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THE 



GLASGOW MEDICAL JOURNAL 



EDITED BY 

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

FOR THE 

(Skjsgoto ano <Uest of Scotlanb JfttbicaJi Association. 



JULY TO DECEMBER 1884. 



VOL. XXII. 



GLASGOW: 

ALEX. MACDOUGALL, 81 BUCHANAN STREET. 

LONDON : H. K. LEWIS, 136 GOWER STREET. 

1884. 



fioi 



<Zi r\i 



THE 



GLASGOW MEDICAL JOURNAL. 



No. I. July, 1884. 



ORIGINAL ARTICLES. 



NEW METHOD OF OPERATING UPON RECTO- 
VAGINAL AND VESICO-VAGINAL FISTULA. 

By DAVID NEWMAN, M.D. 
( With a Lithograph.) 

When the want of success which attended the attempts of 
the earlier surgeons to close by operation fistular communica- 
tions between the vagina and the neighbouring cavities is 
contrasted with the satisfactory results now attained by most 
operators, the question naturally suggests itself, What are the 
improvements in the methods of operating which have led to 
these more successful results in recent times ? Churchill,* 
writing about thirty years ago, characterises vesico-vaginal 
and recto-vaginal fistula as " one of the most distressing and 
intolerable accidents to which females are subject;" and adds, 
" the more so as a cure is but seldom effected." " Indeed, vesico- 
vaginal fistula has long been considered as one of the opprobrln 
of surgery ; and, with some exceptions, of late years the cure 
has been given up as hopeless." Liston, in his Practical Siw- 
gery, published about the same time, advocates the use of the 
actual cautery in such cases, and with regard to plastic opera- 
tions, he says, " Attempts have been made by paring the edges 
of the opening, and introducing sutures to induce the aperture 
to close ; but little benefit, I have reason to believe, has followed 
this operation." These opinions express pretty clearly and 
truthfully the views entertained by surgeons practising during 
the early and middle portions of this present century. How 
different are the views now held regarding the curability of 
* Churchill On Diseases of Women, third edit. 1850. 
No. 1. B Vol. XXII. 



2 Dr. Newman — New Method of Operating upon 

these most distressing affections. The actual cautery is now 
seldom used, except in small fistulse, when it may be relied 
upon only to a limited extent ; for while it may diminish the 
aperture, it rarely indeed wholly closes the fistula. The whole 
tendency of present opinion is to the belief that a plastic 
operation is the only efficient mode of curing the disease, and 
the success obtained by such operators as Marion Sims, Spencer 
Wells, and others, has been so satisfactory that no one is justi- 
fied in refusing to give the patient the benefit of what is now 
a very feasible operation, comparatively easy of achievement, 
and which holds out great prospects of success. 

Before considering the improvements which appear to me 
to have led to this change of opinion regarding the probable 
success of plastic operations upon the vaginal wall, I desire to 
direct attention to certain modifications in the method of 
operating which have suggested themselves to me. In 1880 I 
operated upon a patient, C. S., set. 24, who had then been suf- 
fering from a recto-vaginal fistula for five and a-half months. 
The fistular communication resulted from sloughing and ulcer- 
ation of a portion of the posterior vaginal wall. On vaginal 
examination a fistula about an inch long was seen in the 
middle line, and its upper margin was situated about half-an- 
inch below the external os. The edges were elevated and 
indurated, but there was no evidence of recent ulceration. I 
performed the operation in the ordinary way, and brought the 
edges of the wound together by silver-wire sutures. The 
usual precautions were taken in regard to after-treatment, and 
the stitches were removed on the fifteenth day, when it was 
apparent that the operation was only partly successful, the 
lower portion of the perforation remaining still ununited. I 
then resolved to operate again after some weeks, but deter- 
mined to do it in an entirely different way. 

The manipulative difficulties involved in the performance 
of operations upon the vaginal walls arise from — (1) the 
general flaccidity of the parts ; (2) the difficulty, when it is 
situated high up, of exposing to view and manipulating 
the fistula ; and, on account of the parts being obscured by 
blood, (3) the danger of leaving small portions of mucous 
membrane on the edges of the aperture, which by their 
presence may prevent the union of the cut surfaces. These 
difficulties may be easily overcome by employing an instru- 
ment similar to the one I am about to describe. In devising 
the instrument the purposes I had in view were — (1) to fix 
the vaginal wall ; (2) to compress the blood-vessels so as to 
prevent haemorrhage ; and (3) to drag down the parts so as 



Recto-Vaginal and Vesico- Vaginal Fistula. 3 

to expose them as completely as possible to view during the 
operation. 

The instrument, as shown in Fig. 1,* consists of two steel 
blades about 14 inches in length, the measurement from the 
lock («) to the tip of the blades being a little over 5 inches. 
The instrument is curved at the lock, so that the blades form 
with the handle an angle of about 140°. The upper blade (c) 
is fenestrated, while the other is flat and has on its inner surface 
a sheet of soft lead (J) imbedded in the steel (6). When the 
forceps are applied the handles may be locked together by a 
spring catch at e. 

Fig. 2 represents in a rough way the instrument in situ for 
the operation of recto-vaginal fistula. 

The bowels having been previously cleared out by an enema, 
and an anaesthetic administered, the patient is placed in the 
ordinary lithotomy position, and the parts well exposed by a 
duck-bill speculum. The fenestrated blade of the forceps is 
introduced into the vagina, while the other blade is passed 
into the rectum, and, the walls of both these cavities having 
been distended, the fistula is caught up between the two 
blades of the forceps in such a way that the vaginal aperture 
of the fistula occupies as nearly as possible the centre of the 
open space in the fenestrated blade. The operator then drags 
down the fistula as far as the tissues will admit, so as to 
facilitate the future stages of the operation. By this arrange- 
ment the vaoinal walls are fixed, and haemorrhage during 
the operation is prevented by the pressure on the tissues by 
the blades of the forceps, while at the same time the surgeon 
is enabled, by tilting the point of the forceps forward, and by 
making traction upon the handles, to drag the fistular opening 
well into view. 

In the case mentioned above, the first attempt to- close the 
fistula having been only partly successful, I performed, three 
months after the first, a second operation by the method I 
have now partly described. 

The patient having been put under the influence of ethidene 
dichloride, and placed in the ordinary lithotomy position, the 
parts were well exposed by a large duck-bill speculum, the 
plain blade of the forceps was passed into the rectum, and 
the fenestrated blade into the vagina, and the recto-vaginal 
wall was included between them in such a way as to make 
the fistula show itself in the centre of the opening in the 

* The instrument was shown at a meeting of the Pathological and 
( 'linical Society, in February, 1883. It was made for me by, and may be 
had from, Mr. J. Gardner, 45 South Bridge, Edinburgh. 



4 Dr. Newman — New Method of Operating upon 

fenestrated blade. The handles of the forceps were then 
united by the spring catch, and the handle depressed so that 
the point of the blades pushed the wall of the vagina forwards, 
while the portion of the blades next the handle dragged it 
downwards and backwards. The forceps were retained in 
position by an assistant. By this means the opening of the 
vagina was stretched to its utmost, the fistula was drawn 
down as near as possible to its orifice, hemorrhage during 
the operation was prevented, and the paring of the edges of 
the fistula was greatly facilitated. A hook, of the form 
represented in Fig. 3, was then made to catch the upper 
extremity of the fistula, and the point of the knife was 
passed through the recto-vaginal wall, about a sixteenth of 
an inch above the hook, until it touched the lead plate on 
the flat blade of the forceps. The knife was then carried 
downwards, and with a clean cut made to pare off a strip 
about one sixteenth of an inch broad, from the margin of 
the fistula down to a point a little below its lowermost 
limits. The right margin was then removed in the same 
way. The mucous membrane of the vagina was then care- 
fully dissected laterally from the submucous tissue of the 
rectum, so that the two were separated from one another 
for a distance of about a twelfth of an inch from the mar- 
gins of the wound. On account of the stretched condition 
of the vaginal wall, the aperture, after the edges of the 
fistula had been pared, appeared very large and wide, so 
that before stitching the wound it was found to be neces- 
sary to draw the edges together with artery forceps, then 
by relaxing for a moment the blades of the large forceps, 
the tension was relieved and a fresh hold was taken, includ- 
ing a larger area of tissue, so that dragging upon the tissues 
by the sutures was prevented. 

The cut margins of the mucous membrane of the rectum 
were first united by one set of stitches, and afterwards the 
mucous membrane of the vagina was fixed by another set. 
Three catgut sutures were passed through the whole thickness 
of the recto-vaginal wall. The sutures through the separate 
mucous membranes were placed at intervals of about an eighth 
of an inch apart, and were drawn pretty tightly, while the 
deeper stitches, which passed through both membranes and 
through the intervening structures, were not so firmly fixed. 
All the sutures used were catgut. After they had been 
tied the forceps were removed, and as there was no bleeding 
from the wound, the patient was placed in bed, and a 
half -grain morphia suppository administered. 



