men prefer to do their scientific climb- ing in a balloon. They sail away, inliated with gas, and come back, if at all, with wonderful tales of their discoveries and of the peaks they have visited. But, alas ! seen from a balloon, many peaks are alike, and one cannot verify their observations, still less follow them and make a sure path for following wayfarers. Besides which, balloons have an unfortunate tendency to be carried hither and thither or lost in the clouds, not to mention the danger of burst- ing ; and, in fact, every patli of scientific research nowadays, and most notably bacteriological research, is strewn with the carcases of rash explorers or exploded discoveries, whose remains encumber the way and make progress difficult.

Gentlemen, I fear these discursive remarks may have been tedious, that you may think I have been too much in the vein of Polonius, as well as speaking too much of my own experience. If so, I pray you forgive me.

It would, indeed, have been easier to take some more concrete subject in medical science and to have dwelt upon it. But it seemed more fitting to say what I could of the advantages of this Society. And if so much of good appears to one who is doomed to be and to have been to so large an extent an outsider, what may not you expect to enjoy in the reality if you join this Society. I envy you the opportunity of actually linking your names and your labours with those who have been your predecessors. If I were a student again, I should esteem it my greatest privilege ; and as I cannot be, let me promise that, so far as I can in any way benefit this Society, I shall reckon it an honour to do so.

iPfftt ^ccouQ.

EEVIEWS.

The Principles of Cancer and Tumour Formation. By W. Roger Williams, F.R.C.S., Surgical Registrar to the Middlesex Hospitah London : John Bale & Sons : 1888.

Few subjects have more occupied the minds of pathologists than that with which this monograph deals, and any new light or fresh thought on it is welcome at the present moment. The author begins with a chapter on growth and another on reproduction. In the latter is found tiie key-note of the writer's contention ; it is that " in the higher organisms certain cells never attain a high degree of development, they remain in a lowly organized condition, and serve, accordingly as tiiey are more or less unspecialized, either as germs for reproducing the entire individual, or for forming and

1889.] THE PRINCIPLES OF CANCER AND TUMOUR FORMATION. 639

maiutainintr the various tissues and organs. Such cells are found in all growing parts, they are the only real cancer and tumour germs.''''

Tlie third chapter is a valuable contribution to the study of the evolution of vegetable neoplasms, and the comparative light it throws on animal neoplasms is of much importance and interest. Here, as well as in the subsequent chapter on the evolution of animal neoplasms, the contention is that " the local changes are modelled after the process of normal growth, and that both are subject to the same laws." The author rather tends to over-estimate his own statement of this law. It is doubtless true that new growths, especially the malignant new growths, were in the past looked upon as apart from the ordinary processes of growth and reproduction, and were even regarded by some as parasitic in character; but this surely belongs to the past, and has long ceased to occupy a place in the teaching of pathology. That being so, and as Virchow's aphorism, omnis cellida e celluld, still dominates pathology, the author's contention so far is a truism.

Let us look, however, at his chapter on the evolution of animal neoplasms. Malignant growths have " the power of reproducing themselves locally after removal or in distant parts, whilst others have no such infective properties," and he denies that this implies specific difference. He is right if he means that in both cells arise from pre-existing cells; but is there anything gained save novelty of expression, an.l the degree of pleasure which this always brings, by saying that in the one case the "emancipation" of the cell is more complete than in the other? "We may be ready to accept this term, but the question that remains is only a paraphrase of the old one. What makes the emancipation in the one case more complete than in the other? When that is answered, the conun- drum of malignancy is solved. Nor do we seem to get nearer the goal by the statement that "malignancy then depends upon the indefinitely sustained activity of lowly organized cells, which grow and multiply indefinitely without ever reaching a high grade of organization." The accuracy even of the assertion might be called in question, for it can hardly be granted that the cells of a skin epithelioma or of a malignant adenoma of the stomach are all to be regarded as lowly organized cells. True it is that the malignancy is characterized by an indefinitely sustained activity, but the fore- going definition hardly helps towards the elucidation of its cause. The author objects to the view of Creighton and others that the neoplastic cells infect adjacent cells and excite in them morbid action similar to their own. This is not the ))lace to examine this question on its merits, but the author says, "as it is opposed to biological principles, and without parallel elsewhere in organic morphology, it may, I think, be discarded;" and yet he says, " we may attribute the genesis of all neoplasms to excessive activity of certain lowly organized cells of the part determined by local excess

640 PRINCIPLES OF CANCER AND TUMOUR FORMATION, ETC. [jAN.

of imtritlon, tlie result of intrinsic or extrinsic stimuli." Is it then opposed to all biological principles that the neoplastic cells contain the special stimulus, and that it acts upon the other tissues of the part ?

One of the most striking features in tumour formation is the reversion to embryonic activity, and it has been stated by others; but while it gives us clearer definition more can hardly be claimed for it.

The closing chapter is devoted to etiology, and is distinctly the least satisfactory, and the monograph would not iiavc lost much had it been omitted.

While it has been necessary to examine as critically as we have done the leading doctrines in tliis monograph, it is necessary at the same time to state that we consider it a contribution of value to the discussion of a subject which is again arresting the serious efforts of workers. Because of this very fact, however, it is all the more necessary to closely scrutinize the work that is done, but all iionest and able work will contribute its share to the desired result, and this monograph may certainly be allowed this rank."

Cancer de la Vessie. Par Ch. FerS (Prix Civiale 1880). Paris : A. Delahaze & E. Lecrosnier: 1881.

A PUBLICATION of the Progres MMical, extending to nearly 150 pages, and containing apparently everything that has been written on the subject, even in this country. M. Fer^ describes a number of preparations from the Civiale Museum, gives some interesting cases from the practice of M. Guyon, but mainly deals with the pathology of the various cancerous affections met with in the bladder.