Recto- Vaginal and Vesico- Vaginal Fistula. 5 

The after-treatment was that usually followed in such cases. 
The vagina was washed out by injections of tepid boracic acid 
solution, but no examination of the parts was made till the 
twelfth day, when the wound appeared to be healed. By that 
time some of the sutures had separated, while others still 
remained ; these were not disturbed, but when a careful 
examination was made sixteen days after, the fistula was 
found to be completely closed. 

The second patient, operated upon last summer (1883) was 
a young woman suffering from vesico-vaginal fistula. The 
only differences in the method of procedure in this case and 
the one just described were, that during the operation the 
patient was placed on her face, in the knee-elbow position, 
and the flat blade of the forceps was, by rapid dilatation 
of the urethra, introduced into the bladder instead of, as in 
recto-vaginal fistula, into the rectum. The paring process 
was carried out in the same way as in the other case, the 
mucous membrane of the bladder was carefully separated from 
that of the vagina, and the cut edges of these two layers were 
separately united by fine catgut sutures, while two stronger 
sutures were passed through both of them as in the case of 
recto-vaginal fistula. 

Before the operation the fistula was found, on vaginal 
examination, to be situated about half-an-inch below the os. 
The margins were slightly thickened, and the left one was 
ulcerated. The opening, which was irregular in form, extended 
from above downwards for a distance of about three-quarters 
of an inch. From the rapid dilatation of the urethra, the 
patient was unable to retain urine for the first sixteen days, 
but this was rather an advantage than otherwise, as it pre- 
vented any distention of the bladder, and so gave the parts 
more perfect rest during the process of healing than if the 
urine had been allowed to collect, and as the incontinence 
ceased soon after the wound in the vaginal wall healed, no 
real inconvenience was caused the patient by the distention of 
the urethra. 

While it may be argued by some that an undue amount of 
dilatation of the urethra is apt to lead to an insuperable in- 
continence of urine, which may be a never-ceasing annoyance 
to the patient, it should be remembered that in using the 
instrument I have described, the amount of distention is not 
great; the blade of the forceps introduced into the bladder 
being quite flat, it does not occupy nearly so much space as a 
moderately-sized pair of lithotomy forceps, and, during its 
introduction, does not inflict anything like the injury produced 



6 Dr. Newman — New Method of Operating upon 

by the latter should thej r include between their blades even a 
small calculus. Moderate dilatation, when performed rapidly, 
appears rarely to produce any permanent injury to the urethra 
in the adult, and as vesico-vaginal fistula is very seldom met 
with in children or young subjects, and seeing that the method 
I have described is not applicable to them in the case of vesico- 
vaginal fistula, they do not require to be considered here. 

Every surgeon must have observed the ease with which the 
female urethra may be dilated, either with the finger, or by an 
instrument for the purpose, when the patient is under the 
influence of an anaesthetic, and he must also have been struck 
by the rapidity with which it recovers its function, even when 
the dilatation has been considerable. 

In the case of vesico-vaginal fistula above referred to, I 
dilated with the fino-er, and introduced the blade of the 
forceps at once. The incontinence of urine continued in this 
case for sixteen days, and by that time the fistular opening- 
had healed completely, and since then the patient has enjoyed 
perfect health. 

Brief reference may now be made to the question raised at 
the beginning of this paper — viz., to what improvements in 
the method of operating have the good results achieved by 
modern surgeons been due ? 

To answer this question shortly, I think three reasons may 
be given for the want of success which attended the work of 
the earlier operators on such cases. 

(1.) The operation was seldom resorted to till other means 
of treatment had failed ; and very frequently, by the applica- 
tion of caustic, or by the employment of the actual cautery, 
the edges of the fistula had, in the meantime, been irritated, 
and chronic inflammatory changes induced ; or probably with 
the idea that a certain amount of contraction might take 
place by the formation of cicatricial tissue, the operation was 
postponed, to the disadvantage of both the patient and the 
surgeon. 

(2.) Through a fear of enlarging the fistula, should the 
operation turn out a failure, the edges were simply " rawed," 
instead of freely cut, and two surfaces were brought together 
which, on account of their unhealthy structure, had little 
tendency to unite. 

(3.) The method of applying the sutures, and the nature of 
the sutures employed to bring the edges together, were un- 
suitable and insufficient for the purpose. 

No one will deny that the surgeon of the present day has 
greater facilities for operating; the various stages of the 



Recto- Vaginal and Vesico- Vaginal Fistula. 7 

operation being greatly facilitated by the employment of 
anaesthetics. But while this is true, and is no doubt a factor 
of great importance, it must also be remembered that these 
agents have now been in use for nearly forty years, whereas 
it is within very recent times that really satisfactory results 
have been achieved by the treatment we are now considering. 

To procure union of the cut surfaces by first intention is 
the most important element of success. This should be the 
main object of the surgeon. It is true, union in some cases 
may take place after the formation of granulations, and in 
the presence of suppuration ; but it also will be admitted that, 
as a rule, if the result is not altogether negative, the object 
aimed at is seldom fully accomplished under such conditions. 
Previous to operating it is therefore necessary, as a preliminary 
measure, to place the patient in the best possible condition by 
improving the general nutrition, and by as far as possible 
removing local disturbance. With regard to the success of 
the operation and the benefit obtained from it, everything 
depends upon the method employed, and the previous treat- 
ment to which the fistula has been subjected. 

At the time when it was considered right to employ 
cauterisation by chemical agents or by the actual cautery, 
previous to operating, the state of the tissue was rendered 
unfavourable for union by first intention, and even though no 
such treatment had been resorted to, if the fistula happened 
to be one of old standing, which was very frequently the case 
in the times I speak of, the edges of the aperture were certain 
to have become infiltrated by inflammatory material. Some 
time ago I had the opportunity of examining post-mortem the 
parts, involved in a vesico-vaginal fistula of a few months' 
standing, and, on microscopic examination of them, I found, 
extending inwards for about an eighth of an inch from its 
margin, the tissue greatly infiltrated by leucocytes and recently 
formed connective tissue, but beyond this limit the tissues 
were practically normal in appearance. Now, supposing this 
case had been operated upon, and the surgeon had contented 
himself with denuding the fistula only of a narrow strip, say less 
than one-eighth of an inch broad, the surfaces brought in 
apposition would have been in a condition in which primary 
union was practically impossible, whereas, if he had removed 
a little more than an eighth of an inch all round the 
aperture, the tissue with which he would have had to deal 
would have been healthy and suitable for his purpose. From 
what I have seen in my limited experience, and from what I 
have read, it appears to me that most surgeons err in not 



8 Dr. Newman — Recto-Vaginal and Vesico-Vaginal Fistula. 

removing enough of tissue — that is to say, they bring together 
tissues which are not healthy, and therefore not in a con- 
dition to heal readily. It is the prevailing opinion that, if 
the edges are pared and simply denuded of their mucous mem- 
brane, enough has been done in the way of cutting, and that 
the operator is then in a position to unite the edges by sutures. 
It is by no means an uncommon rule, laid down in books on 
operative surgery, that the incision must not include the 
mucous membrane of the bladder, but the wound should 
present a bevelled oblique line, slanting from a large vaginal 
opening to a smaller vesical one. Why the incision should 
be made so as to avoid the vesical mucous membrane, unless 
it be for fear of haemorrhage from the bladder, I cannot 
understand. That it should be involved in the incision I will 
now try to show. 

It is now generally admitted that the danger of haemor- 
rhage from incision of the vesical mucous membrane is not so 
great as was at one time supposed. In the new method of 
operating I have described, haemorrhage during the operation 
is prevented, and by removing all the inelastic cicatricial tissue, 
the danger of the mouth of a small artery being held open and 
leading to secondary haemorrhage is prevented. If the method 
I have indicated above, of making the incision in a bevelled 
oblique line, be adopted, it is apparent that when the sutures 
are introduced and fixed, there will be a deficiency of tissue on 
the side of the vagina, and an excess on the side of the bladder, 
so that the tension on the one surface will be much greater 
than on the other; and whereas on the vaginal aspect the 
paring of the edges may be so complete as to expose healthy 
surfaces, on the other hand the mucous membrane of the 
bladder is allowed to remain in very much the same condition 
as it was previous to the operation. That is to say, the portion 
of the fistula which has been sufficiently pared to admit of 
ready union is to be subjected to undue tension in order to 
allow a piece of tissue to remain which has very little tendency 
to repair, being probably infiltrated with old inflammatory 
products. What I therefore argue is, that the whole thickness 
of the vesico-vaginal or recto-vaginal wall should be uniformly 
incised, and that all the indurated tissue should as far as pos- 
sible be removed, not merely " rawed," and that the vesical or 
rectal mucous membrane, as the case may be, should be pared 
with the same freedom as the mucous membrane of the 
vagina. 