The work, as will be seen from the titlepage, was selected as worthy of the Civiale prize in 1880. It will make a valuable book of reference on the subject.

A Manual of General Patliology designed as an Introduction to the Practice of Medicine. By Joseph Frank Payne, M.D. Oxon., F.R.C.P., Physician and Joint-Lecturer on Pathological Anatomy at St Thomas's Hospital, etc., etc. With 150 Illustrations. London : Smith, Elder, & Co. : 1888.

We welcome this book as one which, it may be anticipated, will do not a little to mould the teaching of pathology in the near future, when the importance of the subject has been officially recognised by the various examining bodies in the Kingdom, and when, as a result, the teaching will be more methodical and more satisfactory than it is at present in most British schools outside Scotland,

The plan of the book is simple and rational, and in accord witii the recent revolutions which have taken place in our views of disease. It is divided into two large sections: the first dealing

1889.] A MANUAL OF GENERAL PATHOLOGY, ETC. 641

with the Processes of Disease, the second with the Causes of Disease. The former opens with chapters' on disturbances of tlie circulation, goes on to inflammation and fever, and then to degenera- tions. After this, a chapter is devoted to the laws of new growths in general, and the succeeding chapters deal with tumours or new growths ; while the section ends with four chapters on the varia- tions in the blood. This section contains nothing specially worthy of note, but all the chapters contain the latest knowledge or specula- tions on the subjects with which they deal. It is in the second part that the freshness and originality of the design are specially displayed. As indicating the range of subjects treated and grouped under the causes of disease may be mentioned mechanical and physical injuries, the action of poisons, dealing with animal, septic, cadaveric, and specific morbid poisons, and acute specific fevers. Then are taken up parasites, animal and vegetable. Under the latter, he deals at length with micro-organisms, and the value of the book is enhanced by an appendix containing directions for the examination of tissues and fluids for these.

The foregoing gives but an insufficient indication of the work ; to appreciate its merits it requires to be read. Every chapter is so well done, and so bears the mark of being the product of mature thought and extensive acquaintance with diseased processes, that we forbear singling out any for special commendation or foi special criticism. After its perusal we had but one regret, and that is, that the author had not promised to give us a volume on special patho- logy in addition ; this, however, is not to be so much regretted, seeing we already possess some excellent books dealing witii the morbid anatomy of the various organs. While it may readily be granted that the etiological factor in morbid processes did not in the past occupy the place it deserved, it must be remembered that the discoveries recently made in this department have really been the means of elevating etiology into somewhat of an exact science, and in our enthusiasm for new flelds and pastures green, we must be careful not to decry morbid processes in their anatomical relations. The idea which some people tend to entertain, that morbid anatomy will soon be played out, only means that to their capacity our knowledge is final, and that can hardly be taken as the criterion of omniscience. Dr Payne is not likely to fall into this error — his work is that of a well-balanced, clear-cut mind of eminent ability, embellished with much experience and wide acquaintance with the work of others.

Studies in Pathological Anatomy, especially in Relation to Laryngeal Neoplasms. Fasciculi I. and II. By K NoRRis Wolfendkn, M.D., and Sidney Martin, M.D. London : J. & A. Churchill : li

In these fasciculi the authors have considered in very full detail

EDINBORGH MED. JOURN., VOL. SXXIV. — NO. VII. 4 M

642 STUDIES IN PATHOLOGICAL ANATOMY, P:TC. [JAN.

the majority of tlie benign growths occurring in the larynx, papil- loMiata, fibromata, myxomata, angiomata, lipomata, enchoiulroinata, and lymphomata. Their clear and excellent descriptions are beautifully illustrated by drawings of microscopic sections. These are accompanied by key diagrams, which greatly facilitate their study. The book promises to be a valuable addition to our know- ledge of an interesting, if rather difficult, corner in pathology.

Elements of Practical Medicine, ^y Alfred H. Carter, M.D. Lond., Member of the Royal College of Physicians, London ; Piiysician to the Queen's Hospital, Birmingham. Fifth Edition. London : H. K. Lewis : 1888.

The fact that this excellent little introduction to systematic medicine has in eight years reached its fifth edition says more in its favour than the most elaborate eulogy. It has proved of the greatest use to medical students during these eight years, and the present edition may as confidently be recommended in every respect as its predecessors.

The Demon of Dyspepsia ; or, Digestion, Perfect and Imperfect. By Adolphus E. Bridger, B.A., M.D., F.R.C.P.E. London : Swan, Sonnenschein, Lowrey, & Co. : 1888.

Among the many diseases " flesh is heir to," there is perhaps in our time none more universal than that which Dr Bridger has made a special object of study, the product of which is this book. It is said that the belief in spirits had its origin in a too copious supper of roast foe, causing a nightmare, in which the troubled sleepers saw their slaughtered foes menacing them. Since then the causes and symptoms of imperfect digestion have greatly multiplied, until in these latter days the dem )n dyspepsia has become a very Proteus, familiar in one or more of his forms to all but the most exceptionally fortunate. Hence the author thinks " but little apology is needed in offering this small work to the British public ; " the reader will probably conclude that even were the subject of less general interest, the author's able treatment of it would remove the necessity of an apology.

This book, as above stated, is intended for the British public ; and of them, for the intelligent public, whom the author says " he should be paying an indifferent compliment, if, for the sake of an apparent clearness and simplicity, he were to omit any essential part of the subject." For the production of a popular work, perhaps the writer has gone too far to the other extreme, and has committed sins of non-omission which lessen the popular character of the book, but add to its scientific value. The first three chapters are preliminary, and treat of "Man's place in Nature," " Man as an Individual," and " Man as a Machine." The

1889.] THE DEMON OF DYSPEPSIA, ETC. 6.43

second and third contain as much elementary chemistry and physiology as will enable the lay reader to follow intelligently the processes later on described. The well-known " steam- engine" analogy is in the third chapter used to good effect. Another chapter, supplemented by a diagram and table, deals with the principles of digestion, and helps the reader to under- stand the digestive process and the destiny of the various chemical food-constituents. When the author gets on to the main theme of the book, he treats it as exhaustively and efficiently as might be expected from the painstaking way in which he guides his readers step by step in the early part of the book. In the sections on the treatment of disease, his attention is to a large extent directed to the hygienic and dietetic side of this ; while, at the same time, under the head of what he calls " scientific treatment," he gives lists of prescriptions more likely to be useful to the medical man than to the public at large.

The author's style is, as a rule, clear and pleasant, but here and there throughout the book there are involved sentences and other evidences of careless writing.

There are, too, of necessity points practical and theoretical which the author would find called in question by others in the profession, and on which the student might find it dangerous to adopt his views. The object of the book, however, is not contro- versial, but to impress upon the public " that the laws of Nature, as applicable to the maintenance of perfect health, are simple and intelligible, and that it is directly to their interest to study these laws and to apply them."

JJifendetevi dalla Febhre Tifoidea. Professore Dott. Carlo Ruata, Prof, di Materia Medica all' Universita di Perugia.

Defend Yourselves from Typhoid Fever. By Dr Carlo Ruata, Professor of Materia Medica, University of Perugia.

There can be little question of the urgent necessity for the solemn warning thus addressed to the profession and the public in Italy, from the fact that every year from 200,000 to 300,000 indi- viduals are attacked by this insidious and persistent malady, and in the 8257 communi of which the kingdom is composed the average mortality is 27,700 ; and, commencing its ravages from 1 year and continuing to 45 years of age, the risks are from 7 to 45 per 1000 inhabitants ; hence of 1000 persons who attain the age of 45, 325 are seized by this disease, being about 1 in every 3 individuals. To the hygienist these statements are of the utmost importance, being intimately connected with the conditions of the dwellings, the soil, and the water supply, etc. ; and the prevalence of typhoid being a clear indication as to the sanitary position of cities and districts, and where it prevails these are invariably defective.

After introducing the subject, Professor E-uata proceeds to discuss

644 DIFENDETEVI DALLA FEBBllE TIFOIDEA, ETC. [jAN.

the specific virus of typhoid. Alluding to tlie pythogenic theories of Murchison and Carpenter, and those of Budd and Coriield, whose views are that it depends on a specific organic virus which can only originate in a germ of identical nature, regarding the latter as com- pletely demonstrated by the observations of Eberth of Zurich in 1880, proving the causal presence of a bacillus typhoideus in every case of the malady : — 1. This introduced into the human organiza- tion propagates and multiplies itself. 2. It is contained in the alvine discharges of a typhoid patient. 3. It retains its activity for an indefinite time if in favourable circumstances as regards the presence of putrescent animal substance and humidity.

He proceeds to detail the particulars of an outbreak of typhoid in the female prison establishment of Perugia two years ago, wherein the facts bore out these propositions in a very striking manner — showing how water into which the germs have found access becomes a potent agent of infection, as also milk in a minor degree, as shown in Dr Wilson's case in Warwickshire, England, and in the epi- demic in three hospitals in Glasgow, traced by Dr Kussell to Kil- winning and the neighbouring villages of Fergushill and Benslie,

As regards mortality, Italian statistics give a gloomy picture. In Larino, prov. Campobasso, in 1885, out of every 21 inhabitants 1 was stricken mortally by this fever ; in Schio there were 3-35 deaths per 100 inhabitants; Pontremoli, 3-30; San Severo, 3-29 ; Beri, 3-27, etc. ; and as 1 fatal in 10 cases seems to be the average, the above, and numerous other instances quoted, manifest an amount of disease and 'danger that becomes a very serious national question. We see that no region in Italy has any reason to envy the others in this particular ; what occurs in the south is found in the central and northern provinces ; everywhere are to be found magistrates who aspire to the magisterial power without having the conscience of their duty.

How are we to be freed from the typlioid fever ? Two categories of measures calculated to attain the end in view are perceptible : — 1st, The measures to be taken by the authority, as representative of society ; and 2nd, Those to be taken by the individual. How can the latter defend liimself from the pollution of the water he drinks, at several kilometres' distance, by the typhoid patients' discharges being emptied into it ?

The water is tiie primary vehicle for disseminating contagion. Well waters, especially in cities where, from a bad system of drainage, the subsoil has become for centuries infiltrated with ex- cremental substances, cannot fail to be pernicious, these being literally founded on a dunghill. Some use torrential water, which is as frequently contaminated by the discharges from houses or villages situated higher up in tlieir course ; the only remedy for this is the institution of sanitary ofiicers, appointed and salaried by the State, to watch over the purity of water-courses supplying cities ; skilled workmen to attend to water-closets, registered as in England

1889.] DIFENDETEVI DALLA FEBBEE TIFOIDEA, ETC. 645

and America, and the former officials empowered to enforce such sanitary measures as the cases require, as also to supervise the dis- tribution of milk. From the force of enlightened public opinion bearing on provincial authorities tlieie is move to be hoped for than from the central Government. Unless aided by Government, however, the individual cannot keep himself clear from this insidious poison ; but still he can often avoid wells sunk in impure soils; can look after the purification of cisterns, and see they are constructed according to hygienic rules, and inspected suf- ficiently ; scrutinizing closely the conditions of latrines, and taking care that they do not introduce sewer gas poison, are adequately syphoned and ventilated ; also the general dryness and proper hygienic conditions of the dwelling-house. As to milk, this can always be rendered innocuous by boiling it as soon as received, after which it may be securely drunk.