The next point to which I desire to draw attention is the 
method of suturing the cut surfaces. The more accurately 



Mr. Maylard — A Visit to the Hunterian Museum. 9 

they are adjusted the more likely is the operation to be suc- 
cessful. The means usually adopted is to pass wire or silk 
sutures through the whole thickness of the tissues, or even, as 
some writers recommend, to exclude the mucous membrane of 
the bladder and only include the other structures. 

Seeing that the parts are very flaccid and easily disturbed, 
I do not see any objection to, but rather an advantage in, 
uniting the different structures by separate sutures, as they 
are thereby kept in more exact apposition. I have therefore 
adopted the plan of bringing the mucous membranes together 
separately by very fine catgut, and then passing stronger 
sutures through the whole thickness of the wall for the pur- 
pose of uniting the other tissues, and also as a means of 
■support to the weaker stitches in the mucous membrane. 

Besides, by uniting the mucous membrane of the bladder 
and of the vagina firmly, the penetration of irritating fluids 
into the submucous tissue is to a great extent prevented, and 
the chances of a ready union of the cut surfaces is thereby 
facilitated. 



A VISIT TO THE HUMAN ANATOMY SECTION OF THE 
HUNTERIAN MUSEUM, GLASGOW UNIVERSITY. 

By A. ERNEST MAYLARD, B.S.Lond. 

During the months of March and April of the present year 
I had the opportunity, thanks to the kind permission of 
Professor Young, of spending several very profitable hours 
among the rare and beautiful specimens contained in this 
section of the Hunterian Museum. It is with the hope of 
exciting in others the interest felt by myself in going over 
these preparations that I am tempted to pen the following- 
few remarks. That I am correct in assuming: a general lack of 
interest in this particular portion of the Hunterian collection, 
the subjoined reasons, I think, will sufficiently show. First, 
that during the many hours I spent in the Museum scarcely 
half a dozen visitors appeared. Second, that the only com- 
plete catalogue available remained uncut ; although, according 
to the date on the front page, it was published in 1S40, 
i.e., forty-four years ago. This may of course have been a 
new copy, but judging from the little demand for reference 
it seems improbable. Third, and this I would urge as the 



10 Mr. Maylard — Visit to Human Anatomy Section, 

most cogent reason, that of the many graduates of the 
University with whom I have conversed since visiting the 
collection, few have ever seen it, and still fewer are cognizant 
of its valuable contents. How little, indeed, this collection 
appears to be known, either inside or outside Glasgow, may 
be best illustrated by an incident which recently occurred at 
a meeting of one of the medical societies in our city. The 
subject under discussion was one involving much labour of the 
nature of looking up recorded instances and illustrations ; and 
although the author's investigations seem to have been most 
complete, neither the members of the society nor writers upon 
the subject appeared to be aware of a specimen in the 
Hunterian collection finer than many which had been deemed 
worthy of record. 

Concerning the history of the Museum, and other general 
facts in comiection with it, I shall not enter. My object is to 
point out wherein lies what I believe to be the value of the 
collection, and wherein may also be found the lack of interest 
from which it appears to suffer. I would say, in passing, 
with the hope of adding weight to what few remarks I may 
make, that the comparative source from which I venture to 
draw my conclusions rests upon a previous acquaintance with 
the museum of the Royal College of Surgeons, London, and 
the various collections of the metropolitan hospitals. 

Perhaps the first point which strikes the casual observer, 
in looking at the wet preparations, is the absolutely perfect 
state of preservation in which many, indeed most, appear to 
be. When too, it is remembered that nearly one hundred 
years have elapsed since they were mounted, their present con- 
dition becomes still more interesting. This simple mechanical 
consideration of mounting is not without value to those 
engaged in putting up spirit preparations. The numerous 
ineffectual methods now tried, and frequently adopted, may 
well be contrasted with these standing proofs of years. The 
cover which Hunter used, and which has so well stood the test 
of variations of temperature and movement from one place to 
another, consisted of two layers of bladder, between which was 
inserted a sheet of pliable metal about the size of the orifice of 
the vessel, and covering over all a thick coating of Brunswick 
black. This "cap" has resisted any perceptible escape of 
spirit, and permitted, without rupture, the needful variations 
depending upon the expansion or condensation of the spirit 
vapour. Of the other wet preparations, in which turpentine 
has been used, I should like to be allowed to suggest that in 
many cases remounting would be of great service, indeed 



Hunter ian Museum, Glasgoiv University. 11 

rendering many useful which at present are totally useless. 
The object of the turpentine is to clarify the specimen ; and 
while this has been effected, the fluid itself has become so 
turbid as to completely obscure the object. 

Turning now to the more instructive and interesting con- 
sideration of the preparations themselves, one is at once 
superficially struck by the exquisite beauty which they present; 
a beauty too which in form and colour could hardly fail to 
evoke even the admiration of the anatomically uninitiated. 
The perfect whiteness of some of the tissues, as well as the 
unaltered persistence of the coloured injections, render the 
contrast in some cases — as in the specimens of injected intestine 
— truly beautiful. Language however would fail to convey 
what alone can be acquired by observation, and I shall in 
future only refer to such particular points in specimens as will 
serve me for special purposes. While thus admiring what 
may justly be acceded as illustrations of high art, one naturally 
thinks of the artist ; and but very slight attempts to work 
upon one's own account in this direction will be amply sufficient 
to engender the feelings of what patient and exquisite manipu- 
lative skill their completion must have entailed. To accredit 
Hunter however with nothing more than this, to some extent 
purely mechanical skill, would be unjust. The enormous number 
of specimens he collected, while often in themselves individually 
of no apparent value, taken together possess considerable 
inductive interest ; and although there is nothing which 
pointedly indicates that Hunter had this object in view, there 
is sufficient for us to conclude that his labour was in many 
cases based upon pure scientific principles. In reading through 
the description of many of his preparations, instances are often 
met with where inferences are drawn and queries posed, thus 
showing a deeper interest in the preparation than a mere 
objective one. As an illustration of the former, I may quote 
the following from the catalogue — "PP. No. 5. Twelve teeth 
from pigs fed on madder, become red throughout, si 1 . owing 
that the arteries convey the colouring matter of the madder to 
the teeth as to other bones ; but the madder is taken out of 
other bones, but always remains in teeth, as if they had no 
absorbents." As an illustration of the latter, the following, 
although the specimen itself will be found elsewhere amongst 
the comparative anatomy series — "D 46a. The body of a 
monkey, the aorta injected red, the thoracic duct with quick- 
silver. The valves in the duct are at every sixteenth of an 
inch through the whole length, and give it a very knotted 
appearance. Will the horizontal position of the horse account 



12 Mr. Maylard — Visit to Human Anatomy Section, 

for the almost total want of valves in the duct of that animal? 
and will the erect position of the monkey make their frequency 
in him appear perfectly proper ?" Still further, while in many 
cases Hunter accidentally came across facts he neither expected 
nor sought for, he far more frequently started with the definite 
object of eliciting some truth, the probability of which theory 
alone had suggested. 

In these few observations upon what appears to me to have 
really been Hunter's chief object in making his collection, are 
to be found, I think, the most instructive methods for study- 
ing it. As he sought to infer from the results of his careful 
dissections and injections, so should we seek to do likewise ; 
and under how much greater advantage do we labour than 
he ! Starting as it were upon the same footing — for the 
preparations are as fresh to us to-day as they were to him 
a hundred years ago — we have the experience and scientific 
investigations of a whole century at our backs to aid us. 
One cannot help feeling that if more time and attention 
were devoted to the study of such "speaking" preparations 
as are to be found here, many recondite hypotheses and 
chimerical theories would be advantageously quashed, while 
others based on sounder principles would receive additional 
support. 

There are some pathologists who disbelieve in the existence 
of endo-phlebitis, admitting only a peri-phlebitis in the adven- 
titia and in the areolar tissue around the vein, but there are 
two beautiful preparations in the Museum which, although 
simply described as inflammation of the vein, could hardly 
be accepted as representing any other than this particular 
condition. The theory that cysts of the lower and upper jaw 
are in all probability connected with the teeth seems to obtain 
some support from the consideration of preparations PP3 and 
3a. It is known as a clinical fact that in the upper jaw cysts 
usually develop in the antrum, while in the lower they 
project through the external surface of the maxilla. Now 
these preparations are mounted to show the comparative 
thickness of the two sides of the alveolus ; thus, in that of the 
lower jaw the external wall is thinner, whereas in the upper 
there is no difference. Supposing then a tumour grew from 
the apex of the fang of a tooth, the most probable seat of its 
origin, what more likely than that it should extend in the 
direction of least resistance, which in the case of the lower 
maxilla would be through the external wall, and in that of 
the upper into the antrum, where the apices of the fangs are 
sometimes covered with little else than the mucous lining of 
the cavity ? 