This sketch cannot reproduce the lucid elegance of the style of the original. We have had previous occasion to remark on the high position attained by Professor Ruata as a pharmacologist and thera- peutist at Padova ; his appointment to the chair of Materia Medica at Perugia has now given occasion to the display of his charac- teristic mental vigour and acuteness, comprehensive learning, and patriotic devotion to the best interests of his country.

J

Be VEpilepsie Jachsonnienne, Memoire couronnS par la SociitS de Medecine et de CMrurgie de Bordeaiix. Par Le Dr E. Rolland. Paris : Aux Bureaux du Progr^s Medical : 1888.

To the medical fraternity in France this monograph may be of considerable service, in bringing clearly before them tiie features of the striking malady which is so well known to British physicians through the admirable researches of Hughlings-Jackson.

The work is practically a compilation ; and the author has, we think wisely, not hesitated to quote largely from the works of Jackson. His description of the disease is little more than a transcript of the latter's lucid paper, read before the Medical Congress in London in 1881.

All that is original in the book is the record of two or tiiree cases which have come under Dr Eolland's immediate notice.

Perhaps the most useful feature in the work is an exceedingly carefully and laboriously compiled table of nearly all the recorded cases of the disease in which post-mortem examinations have been made, giving the age and sex of the patients, the parts convulsed, the parts paralyzed, the chief symptoms, and the nature and position of the encephalic lesion, as well as a reference to the observer and place of publication.

In the chapter on Diagnosis, we miss any careful discussion on the determination of the difficult question of whether the case is suitable for operative treatment — a matter so admirably dealt with

646 DE L'EPILEPSIE JACKSOIsNIENNE, etc. [JAN.

by Dr M'Ewan. The English physician will find nothing new in the parts of the work devoted to treatment. In fact, after a brief account of some of tlie older methods employed, we find merely a translation of Ilorsley's paper read before the British Medical Association two years ago. It is curious to note how entirely the author has ignored all the recent German and Russian experi- mental researches upon the production and etiology of convulsions.

As a whole, the book cannot be regarded as a valuable contribu- tion to the study of Jacksonian epilepsy. It is, in fact, entirely unworthy of a student of the philosophic physician whose name is so closely associated with the disease. To demonstrate this, it is only necessary to give the first of the author's general conclusions.

*' Jacksonian epilepsy has absolutely nothing in common with epilepsy, except the name." Every one who has devoted any time to the careful study of convulsive seizures knows perfectly well that there is no hard and fast line between Jacksonian convulsions and idiopathic epilepsy ; and that between seizures associated with gross cortical lesions and the most characteristical idiopathic attacks all gradations may be observed.

Lectures to Practitioners on the Diseases of the Kidney amenable to Surgical Treatment. By David Newman, M.D., Surgeon to the Glasgow Western Infirmary, etc. Loudon : Longmans, Green, & Co.: 1888.

These lectures were delivered in 1886 as part of a post-graduate course given in Glasgow by Prof. W. T. Gairdner, Dr Joseph Coats, and the author. They are very interestingly written, are illustrated by numerous cases, and contain a vast array of facts which have evidently been collected at considerable cost of investigation and observation.

Dr Newman has made the kidney his special study from the physiological, the pathological, and then from the surgical point of view. The book is not arranged in the usual text-book form, with divisions into heads and systematic arrangement. It is not, there- fore, in the best form for reference, but when read continuously gives one an interest in the subject, illustrations by cases or prepara- tions being brought forward in support of every point. There are several valuable tables of cases operated on, many of them unpublished. There is also a useful index at the end of the book.

Contributions to Practical Gyncecology. By S. James Donaldson, M.D., New York. Read before the New York Medico-Chirur- gical Society. New York: Trow's Printing & Bookbinding Company.

Notes on Diseases of Women. By James Oliver, M.D. Edin., F.E.S. Edin. London : Hirschfield Brothers : 1888. The above two works come fairly under the category of essays.

1889.] CONTEIBUTIONS TO PRACTICAL GYNECOLOGY, ETC. 647

Neither of them professes to deal with the whole of the questions under discussion, but in each case the author presumes a full acquaintanceship with the subject on the part of his readers, and handles the matter mainly with a view to illustrate and support his own views. Such essays may or may not be of considerable interest and value. In the above two works we have this illus- trated. Dr Donaldson's papers will well repay perusal. His criticisms are able and convincing, and his reasoning fair and clear. The first question dealt with is that of displacements ; and after showing that all existing forms of pessaries are bad, he describes and figures what he regards as perfect appliances — "Dr Donaldson's retroversive and prolapsus pessary," and "Dr Donaldson's adjustable pessary for the cure of flexions." Both these instruments would seem, from the description given of them, to be safe and useful. The flexion pessary is an ingenious modification of the stem and shelf instruments, the stem consisting of a spiral spring surrounded by soft indiarubber tubing, and the shelf being a band of rubber stretched across a frame fasliioned somewhat after tlie model of the Hodge pessary. The author states that it is easy of introduction, and this being so, we would say that the apparatus seems admir- ably designed to answer the requirements of many cases, and also seems to be free from many of the disadvantages pertaining to intra- uterine pessaries. The second part of the book is devoted to dys- menorrhoea, and quite deserves the title given to it, as being a thoroughly practical contribution to the study of this intricate subject.

We would commend the reading of Dr Donaldson's little volume to all interested in the subject treated of in it.