Hunterian Museum, Glasgoiv University. 13 

Many other illustrations might be given, but these two will 
be sufficient I hope to indicate how, on the simple question 
of theory and fact, much good might be derived from a little 
thoughtful study of the preparations. 

From a less scientific point of view, though practically 
not less important, the consideration of such specimens as 
exhibit sections of the nose and ear may be alluded to. The 
parts in many of the preparations are seen in situ, and the 
injected specimens of the nasal cavities are most natural. 
The practical value of such dissections as these must suggest 
themselves to almost every surgeon, either from the difficulties 
which he has experienced himself or the evil results he has 
seen follow in the hands of others, from a simple ignorance 
of the normal anatomical relations of parts. I allude, of 
course, to the various affections needing surgical inter- 
ference — the extraction of foreign bodies, removal of polypi, 
accumulated masses of secretion, &c. How many unfortunate 
patients have had pieces of the inferior turbinated bone removed 
for supposed polypi, or the membrana tympani ruptured bv 
pushing in a foreign body in the fruitless endeavour to pull it 
out, from ignorance in the one case of the relative position of 
the parts in the nasal cavity to the meatus, and in the other 
to the curves and direction of the external auditory canal ? I 
know of one case, which came immediately beneath my own 
notice, where death occurred indirectly from the inflammation 
set up by a foreign body in the ear. The body was extracted, 
but not until all the evils of previous delay and vain endeav- 
ours at removal had rendered the patient's recovery hopeless. 
But instances too numerous must exist in the knowledge of 
every surgeon. With such facts therefore before one, the 
examination of these specimens cannot fail to excite interest, 
especially too when it be remembered that neither in the 
dissecting nor in the pathological room are illustrations forth- 
coming to show precisely what these sections do. 

Of other wet preparations I may allude to those illustrating 
gestation. Perhaps this forms by far the finest class, and 
to the obstetrician offers a good field for study. The oculist 
and the dentist will each find his particular department well 
represented, and equally worthy of consideration. 

Among the dry preparations will be found a very large and 
valuable assortment of bones. Although not in the same 
state of preservation as those kept in spirit, for all practical 
purposes they are of equal value. Existing as a mass of 
uncatalogued specimens, they form a fine field of speculation 
for the pathologist, though of little instructive value to the 



14 Hr. XIaylard — Visit to Human Anatomy Section, 

student. The more advanced student however could not fail 
to recognise many of the more typical specimens, such as 
those for instance illustrating the various forms and degrees 
of necrosis. The preparations illustrative of inflammation of 
bone certainly form a very valuable series, presenting almost 
every grade of the process, from the most perfect examples 
of constructive osteo-plastic osteitis to the opposite equally 
extreme instances of destructive rarefying osteitis. Of 
individual specimens there are several, which it is impossible 
to class under any definite head. There is a tibia for 
instance, enlarged from what cause I know not, which seems 
to illustrate simple expansion of bone, the possibility of which 
is denied by some pathologists. Another tibia also gives a 
still wider field for speculation, for neither by growth (tumour) 
nor inflammation does it seem possible to explain it. The 
compact covering of the bone is diminished to a thin shell- 
like consistency, and the epiphysial ends of the bone, as well 
as the diaphysis, are irregularly dilated into large projecting 
masses. Where the thin bony covering of compact tissue has 
been removed, the part beneath is seen to consist of a uniform 
cancellated structure, but the spaces are much larger than 
those of normal cancellous tissue. Notwithstanding these 
large excrescences, the bone is excessively light. Neither 
in weight nor appearance does it at all resemble that 
porous condition of bone described under "osteoporosis." 
The only condition to which it in any way appears to 
approach is one referred to by Wilks and Moxon, where, in 
several recorded instances (a case of Dupuytren's and one 
of Saucerotte's being specially mentioned), progressive enlarge- 
ment of the skeleton affecting some parts more than others, 
and causing tumour-like masses in places have been noticed. 
Here again I must remark, that even Saucerotte's case, as 
more elaborately detailed by Sir James Paget in the sixtieth 
volume of the Medico - Chirurgical Transactions, presents 
features unlike those which must have existed in the clinical 
aspects of the present case. 

There is a large collection of bones illustrating osteo- 
arthritis ; and a still larger one of united fractures. This latter 
forms a very instructive class, both as showing the usual 
displacement of fragments and their method of union. Indeed, 
the number and similarity in some cases would almost 
justify one in arriving at some general law ; thus, in all the 
specimens — six in number — of fractured ribs, where the line 
of separation has taken place within four inches of the 
tubercle, the distal fragment is displaced inwards and 



Hunter ian Museum, Glasgow University. 15 

backwards. Again, in four specimens of bony ankylosis at 
the elbow joint, apparently the result of previous destructive 
inflammation, the radius has escaped union, both with the ulna 
and the humerus, and from the smooth surfaces seen in the 
situation of the radial head there must have existed pronation 
and supination. The question of transverse fracture of a 
bone is also interesting- when considered in the light of the 
specimens found here, with special reference however to the 
femur. In all the specimens of fracture of this bone — 
fourteen in number — the line of separation is oblique. 

As illustrating to what extent bone may waste from simple 
loss of function, there are two specimens, made very valuable 
from the almost total abolition of the operation which rendered 
their acquisition possible. They consist of the upper end of 
tibia and fibula, the leg having been amputated close to the 
knee joint ; so that the remaining fragments would thus exist 
absolutely useless. They have not so much lost in shape and 
size as in density. 

The numerous curves found in long bones affected with 
rickets are illustrated by several specimens, which likewise 
exhibit well the total loss of all normal anatomical configura- 
tion which in the more extreme cases they undergo. The 
condition of skoliosis, or lateral curvature of the spine, is 
represented by some six or seven specimens. One consisting 
of the whole trunk, being a very typical case, is exceptionally 
instructive. 

There are about half-a-dozen specimens of mollities ossium, 
three of which are wet preparations, and remarkably fine. 
Seeing that these, so far as the museums of the Western and 
Royal Infirmaries are concerned, are the only illustrations in 
Glasgow of this well recognised disease in the human subject, 
they possess a value above that for which they are simply 
intended. 

There are numerous other preparations which might be 
alluded to, such as typical examples of syphilitic disease of the 
cranial bones, malignant tumours of bones, exostoses, and so 
on ; but enough has been said I hope to excite such interest 
as will induce others to seek amongst these " dry bones " for 
what will amply repay any little trouble. I might add, that 
owing to the interest which in late years has been attached 
to an affection of the bones — osteitis deformans — described by 
Sir James Paget and by Charcot, where, in the immediate 
neighbourhood of joints affected with ataxic arthropathy, 
the bone has undergone extreme erosion changes, I looked 
carefully for any specimens illustrative of these con- 



16 Mr. Maylard — Visit to Human Anatomy Section 

ditions, but found none. The fact is interesting, because the 
question which has been raised in connection with them 
is as to whether they actually existed a century back, whether 
indeed they may not be, as Sir James Paget has suggested, 
the outcome of an evolutionary process in the progress of 
certain diseases. When it is remembered that Hunter, judging 
from the nature of his whole collection, must have preserved 
everything that came beneath his notice presenting the smallest 
feature of abnormality, the absence of any such preparation 
is not without its bearing upon the suggested theory of 
origin. 

If, in the above few remarks, I have been able to show 
that there exists some real intrinsic value in the collection, 
I may reasonably be allowed to ask, Why is it so little known 
outside Glasgow, and so meagrely recognised inside ? The 
former question is answered by replying to the latter; for 
were it more freely consulted by those who, as students and 
practitioners, have ready access to its treasures, the collection 
could not fail, sooner or later, to receive a more general and 
widespread recognition. The reason for lack of local interest 
can hardly rest upon the need of any such superficial 
exposition of its contents as I have ventured to give ; for 
there are those who know far better than myself the value 
of all it contains, and Avho have ere now proclaimed by word 
or pen its inestimable merits, but for which indeed I for 
one should not have had the pleasure of profiting by its 
instructive lessons. 