Diseases of Women : A Handbook for Physicians and Students. By Dr F. Winckel, Professor of Gynaecology and Director of the Eoyal University Clinic for Women in Munich. Authorized Translation by J. H. Williamson, M.D., under the Supervision of, and with an Introduction by Theophilus Parvin, M.D., Pro- fessor of Obstetrics and Diseases of Women and Children in Jefferson Medical College, Philadelphia. Edinburgh : Young J. Pentland : 1887.

Wingkel's name and well-known reputation are a sufficient guarantee for the quality of any work coming from his pen, and English readers owe a debt of gratitude to the translators for their labour in placing the work within their reach, and to the publishers for their enterprise and for the skill and success with which the numerous original illustrations have been reproduced. A special feature of the work, to quote from Dr Parvin's introduction, is " the importance given to pathological anatomy, and thus a firmer foundation made for thorough knowledge. Only by the knowledge thus acquired can we learn correctly to discriminate between dis-

648 DISEASES OF WOMEN, ETC. [jAN.

eases, and arrive in many instances at the appropriate application of therapeutic agents." The majority of the illustrations are representations of pathological specimens, and we entirely miss, without much regret, the plates of instruments, pessaries, etc., etc., which are so freely introduced in the various text-books of gynae- cology.

As a work of reference on the anomalies and diseased conditions of the sexual organs, the book before us will form a valuable addition to the library of the specialist. As regards treatment the author, while not neglecting the most recent advances in gynaecological surgery, is eminently conservative in much of his teaching, and gives great importance to gynaecological medicine. To quote again from Dr Parvin's introduction — " No one can read and thoroughly study this volume without deriving not only much important practical information, but also finding his views of gynaecology growing larger, and the superstructure resting upon a broader and firmer foundation."

La Goutte sa Nature et son Traitement. Par Dr W. Ebstein, Professeur de M^decine a I'Universite de Goettingue. Traduc- tion du Dr E. Chambard. Introduction du Professeur Charcot. Paris : J. Eothschild : 1887.

This important and valuable monograph on Gout by Professor Ebstein has been translated into French, and the value of the work it presents is guaranteed by an introduction by Professor Charcot.

After a short resume of the historical relations of the subject, the second chapter takes up its pathological anatomy, and here we shall only indicate the author's contentions on tliis point. He maintains that in the histological alterations which are character- istic and typical of gout there is, beyond the deposit of crystalline urates, an alteration which is common to them, and that is the necrosis of the tissues and the organs at the seat of these deposits. This necrosis he regards as, in a way, specific, because he has never found it absent. In fact, he regards the combination as characteristic of the gouty process. The area of tissue necrosis extends somewhat beyond the area containing the deposit. The development of these necrotic areas is preceded by a stage which he calls the necrosing stage, in which the death of the tissue is not complete, and in this stage there is no deposit of crystalline urates. The first change, he insists, is a nutritive change in the tissues which goes on to necrosis, and that, follow- ing upon that, there is the deposit of crystalline urates. The conditions which lead to the death of the tissues is the gouty material which accumulates at the part in a liquid form. The process of crystallization in a necrosed area has its analogue in

1889.] LA. GOUTTE SA NATUEE ET SON TRAITEMENT, ETC. 649

the deposit of calcareous salts in tissues, the nutrition of which has been impaired.

The author's contentions are supported by an experimental inquiry of considerable value, the details of which we cannot attempt to give here.

The volume ends with a clinical study of gout : first, as primarily attacking the joints ; second, as primarily attacking the kidney.

The coloured illustrations are of great beauty, and the work is well worthy of perusal by those who have not already seen it in the original.

Em'pycBma : a MetJwd of Subcutaneous Drainage. By G. J. KoBERTSON, M.B., CM., Surgeon to the Oldham Infirmary. Reprinted from the Med. Chronicle.

Mr Robertson suggests a method of draining an empyaema that seems to recommend itself. The idea is to get out the pus in such a way that air shall not enter. Expansion of the lung, the most important agent in effecting a cure, is thus encouraged.

Mr Robertson publishes thirteen cases, of which ten ended satisfactorily, there being three deaths. The average age of the successful cases was a little over four years. We know that in children recovery from empysema is common, whatever method of treatment is adopted. Mr Robertson's results, therefore, are not unusual except in regard to time, cure being effected in a few weeks — in one case in ten days. The apparatus employed by Mr Robertson is complicated. It is to be hoped that some simpler adaptation of the valvular principle in drainage may be suggested.

Le Crachat dans ses Rapports avec le Diagnostic, le Pronostic, et le Traitement des Maladies de la Gorge et des Poumons. Par le Dr Hunter Mackenzie, d'Edimbourg. Traduit et Annote par le Dr Leon-Petit. Pr^c^de d'une Preface, par le Professeur Gkancheur. Paris : Octave Doin : 1888.

Dr Hunter Mackenzie's work on The Sputum is well known to the majority of our readers. It was reviewed in these columns about two years ago. It was well received by the profession in this country, and now a French translation has appeared. This translation has been made by Dr Ldon-Petit, who has also enriched the book by some very valuable notes. Prof. Grancheur has written a commendatory preface, in which he speaks highly of Dr Mac- kenzie's observations from the clinical side. It is quite a charming volume in its French dress, and compares very favourably with the English edition. We have no doubt, after reading Prof. Grancheur's preface, that it will be popular among our French brethren.

EDINBURGH MED. JOURN., VOL. XXXIV. — NO. VII. 4 N

650 QUAND ET COMMKNT DOIT-ON PRESCRIBE LA DIGITALE, ETC, [jAN.

Quand et Comment Doit-on Prescrire la Digitale. Par Henri HuCHARD, M^decin de I'Hopital Bichat. Paris : Librairie Medicale Leclerc : 1888.

This little work contains much that is of the greatest use to the medical practitioner, conveyed in terms at once terse and clear, some ot" the statements being almost worthy of being termed epigram- matic. It contains a critical survey of the action of the drug, followed by a careful analysis of the indications for its employment, and the symptoms which render its use unadvisable. It is impos- sible to agree with all the conclusions which are reached by the author, but it is, at the same time, equally impossible not to recognise the clinical acumen and therapeutic resource of the author. The work is eminently worthy of careful perusal.

La Fihvre typhoide trait^e par les hains froids. Par E. Tkipier, Professeur h, la Faculty de M^decine, Medecin des Hopitaux de Lyon; et L. Bouvkket, Agrdg^ '^ la Faculte de Medecine, Medecin des H6pitaux de Lyon. Paris: Librairie J. B. Baillifere et Fils. Lyon : Henri Georg et J. P. Megret: 1886.

Although published two years ago, this work has only now reached us, and we hasten to make a {%vf remarks upon it. It begins with an excellent historical review of the use of cold water in disease from the days of Hippocrates down to the present time, forming one of the best written descriptions of the gradual develop- ment of opinion in regard to the medical uses of cold water with which we are acquainted. Personal observations follow, embody- ing statistical results, and the authors afterwards pass on to the consideration of indications, and contra-indications, complications, effects of cold baths, progress and duration, prognosis and mortality, which lead up to a careful description of the methods to be employed in the use of cold batiis in this condition. The work is characterized by extreme care throughout, and may be regarded as one of the most important contributions to this subject within recent times.

Hydrophobia : A Revieio of Pasteur's I'reatment. By W. Collier, M.A., M.D. Cantab, M.KC.P., Physician to the Eadciiffe Infir- mary, Oxford. London : H. K. Lewis : 1888.

This pamphlet of 30 small pages "has been written with the hope of making Pasteur's many valuable discoveries, and the experi- mental evidence and other facts on which his treatment of hydrophobia is based, more widely known to the general public."

The author seems to think that because Pasteur proved that fermentation was due to the action of minute organisms, that the

1889.] HYDKOPUOBIA, ETC. 661

p^brine of silkworms was also bacterial ; that splenic fever was caused by bacilli and chicken cholera by another organism, and that in both cases an attenuation of the virus could be brought about by certain treatment ; and that inoculation with this mitigated virus made the respective animals experimented on refractory to the strongest similar virus ; it is quite a likely supposition that he is also right with regard to hydrophobia. He details, in popular form, how Pasteur gradually arrived at his conclusions, and ventured at length to try his methods of inoculation, unfailing in dogs, on man. How far Pasteur has been successful, and how much he has failed, are still questions siih judice • and Dr Collier does nothing, nor does he pretend in his hrochure to help to settle the question by argument or experiment. The reviewer agrees with Dr Gordon in thinking that the policeman and the muzzle would stamp out rabies more efficiently than the scientist.

Therapeutics : its Principles and Practice. By H. C. Wood, M.D., LL.D., Professor of Materia Medica and Therapeutics, and Clinical Professor of Diseases of the Nervous System, in the University of Pennsylvania. Seventh Edition, rewritten and enlarged. London : Smith, Elder, & Co. : 1888.

The fact that the seventh edition of Wood's Therapeutics has appeared within three years of the publication of the sixth edition, shows the great popularity of this work. The work is well known as a standard treatise on therapeutics, not only in America, but also in this country.

This edition differs from previous ones in some particulars, but only to increase the value of the book. The present edition has interesting chapters on Massage, Feeding of the Sick, Dietetics, etc.

The author has brought his work well up to date by introducing articles on such new drugs as hydrastin, strophanthus, iodol, urethan, papain, etc.

The work is too large (908 pages) for a students' text-book, but is one which students would do well to possess, and as a work of reference will form a most valuable addition to the library of every member of the medical profession.

Mind and Matter : A Sermon preached before the British Medical Association on Tuesday, 7th August 1888. By John Caird, D.D., LL.D., Principal of the University of Glasgow. Published by request of the Association. Glasgow : James Maclehose & Sons: 1888.

This magnificent contribution to Theism from one of the master thinkers of the age well deserves a permanent place in type. It will repay, as it needs, deep study. It meets the materialist on his

652 MIND AND MATTER, ETC. [jAN.

own ground, and foils his attack with his own weapons. The argument for a God and for a religion is taken in this duel not from Kevelation, but from science. The simple Christian man who accepts his Bible will neither need nor greatly value the powerful reasoning, but to use Principal Caird's own words in his noble peroration — " It is some reward of a truer speculation if it enables us to put away this phantom of nescience, and to think of God as the God of truth, of science, the Being whose dwelling-place is not thick darkness, but wherever knowledge sheds its kindly light over the paths of men, whom every true thought, every fresh discovery, every idea of the wise, and every intuition of the good are helping us to know more fully — the Being, in one word, who is Himself the Truth absolute and inexhaustible, after which the greatest of the sons of men have sought with a thirst which is unquenchable, and which, when they have in any measure grasped it, is the inestimable reward of all their endeavours."

The Son of a Star : a Romance of the Second Century. By Ben- jamin Ward Richardson. In 3 volumes. "Ficta voluptatis causa, sit proxima veris," — Hor. London : Longmans, Green, & Co.: 1888.