I am forced therefore to look elsewhere for the cause, and 
believe it to be found in the simple physical inconveniences 
which at present exist. If the University take no further 
interest in the collection than that of its maintenance as a 
valuable relic of the past, then let it remain as it is, and let 
him who would venture to visit it during the six winter 
months run the dignified risk of being preserved there also. 
The collection, where it is now to be seen, is approached 
through the main portion of the Hunterian Museum, and no 
visitor to this part would, without previous knowledge that 
such a collection existed, or without special inquiry, either see 
or find his way to it. Supposing a slight interest evinced 
but not sufficient to induce inquiry, the door which leads to 
the museum has " private " marked upon it, so that he whose 
enlightened curiosity might lead him in the right direction is 
hindered, and he who is bold enough to enter would at once 
return from what would only appear, and is, simply a lumber 
room. It is at the far end of this room that a door opens 



Hunter ian Museum, Glasgoiv University. 17 

directly into the collection. The chamber, which I should 
imagine was originally intended for a class room, is situated 
at the top of the extreme north-east angle of the building, 
having its four walls exposed to the external atmosphere — 
two, the one looking north and the other east, are completely 
unprotected, the other two only partially exposed. In the 
southern wall is a door leading into an open stone staircase. 
Perched up thus in regions above the roofs of almost every 
house in Glasgow, and with not one particle of warmth 
reaching the place, it is needless to say that at times the 
cold is intense, rendering anything of the nature of study a 
physical impossibility. 

I cannot think however that the University has any such 
ulterior object as to maintain this valuable collection as simply 
a fossil one. Were its motives so illiberal I should humbly do 
my best to argue for some alteration, both from precedent (as 
in the John Hunter museum), that no possible harm could 
accrue, or at least nothing comparable with the good which 
might arise by giving greater facilities for its being better 
consulted ; and from the belief that such conservative 
system would have been far from the wishes of William 
Hunter, who, as a great teacher, would naturally desire that 
his labours should live as memoirs of instruction. 

I must confess that though I have found it easy to find 
fault, I feel it much more difficult to suggest a remedy ; but as 
one should always follow the other, I will venture the following- 
proposals. First, that while the Museum must remain where 
it is, a temperature of about 60° should be maintained during 
the winter months ; this would remove one of the gravest 
inconveniences. Such a temperature is kept up in the Hun- 
terian Museum in London, with the only objection, as Dr. 
Goodhart, one of the Curators, tells me, that the spirit prepara- 
tions require occasional remounting ; this, however, when 
cautiously carried out by skilful hands, need never harm the 
specimen. 

Second, and this would appear to me, for numerous reasons, 
by far the most commendable, the erection of a museum, not 
simply to contain the collection, but to hold it as a foundation, 
upon the principles of which a large and instructive class of 
both normal and pathological anatomical specimens may be 
built up. I say upon the same principles, because, as a means 
of instruction, I believe facilities for the comparison of the 
healthy with the diseased part to be of the utmost importance. 
At present, rich as is this great city in material, and numerous 
as are the medical men in and around it, there is no centre to 

No. 1. C Vol. XXII. 



IS !Mr. Yost — Case of Tubercular Tumour of the Cerebellum. 

which specimens of interest can be sent, or individual collec- 
tions left. 

I believe, with regard to the erection of a museum, the 
University has some plan in hand, and that lack of funds is 
the only obstacle to its being carried into effect. If this be so, 
what an opportunity exists for some good and charitable 
citizen, a lover of human science and human art, to immortalise 
his name, and to confer upon posterity a means invaluable 
towards the relief and cure of suffering humanity ! 



CASE OF TUBERCULAR TUMOUR OF THE 
CEREBELLUM. 

By Wm. YOST, M.B., CM., Belvidere Hospital. 

A. C, a healthy looking school boy, aged 12 years, was 
admitted into Belvidere Fever Hospital, on 26th March, 1884. 
He took ill on 20th March with feeling of malaise, and two 
days afterwards a purpuric rash appeared all over the body, 
from head to foot, but chiefly on the back and thighs : he also 
had a cough. 

Shortly after taking ill, the friends noticed that he staggered 
like a drunk man, and sometimes fell to the floor. He com- 
plained of pain in the left side. 

When admitted to Belvidere Hospital he was unable to 
walk. He lies in his bed with his knees drawn up towards 
his abdomen ; complains bitterly of pain when his limbs are 
extended, but nothing can be found to explain it. His eyes 
are fixed, prominent, and glistening ; pupils extremely, though 
equally, dilated, and do not respond to the stimulus of light. 
He picks his nose and the canthi of both eyes. He is 
talkative and querulous. He cannot put out his tongue, but 
it is dry and covered with a thick brown fur. The teeth are 
coated with sordes. There is no paralysis of movement or of 
sensation of his limbs or body, and there has been no priapism 
or vomiting. 

27 th March. — He lies sometimes on one side, sometimes on 
the other, with his eyes shut : at times he opens his eye, gives 
a blank stare, and closes them nearly immediately: cannot 
bear the light. 

On rousing him he answers questions — his name — how 



Me. Vost — Case of Tubercular Tumour of the Cerebellum. 19 

many fingers he has — his sisters' and brothers' names — that 
he can see — has " roasting " pain in the abdomen and lower 
part of the left pleura — pain in the forehead — does not know 
where he is, but fancies himself at home. 

He soon becomes tired, and desires to be let alone, and 
moans. He occasionally asks for a drink, and, when made to 
sit up in bed, and the cup with the milk is held before him, he 
holds out his hand for it, but seems unable to direct it towards 
the cup, and, becoming angry, asks for it to be given to him. 
Tache cerebrale is well marked: abdomen is not retracted. 
We had to draw off the urine. When the catheter is in the 
bladder he aids the expulsion of the urine. The bowels are 
constipated. 

On the night of admission the temperature in the axilla 
was 102°, and on 27th, 28th, 29th, and 30th March, the morn- 
ing and evening temperatures were respectively — 102'2° and 
102-4°, 102-4° and 101-6°, 101-8° and 101-6°, 100-8° and 100°. 
On the morning of 27th, pulse was 110, and on 30th 156, 
and the respirations 56 a minute. 

He gradually sank and died on 30th March. The only 
changes noticed after admission were that, four or five hours 
before death, his eyes, instead of being fixed, moved slowly to 
and fro, and that the right eye was slightly turned downwards 
and outwards : he also had Cheyne-Stokes respiration for 
a short time. No vomiting occurred from first to last or 
before admission. There was no heart lesion. The family 
history is very bad, nearly every member having some form 
of tubercular disease. 

Poxt-mortem eaxmrvmation. — A tumour, the size of a 
walnut, of a greenish-yellow colour, granular, not involving 
the brain substance, but apparently let into it as it were, 
was found occupying the under surface of the left lateral hemi- 
sphere of the cerebellum. 

The pia mater was congested, studded with tubercles, and 
adherent in many districts to the grey substance of the 
convolutions. A considerable quantity of serous fluid occu- 
pied the space between the dura mater and arachnoid, and 
also the ventricles. The superficial cerebral veins were 
congested. A large cluster of tubercles was situated deep in 
the right middle cerebral lobe, between two of the convolu- 
tions. The dura mater was slightly adherent to the inner 
table of the skull. At the upper part of the left lung there 
Was old standing pleurisy, probably tubercular, as glands with 
caseous matter were found at the root of the same lunc;. A 
tew tubercular points occurred in the apex of the left lung, 



20 Mr. Forbes — Mole Fern and Pomegranate Root Bark 

but no cicatrices were seen. Right lung was healthy. 
Although patient complained of so much pain in the lower 
part of the left pleural cavity and in the abdomen, no pleurisy, 
peritonitis, or enteritis could be found. 

The bladder was full of urine. 

Microscopic examination showed that the tumour was made 
up of round cells very imperfectly organised, and contained 
tubercles. Laminae of cerebellar fibres intersected the tumour. 



MALE FERN AND POMEGRANATE ROOT BARK 
COMPARED IN THEIR ACTION ON TAENIA 
SOLIUM. 

By CHARLES FORBES, M.B., CM., Moriani, Upper Assam. 

The three cases which form the basis of this article present 
the following points in common. 

In all the worm was solitary and tasnia solium. All three 
were lono- standino- cases, in which male fern (as well as 
kousso, kamala, and turpentine) had been repeatedly unsuc- 
cessful. I may here add that in these cases male fern, when 
first used, brought away large quantities of the worm but 
failed to expel the head, and that the worm seemed to acquire 
a tolerance of this drug in time. 

The effect of the pomegranate root bark was identical in all, 
both as regards the patient and the worm. 

The mode in which the worm was expelled was also 
precisely similar in the three cases. 

The first and third cases were Europeans who had been 
passing joints for about eighteen months. 

The second case was a Bengalee coolie woman who had 
suffered for the past five years. 

The points of similarity being such, one only need be cited. 
I take the first case as being typical. 

S. S. N., tea planter. 

Treatment by pomegranate root bark. Took a light break- 
fast at 12 noon and went to bed without any dinner. At 
6 A.M. next morning took half ounce castor oil, and at 7 a.m. 
one ounce of the fluid extract of pomegranate root bark. 
This was ejected about 10 minutes after, and a second dose 
was administered, which was retained. 