Novel reading may be allowed to the wearied medical man in his arm-chair as a diversion to his mind from more serious subjects, though, alas ! too frequently the sorrows we see in real life, and the hidden skeletons in many an unexpected closet, call so much on the sympathies of the doctor that he can hardly be troubled with unreal anxieties and imaginary catastrophes. Novel reviewing is not much in the line of a serious medical monthly, in which the scientific use of the imagination confines itself to the loves of the plants or the hates of the micrococci.

But when a man in the first rank of the profession, an original thinker in many branches of science, a veteran physiologist, and a most suggestive and learned physician, spends his leisure time in the writing of a novel, it deserves our fullest attention.

How Dr Benjamin Ward Richardson obtained the leisure is a marvel. The work he gives to the profession every quarter in his Asclepiad would be too much for any ordinary glutton for work. But here it is in three handsome volumes, fit for any circulating library. A very remarkable novel it is, full of incident, of battle, murder, sudden death, love-making, politics, history, geography, science, and humour.

We will not forestall the reader's pleasure by telling even the outline of the story. It is a tale of the second century, with a hero and two heroines, plenty of noble Romans, crafty Jews, and even a comic subordinate hero and heroine. There are admirable descrip- tions of Roman camps and scenery both in Britain and Palestine, a most touching deathbed of a fine old centurion, glimpses of

1889.] THE SON OF A STAR, ETC. 653

emperors and procurators, priests and pagans. There is one very curious underlying characteristic, that while the writer's sympathies seem to be with that marvellous race which hastes not, neither rests, which is stubborn, crafty, and rebellious, the reader's sympathy will almost certainly follow the Roman leaders and centurions, who by simple discipline seem unexpectedly to win in the end. It is also curious to mark the strange youthfulness and overflowing vitality of the whole story. It is full of promise for the future if the author will write more novels; for what faults tiie book has are those that pruning will cure. What we like least is the comedy, possibly because we don't quite see the joke. There is a chapter on Novimagians, who live about seven miles from London, who amuse the Emperor Hadrian more tlian they do us, and the whole Irish question as dimly shadowed to our possibly too old and dim eyes seems unnecessarily Utopian. The virtues of fresh air, temperance, and fair water are lauded most wisely. Dr Richardson has really made a great hit in a new line of work, and given novel readers a book wise and witty, powerful and yet abso- lutely pure and healthy.

Witli a weaker man the fighting would have become massacre ; with a less wise one, the simplicity of the age might have been coarseness.

The A. B. G. Medical Diary and Visiting List ; vHth which is com- bined the A. B. C. Materia Medica and Numerous Tables prepared especially for ready reference by Medical Men. Price 2s. each. Burroughs, Wellcome, & Co., London, 1889.

This is a wonderfully cheap compendium of information as to drugs, new and old, irritant poisons, and the like, bound up in compact form into a pocket diary, which includes visiting list, cash accounts, memoranda. No medical man need miss an opportunity from for- getfulness or be at a loss at the prescribing of new drugs if he carries this little book in his pocket.

MEETINGS OF SOCIETIES.

MEDICO-CHIRURGICAL SOCIETY OF EDINBURGH.

session LXVIII. — MEETING II. Wednesday, 5th December 1888. — Dr John Smith, President, in the Chair.

I. Election of New Members.

The following gentlemen were elected ordinary members of the Society : — George P. Boddie, M.B. ; Kenneth Mackinnon Douglas,

654 MEETINGS OF SOCIETIES. [jAN;

M.B., CM. ; G. Lovell Gulland, M.B., M.A., B.Sc, M.RC.P. Ed. ; W. Bum Macdonald, M.A., M.B. ; James W. Martin, M.D.

II. Exhibition of Patient.

Professor Grainger Stewart showed a case of gout with numerous tophaceous deposits in the skin. The patient was a man, aged 58, who had suffered from gout for twenty-three years, the hands having gradually become so deformed as to make work impossible for a long time past. Till lately there was no manifestation except in the joints and skin, but albuminuria had now appeared, and hyaline casts were sometimes seen. Probably there was no case on record with so many deposits in the skin. The case was well known in the London hospitals, and has been referred to by Dr Pye Smith in the last edition of Hilton Fagge's book. The family history could be traced back at least a hundred years on both father and mother's side, and there was absolutely no case of gout on either. Though he was not an abstainer he was not a self- indulgent man, and his personal habits did not give them any clue to the cause of the early and severe development of the disease.

III. Exhibition of Instkument. Dr James Foulis showed a new form of aspirator syringe.

IV. Exhibition of Pathological Specimens.

1. Mr Scott Lang showed for Mr Joseph Bell a carcinoma of the mamma associated with Paget's disease of the nipple, and a cast by Mr Cathcart showing the external appearance of the breast immediately after removal and before a section was made. A microscopical specimen was also shown. Under the microscope the condition of the breast was seen to be very similar to that recently described by Sir Spencer Wells as alveolar cancer, or otherwise as duct-cancer. There was a history of heredity in the case, Mr Bell having seen in consultation the lady's aunt for a precisely similar condition, which had come on late in life and lasted for many years. No operation was possible in her case, on account of advanced age and frequent attacks of hemiplegia with aphasia. The eczema appeared to have begun in the areola around the nipple, and, according to Sir Spencer Wells, was connected with the orifices of the sweat glands in the areola. In this case the patient made a rapid recovery, and the prognosis in such cases was favour- able, according to Sir Spencer Wells in his recent lectures on cancer and cancerous diseases.

2. Prof. Chiene showed specimens recently added to his class museum, (a.) The first of these consisted of a series of urinary calculi from four patients — three male and one female. One of the male patients was a boy aged 4^ years, the point of interest in his case being an illustration of the risk during operation of

1889,] MEDICO-CHIRURGICAL SOCIETY OF EDINBURGH. 655

tearing the membranous urethra and pushing the bladder up into the abdomen. As Mr Chiene introduced his finger, he felt the urethra beginning to give. He therefore desisted, and incised the neck of the bladder more freely. The other two were adults, aged 52 and 60 respectively. In the former, there was rigidity of the prostate requiring free division, which resulted in con- siderable delay in the healing of the sinus. In the latter, the prostate was so much enlarged that the finger could not reach the bladder. In the female, aged 20, the trouble was due to the introduction of a foreign body. Dilatation of the urethra was found insufficient, and an incision had to be made into the floor of the urethra before the stone could be removed. Neither incon- tinence nor retention followed the operation. (&.) Tumours. Of these, three were exostoses — one of the lower end of the fibula in a patient aged 30, and ascribed to a strain twelve years before, another of the femur in a patient aged 18, and the third from the posterior border of the scapula of a patient aged 15. The fourth was a cartilaginous tumour, growing from the perichondrium of the fourth left rib at the junction of the cartilage with the bone. It was removed by crescentic incision at the lowest part of the tumour, by which the skin and pectoral muscle could be easily raised from the surface of the growth. As the attachments could not be made out easily, the tumour was removed in slices. A cast showed the appearances before removal. Fifth, two bursal tumours, one from the right, the other from the left patella of the same patient. The right had existed for thirteen years, the left for six. Sixth, a myeloid sarcoma of the lower jaw of a man aged 59. It had existed for nine months. Half of the jaw was removed immediately after a preliminary tracheotomy. Four days after, symptoms of pneumonia appeared; eleven days after the occurrence of the pneu- monia, there was evidence of gangrene of the lung, and death took place in forty-eight hours. Prof. Chiene was inclined to think that there must have been some regurgitation of food from the stomach into the trachea which would account for the result. Seventh, a fibro-cellular tumour from a patient aged 25. It was situated below the auricle, and had first been observed ten or twelve years before, (c.) Tubercular testes, removed on separate occasions from the same patient (aged 30). The left was first affected after a blow. Five months after its removal he returned with the epididymis of the right enlarged and diseased, (d.) A BRAIN with an abscess in the frontal lobe. The patient was a boy aged 13. Four months before admission he was hit on the fore- head by a snowball. An abscess formed, which was lanced and healed up. Three months later, after a cold, the swelling returned, and was opened the day before admission into the Hospital. The sinus was explored, and an exfoliation removed from the external angular process of the frontal bone. The pulse was rather slow, but, beyond complaining of headache on the tenth and eleventh days

656 MEETINGS OF SOCIETIES. [jAN.

after admission, he showed no symptoms of brain mischief. On the 21st day he ate a quantity of cheese brought in by a relative. This was followed by vomiting and pain in the stomach. The follow- ing day he complained of pain under the chin; in the afternoon he was screaming loudly and complaining of pain in the neck and frontal region. Meningitis was then diagnosed. He died the same night, and at the post-mortem examination a subdural abscess, about the size of a walnut, was found in the frontal lobe, (e.) Astragalus and foot showing the perforating ulcer of locomotor ataxy. The astragalus was lying bare, and was lifted out when the patient was admitted. (/.) A specimen showing the effect of operation for kadical cuke of inguinal hernia. The hernia had been reduced four days before admission into hospital ; the symp- toms of strangulation, however, continued, and the hernia was therefore cut down upon. It was then found that reduction en bloc had occurred, the constriction was divided, and the radical opera- tion performed. The patient was doing well till, on the twenty- third day after operation, he was seized with angina pectoris, and died suddenly. The specimen, obtained post-mortem, showed closure and dimpling opposite the internal abdominal opening. (g.) Hammer-toe, showing contraction of the fibrous structures, as well as of the flexor tendons, (h.) A couple of peas. A stout middle-aged woman put these in her mouth when feeding pigeons. One of them passed down " the wrong way." She brought the other with her to hospital to show it. There was some difficulty of breathing for twenty-four hours after the accident. She was kept in bed, and a pneumonic-like sputum appeared, but no physical signs. This, as well as the cough, passed off, and on the twelfth day she was allowed to go home. On going upstairs she coughed out the pea which had lain in her bronchus for twelve days. (/) A discoidal-shaped whistle, larger than a halfpenny, which had lain in a child's intestinal canal for twelve days and then passed per anum. (^^) Fragments of bone removed from the lower jaw by trephining. The operation was performed for resection of portions of the lingual and inferior dental nerves to relieve the pain of an epitheliomatous ulcer of the tongue. Forty-eight hours after the operation there was con- siderable salivation and bleeding from the ulcer, due apparently to irritation at the peripheral end of the divided chorda tympani inhibitory and secretory fibres of the lingual nerve. So far as the relief of pain went, it had been a success, (l.) Microscopic sections of the fibro-cellular tumour, a healing ulcer, and a hard chancre were also shown.

3. Mr J. M. Gotterill showed a perforated vermiform appendix.

V. Original Communication. Mr J. M. Cotterill read his paper on a case of gangrene of

*

1S89.] MEDICO-CHIRUIIGICAL SOCIETV OF EDINBURGH. 657

THE TRANSVERSE COLON IN AN UMBILICAL HERNIA, which appears Oil

page 602 of this Journal.

The President said he believed he was only expressing the feeling of every member present in saying how much the Society was indebted to Mr Cotterill for the communication just read. The case had been a very remarkable one; many great and remarkable operations had, since the founding of the Royal Infirmary, now more than 100 years ago, been performed within its walls ; some of them, in one way or other, not having obtained sufficient credit throughout the world as having originated or been brought to per- fection in Edinburgh. Not a few of these remarkable operations had been recorded in the minutes of the Medico-Chirurgical Society, and the operation