Mr. Frew — Epidemic Gerebro-Spinal Meningitis. 21 

About half-an-hour after the tape-worm was expelled, head 
tirst, in a complicated knot, and entire. 

The animal was not dead, but seemed rather to be intoxi- 
cated, and the patient described his sensations to be of the 
same character. 

A third dose was then administered, on the chance of 
there being a second worm, but without effect. 

In this and the other two cases, the head of the worm under 
the microscope proved to be that of" tamia solium. 

The following are the points I consider worthy of note : — 

1. The superiority of the pomegranate over the male fern. 

2. The primary emesis and subsequent tolerance. In this 
respect pomegranate resembles ipecacuanha. 

3. The intoxicant effect. 

I annex label, as this drug, unless freshly prepared, has been 
found inert. 

" Fluid Extract of Pomegranate Root Bark (prepared in vacuo) 
for Tapeworm. Directions. — A dose of castor oil should be taken 
early in the morning, and the fluid extract should then be taken in 
three doses, one-third of the bottle each dose, at intervals of one hour, 
commencing one hour after the castor oil. Each dose may be taken 
in a wineglassful of water. Three ounce bottle. Prepared by 
Kemp & Co., Limited, Sassoon House, Bombay." 



REPORT OF A SLIGHT OUTBREAK OF EPIDEMIC 
CEREBRO-SPINAL MENINGITIS, WITH NOTES 
OF SIX CASES.* 

By WM. FREW, M.B., CM. Edin., Galston. 

During the last few months I have had the opportunity of 
observing a slight outbreak of this formidable disease in the 
town of Galston, Ayrshire. The number of cases which may 
I think without doubt be ranked as cases of this disease was 
six. In two of these six cases the diagnosis was verified by 
post-mortem examinations ; in other two, where the result was 
a fatal one, no post-mortem examinations were made, but the 
symptoms of the disease were so well marked that no reason- 
able doubt of their true nature can be entertained ; and of 

* Read before the Pathological and Clinical Society of Glasgow on 13th 
May, 1884. See Report of Society's Proceedings, page 72. 



22 Mr. Frew — Report of a Slight Outbreak of 

the remaining two cases, in which recovery took place, the 
same may be said. Besides these six cases, however, there 
occurred in the district at the same time perhaps as many 
more cases, in which the initial symptoms of the illnesses bore 
a striking resemblance to those of epidemic cerebro-spinal 
meningitis ; but the cases, after continuing for a few days, 
seemed to abort, and the patients got quickly well ; and I find 
that in the reports of epidemics of this disease in America 
such abortive cases have been very generally observed. 

Before reading the notes of the cases, I may state, for the 
information of those not acquainted with the district, that the 
town of Galston is situated in the valley of the Irvine, distant 
5 miles east from Kilmarnock (the nearest large town), and 
21 miles south from Glasgow. The population, which is 
chiefly a mining one, is about 5,000. The town is low lying on 
the left bank of the river, several of the streets in the lower or 
west part of the town being almost on a level with the river's 
bed, which is also unnaturally raised by a dam which stretches 
across it just at the lower end of the town. The town is in 
general moderately healthy, the death-rate being from 15 to 
18 per 1,000 ; but during the cholera epidemic of 1848 it 
seems to have suffered much more severely than many of the 
surrounding villages. About 20 years ago it was made a 
Police Burg-h, since which time the drainage, &c, have been 
improved considerably. The water supply is entirely from 
wells, and is plentiful. The drainage of the lower part of the 
town has never been in a satisfactory condition, and of late 
years it has become still more unsatisfactory on account of 
various subsidences of the soil, which have occurred by reason 
of the extraction of the coal underneath. The whole of the 
sewerage from the lower quarter of the town is led into an 
open ditch ; and during the past winter, at several places in 
the course of this ditch, subsidences have occurred, with the 
result that the flow has been interfered with, and the sewage 
has saturated the surrounding soil to such an extent as to 
form in certain places quite a morass. At the present time 
the Burgh Commissioners are considering the question of 
introducing a new drainage scheme ; but, as in the past, the 
ratepayers have shown a preference for returning men to the 
Commission who pledge themselves to take special care of 
their pockets (and not of their lives), the adoption of it is a 
matter of some doubt. 

Case I. The first case which I observed occurred in one of 
a row of miners' houses, situated about half a mile west of the 



Epidemic Cerebrospinal Meningitis. 23 

town,, and past which courses this open ditch, containing the 
sewage from a considerable portion of it. The patient was a 
girl aged 10 years, named J. A. On the evening of Saturday, 
12th January, 1884, this girl left home in good health to 
attend a Band of Hope meeting in the town. On returning 
from the meeting about 9 p.m., she complained of headache, 
and soon afterwards vomited. The headache and vomiting 
continued until I saw her, about midday on the 13th. She 
was then in bed, with a hot skin and quick, full pulse ; she 
complained of headache, and of pain in the region of the 
stomach, and was vomiting bilious matter. The tongue was 
coated, and the bowels had not been opened since the previous 
day. I ordered a few powders containing small doses of 
calomel and bismuth, one to be given every two hours, a 
sinapism to be applied over the stomach, and cold applications 
to the head. 

14-th January — morning. — She appeared to be somewhat 
better ; the head was not so painful, but vomiting of greenish 
fluid continued at intervals. The bowels had not been 
moved, so I prescribed a powder of calomel with jalap to be 
given at once. In the evening she was worse ; I found her 
tossing restlessly in bed, crying loudly with the pain in the 
head. T. 104° ; pulse quick, and slightly irregular ; face 
flushed. I now ordered six leeches to be put to the temples, 
and after these had bled freely, ice cloths to be kept to the 
head (the hair having been cut), to have the bowels cleared 
out by an enema, to be kept very quiet, and to have the 
following mixture : — 

R. Potass. Iodidi, .... 3iss. 

Potass. Bromidi, .... 3jj- 

Syr. Simplic., ..... 3iij. 
Aquam ad, ..... §iv. M. 

Sig. — Two teaspoonfuls to be given every three hours. 

15th January — morning. — She had passed a very restless 
night, tossing herself about in bed, and crying out with the 
pain in the head. Was delirious at times, and continues so 
to-day. The vomiting and retching had stopped after taking 
the first dose of the medicine, and the bowels had been opened 
freely by the enema. The temperature could not be taken on 
account of the restless condition of the patient. In the even- 
ing the delirium was much more pronounced, and the symp- 
toms altogether much worse. The pulse was very rapid, weak, 
and irregular. She inclined to lie with her face turned from 
the light, with the head thrown back, and still screamed at 



24 Mb. Frew — Report of a Slight Outbreak of 

intervals with the pain. No rash was observed, but no par- 
ticular examination was made on this point. Sordes was 
present on the lips and teeth, and altogether the child seemed 
to be in extremis. The medicines had been given very irregu- 
larly on account of the patient's delirious condition, but the 
ice had been kept very constantly to the head. 

16th January — morning: — Her general condition was much 
the same as at last night's visit. In the evening I thought I 
could detect some slight improvement. 

17th January. — The signs of improvement were more mani- 
fest, although she was not yet conscious. She was much 
quieter, and was taking small quantities of beef tea and milk, 
along with small doses of brandy. The ice has been kept to 
the head only at intervals. 

18th January. — She regained consciousness this morning, 
and the temperature, which could now be taken for the first 
time since the delirium began, was 101" F. The pulse was 
more regular, tongue moist, and beginning to clean, and the 
bowels had again been moved freely by an enema. I ordered 
the medicine to be resumed in smaller doses. 

During the course of the next few days, while improvement 
was going on satisfactorily, a suspicion began to arise that the 
child was deaf. This could not be ascertained with perfect 
certainty for a few days longer, on account of the apparently 
stupid condition of the girl ; but as she progressed towards 
recovery, such was found to be the case. In about two weeks 
from the commencement of the illness she could sit out of bed. 
When she began to walk she did so with a very staggering 
gait, which gave herself and those around her considerable 
amusement. This staggering gait disappeared very slowly, 
continuing long after her general health was quite restored. 
The deafness remains complete. I made an examination of 
the ears with the speculum, but discovered nothing abnormal. 
She did not seem to hear a tuning fork applied to the vertex 
or to the teeth. The treatment during the stage of recovery 
was by iodide and bromide of potass in infusion of cinchona, 
with nourishing diet. 

While satisfied, during the progress of this case, that I was 
dealing with a meningitis differing as regards course and 
symptoms from any case I had previously observed, I frankly 
confess that I did not realise its exact nature until the occur- 
rence of the next two cases brought it vividly back to my mind. 
Considering, however, that we have been in the habit of ex- 
cluding epidemic cerebro-spinal meningitis from our thoughts, 
this is not to be wondered at. 



Epidemic Cerebrospinal Meningitis. 25 

Case II. Was an example of the fulminant form of the 
disease, and occurred in an infant named A. M., aged 1 year, 
living in one of the streets in the lower part of the town. I 
was asked to see the child on the forenoon of the 14th 
February. It had been apparently well up till about 8 o'clock 
the same morning, when the mother noticed it " trembling " 
and " drawing itself together " every now and then, as if in 
terror. It had also vomited several times, and had passed one 
or two loose motions previous to my visit. I found it lying 
on its mother's knee, with its legs flexed on the abdomen, and 
looking very ill. It cried much when moved, as if in pain. 
The skin was hot, pulse quick, and the countenance alternately 
Hushed and pale, the stage of pallor being accompanied by an 
appearance of great weakness, as manifested by the failure of 
both pulse and respiration. The child was suffering from 
hooping-cough, and on examining the mouth I found two 
teeth with the gum over them tender and swollen. These I 
cut. Nothing abnormal could be detected in chest or abdomen. 
I prescribed a sedative mixture containing bromide of potass, 
combined with a little febrifuge, a dose of which was to be 
given every 3 hours. At 1 p.m. of the same day I received a 
hurried message to visit the child ao-ain, as it had taken a fit, 
and was also having "very bad turns." The temperature 
then was 104° F. The pulse was very quick, and a faint, but 
quite distinct, measly-looking rash was visible on forearms 
and legs. The vomiting had continued, so that none of the 
medicine had been retained. After examining the child 
carefully again, I had to confess to the parents that as yet I 
could not say what the disease might be, but that it was 
manifestly of a serious nature, and resembled the malignant 
forms of some of the eruptive fevers (none of which were 
prevalent in the district at the time) more than anything else. 
I advised them to give the child a warm bath, and to continue 
the medicine. I did not see the child again that night, having 
been called from home, and on visiting the house early next 
morning, was informed that it had died at 10 o'clock the 
previous evening. They also informed me that the child 
became covered with dark coloured spots from the middle of 
the body downwards. Thinking that this probably referred 
to hypostatic congestion, I did not ask to view the body, 
neither did I ask for a post-mortem examination. 

Case III. On the 19th of February (5 days after the 
previous case), I was called to see H. M., aged 7 years, sister 
to the child in the preceding narrative. It was stated that 



26 Mr. Frew — Report of a Slight Outbreak of 

she had felt unwell since Sunday the 17th, on the afternoon 
of which day she had a rigor, and complained of headache, 
pain in the abdomen, and general malaise. On the 18th she 
had vomited frequently, and complained more of the headache, 
pain in abdomen, and also of pains in the legs. On that day 
she lay in bed, and her mother administered some pur- 
gative medicine which was immediately rejected. When I 
saw her on the morning of the 19th she was in bed, com- 
plaining as before mentioned, and had just been vomiting- 
some greenish fluid. She was quite sensible. The pulse was 
quick, full, and regular ; temperature 103° F. Tongue coated. 
Thirst great, and the bowels had not been moved since the 
17th. The pupils were natural. Nothing abnormal could be 
discovered in chest or abdomen. I ordered a few powders of 
calomel and bismuth, one to be given every hour, cold to the 
head, and a sinapism over the stomach. At 2 p.m. she was 
worse. None of the powders had been retained, and the 
pain in the head, vomiting, as well as all the other symptoms, 
were increased in severity. The pulse was also slightly 
irregular. I now ordered 6 leeches to be applied to the 
temples, and after these had bled freely, ice to be kept to the 
head, to have ice to suck for the thirst, and to have the 
bowels moved by an enema. I also prescribed the following 
medicine : — 

R. Potass, iodic!., .... 3 SS - 

Potass, broniid., . . . . ~)j. 

Tinct. digital., .... 3 SS - 

Aquam ad., ..... §ij. M. 

Sig. — A teaspoonful in water to be given every hour. 

At 9 p.m. she was continuing to get worse, with the 
exception that the vomiting had somewhat abated. She 
was very restless, starting up every few minutes with deeply 
flushed cheeks, and crying loudly with the pain in the 
head. In the intervals she lay quietly as if asleep, and the 
flush disappeared. The temperature was 104° F., as nearly as 
could be ascertained, on account of the restless condition of 
the patient. The pulse was extremely rapid and irregular. 
During the quiet intervals she answered questions sensibly, 
but apparently with an effort, as if she had to collect her 
thoughts first. The bowels had been freely moved with the 
enema. Treatment to be persevered with. 

Wtli February, 8 A.M. — Condition still becoming worse. 
She now lay in bed with her face turned from the light, the 
head retracted, the thighs partially flexed on the abdomen, 



Epidemic Cerebrospinal Meningitis. 27 

and the legs on the thighs. There was some swelling of the 
sides of the neck, and the thyroid gland was prominent and 
large. She complained of sore throat, and evidently felt some 
constriction there, as she begged her mother several times to 
loosen her scarf (there being none). The restlessness during 
the night had been very great, and she had also been evidently 
somewhat delirious. The extremities were cold, so that hot 
bottles had to be kept to the feet, and this condition still 
persists. Exposing the surface of the body to the air seemed 
to cause her great suffering, as she would pull up the bed 
clothes again, and creep under them, crying bitterly to be 
covered up. The pupils were moderately dilated and rather 
sluggish. The pulse was very rapid, weak, and irregular. 
The temperature could not be taken. The face still flushed 
frequently, and a mottled purplish rash could be seen over 
the forearms and legs. At 11 P.M. the condition of the child 
was extremely bad. There was sordes on lips and teeth. 
She was quite delirious, tossing herself about in the bed, and 
screaming loudly at intervals with the pain in the head. The 
head was greatly retracted, both the superficial and deep 
muscles being in a state of tonic spasm. Extremities still 
cold. 

21st Feb., 8 a.m. — She did not seem any worse since the pre- 
vious night, was perhaps slightly better. The vomiting had 
quite stopped, but retching continued at intervals. She con- 
tinued in the same restless delirious condition, with marked 
retraction of head. The medicine had necessarily been given 
very irregularly, but the ice had been kept very constantly to 
the head. At 9 p.m. the improvement seemed to be more pro- 
nounced, and she la}- more quietly. 

22nd Feb., 8 A.M. — She regained consciousness this morning, 
but remained in a very stupid condition. The retching had 
also ceased since last night, and the bowels had been moved 
again by enema. The headache was less violent, but she said 
that she had pain down the back, and the spine was tender on 
pressure, especially at the upper part. There was some degree 
of opisthotonos. The pupils were moderately dilated, and 
there existed intense photophobia. I tried to move the head 
forward but did not succeed, and the attempt was manifestly 
painful. The superficial muscles were now relaxed, but the 
deep muscles were evidently still in a state of tonic spasm. 
The swelling which existed at the sides of the neck was gone, 
but the thyroid still remained enlarged (this enlargement per- 
sisted all through the illness). The tongue was becoming moist 
and was cleaner at the edges. The mottled rash had dis- 



2s Mr. Frew — Report of a Slight Outbreak of 

appeared. She had been taking nourishment in the shape of 
beef-tea, milk, and lime water, and also had small doses of 
brandy given her at short intervals. Extremities were still 
cold, necessitating the continued application of hot bottles to 
the feet and around her. The ice had been only occasionally 
applied to the head. 

During the progress of the case so far I had become con- 
vinced that the illness was very similar to that of the case first 
recorded, and on referring to authorities I could not resist 
coming to the conclusion that all the three cases were cases of 
cerebro-spinal meningitis of the epidemic type. I also sent 
short notes of them to my friend Dr. Finlayson, who replied 
that my " diagnosis was probably correct, but that a post- 
mortem examination of some fatal case would be required to 
enable the other cases to be definitely settled." Such an 
opportunitjr, as you will hear, soon occurred. 

The further progress of Case III was a very tedious one. 
She had several relapses, during which pain and retraction of 
the head, vomiting, pains in the abdomen and legs, hyper- 
esthesia of the skin, constipation, &c, always recurred with 
more or less violence. No albumen was ever found in the 
urine, although it was tested frequently. She vomited blood 
on several occasions, but never to any great amount. The 
temperature during the remainder of the illness (of which I 
have careful notes down to the 31st of March, when convales- 
cence seemed to be fairly established) never rose higher than 
102°, and at one time fell as low as 96°. The pulse varied 
from 72 up to 140, and was irregular during the whole period. 
The emaciation and weakness at one time was extreme, so that 
for a few days she seemed at the point of death. The treat- 
ment consisted of iodide and bromide of potass with tinct. of 
belladonna and infusion of cinchona. Nourishing diet, stimu- 
lants, blisters to the spine, and the re-application of ice to the 
head during the relapses. An occasional opiate was also 
required to procure rest. The child remained weak for a long 
time, and even now (the beginning of May) is scarcely able to 
stand upon her legs. However, no paralysis or affection of 
the special senses occurred. 

Case IV was that of a girl named M. R, aged 8| years, liv- 
ing in the upper part of the town. The case was one of the 
fulminant type, and its duration one of the shortest on record. 
The girl was apparently in good health up to the time she 
went to bed on the night of 26th Feb. After going to bed she 
was observed to get out again and sit for a time at the fire 



Epidemic Cerebro-Spinal Meningitis. 29 

with toothache (a thing she was frequently troubled with). 
She returned to bed and nothing further was known of her 
condition until 4 A.M. of the 27th, when her mother awoke and 
heard her moaning. She went to her and enquired what 
was wrong, but had difficulty in eliciting any answer; she did 
complain, however, of her throat, and asked for water, which 
she drank greedily, but which was immediately vomited again, 
mixed with greenish fluid. The mother also noticed that she 
had been vomiting in bed previously. After this she spoke 
very little, but continued to drink greedily and to vomit. 
About 6 a.m. she got out of bed apparently in a partially 
unconscious state, and walked across the apartment for more 
water. She vomited when up, and was observed to walk 
unsteadily and to be "shaking all over." As the girl was 
getting rapidly worse, and they had failed to get their own 
medical attendant, I was sent for about 8*30 a.m. ; but before 
I reached the house (a little before 9) she had died. The death 
was reported to the authorities and a post-mortem examination 
of the body was made by Dr. Guthrie Rankin, of Kilmarnock, 
and myself, about 30 hours after the death. We found 
numerous petechial spots scattered over the legs, especiallv 
below the knees, varying in size from a threepenny piece to "a 
half-crown. On removing the calvarium, the membranes of the 
brain were found to be intensely hyperaamic. The two surfaces 
of the arachnoid membrane were slightly adherent by fresh 
lymph over the superior parietal convolutions and in the 
longitudinal sinus. Underneath the arachnoid membrane the 
surface of the brain seemed covered with a recent inflammatory 
exudation, especially at the vertex. A similar condition of 
matters existed at the base, and was continued over the 
cerebellum and medulla oblongata. On opening the spinal 
column a similar hypernemic condition with inflammatory 
exudation existed along the whole length of the cord. We made 
a careful examination of all the other cavities, but could not 
discover any other lesion to account for death. We therefore felt 
justified in certifying the death as one due to epidemic cerebro- 
spinal meningitis. I forwarded a portion of the spinal cord to 
Dr. Finlayson, who handed it to Dr. Coats for examination. 
Dr. Coats reported that he found clear indications of inflam- 
atory exudation between the membrane and the cord. 

I made a careful enquiry into the girl's movements previous 
to the onset of her illness, and found that she had visited the 
girl H. JVL, who was at that time very ill with the disease, on 
Saturday, the 23rd Feb., three days previous to her own 
seizure. The two girls had been schoolmates, and during this 



30 Mr. Frew — Report of a Slight Outbreak of 

visit she had been in the bed beside H. M. The two families 
lived half a mile apart. 

Case V. This case occurred in the practice of a neighbouring 
medical gentleman — viz., Dr. R. Lyon, Darvel. It was in an 
advanced stage before Dr. Lyon's services were called in, but 
he has kindly furnished me with the particulars of the illness, 
so far as he could collect them from the parents. They are 

as follows : — " D C , aged 3 years and 10 months, had 

always been healthy, except when he had scarlet fever in the 
summer of 1882, when he was very ill, but ultimately made a 
good recovery. I was called to see him on 8th March, 1884, 
at 1*30 p.m. I was informed that he had been seized on the 
6th with a sudden vomiting of bilious matter. On the 7th 
his mother administered to him some infusion of senna, which 
operated freely. On that afternoon he complained of pain 
in the head, and was observed to be ' quivering ' over the 
whole body. At my visit I found him lying in bed, breathing 
regularly (30 per minute), pulse 110, temperature 102° F. 
He would not open his mouth to show me his tongue. The 
teeth were dry, and covered with sordes. He lay calmly, but 
occasionally rolled his head on the pillow. When spoken to 
he pays no attention, which has been his condition since 
morning. There was no rash of any kind visible on the skin. 
I ordered a sinapism to nape of neck, and prescribed a mild 
antipyretic mixture. At 6 p.m. I received a hurried message 
to see the patient again. I found him on his mother's knee ; 
the pulse was scarcely perceptible (40 per minute), and the 
breathing seemed about to cease. The cheeks were a mottled 
purple, lips blue, eyes closed, extremities cold. I administered 
a little brandy and water, and applied warmth to the 
extremities, after which he seemed to revive somewhat, and 
slept in a short time, with the pulse at 80. At 10 P.M. he 
was lying quietly ; the pulse was 100 and steady, temperature 
100° F., eyes half closed. Small quantities of brandy were 
ordered to be given at short intervals. 

" 9th March. — I was summoned again at 3 A.M., and found 
the patient in convulsions, which had already lasted for an 
hour. The head was hot and steaming, hair wet with perspira- 
tion, and beads of perspiration over forehead and face. The 
eyes were widely open, suffused, and quite insensible to the 
touch ; nostrils dilating widely, and a white froth working 
from the mouth. There were constant convulsive twitchings 
of the muscles at the left angle of the mouth, and also occasion- 
ally at the right angle. The right arm lay motionless, while 



Epidemic Gerebro-Spinal Meningitis. 31 

the left one was jerked occasionally in choreic-like movements. 
Rales were heard all over the chest. Pulse regular, 115 ; 
temperature 103° F. ; respiration 33. At 5*30 A.M., the con- 
vulsions persisting, I put him under the influence of chloro- 
form, which seemed to induce a collapsed condition that soon 
passed off again when the chloroform was withdrawn. The 
patient gradually sank, and died at mid-day, the convulsions 
continuing till death." Dr. Lyon kindly communicated to me 
his suspicions that it was probably a case similar to those I 
had been seeing in Galston, and, with the consent of the parents, 
we made a post-mortem examination of the body 45 hours after 
death. We only obtained liberty to examine the head and 
spinal column. The external aspect of the body was natural, 
and no trace of any eruption could be found. Rigor mortis 
was not very marked. A small ecchymosis was seen on the 
inner surface of the scalp over the frontal region. The 
calvarium presented a striking appearance, being of a bright 
pinkish tint — an appearance evidently due to hyperemia of 
the blood-vessels of the periosteum. (This appearance, I 
afterwards discovered, had formerly been observed in cases 
of this disease by Dr. Oscar Medin, of Stockholm.) On 
removing the calvarium with the dura mater, the surface 
of the brain presented a peculiar bluish-grey appearance, 
due to the intense venous congestion, and the presence of a 
" gelatino-purulent " exudation which existed over the whole 
of the exposed surface. This exudation, which was under- 
neath the arachnoid membrane, filled up the sulci between 
the convolutions, and marked these off most distinctly. The 
two surfaces of the arachnoid membrane were glued together 
by recent lymph effusion over the vertex and in the longitud- 
inal sinus. The "gelatino-purulent" exudation was thickest 
over the anterior region, especially on the right side (specimen 
and coloured drawing of this part of the brain were exhibited). 
On removing the brain the same gelatino-purulent exudation 
was found to exist over the whole under-surface, but in a 
slightly thinner layer. It was also continuous over the 
cerebellum and medulla oblongata; and on opening the spinal 
canal it was also found to extend over the entire length of 
the spinal cord. The brain tissue was very soft. 

Case VI occurred in my own practice and was under obser- 
vation from an early stage. Occurring as it did in a young- 
child, where the diagnosis, in the absence of any skin eruption 
is a matter of more difficulty, and where, as in this case, no 
opportunity was given of making a post-mortem examination, 



32 Mr. Frew— Report of a Slight Outbreak of 

the case is perhaps more open to question. Few, I think, will 
fail, however, to see considerable resemblance in the symptoms 
and course of the disease to Case V. 

J. M'K., aged 14 months, had been a very healthy child up 
till the time of present seizure. The child's mother was a fac- 
tory worker, and during the day it lived with its grandmother, 
who inhabits a house closely adjoining the one in which Case 
IV occurred. The child suddenly sickened and vomited about 
midday, on 27th March, 1884. The vomiting recurred at 
intervals during that afternoon and evening, and was accom- 
panied by feverish symptoms. On the following morning it 
appeared considerably better, but again sickened and vomited 
about midday, and continued vomiting at intervals until I 
saw it about 7"30 same evening. It was then lying on its 
mother's knee, breathing loudly and rapidly. The skin was 
hot, temperature 102 , 8° ; pulse 180 (as nearly as could be 
reckoned, for the child was restless if touched). The mother 
said that it seemed to be sore when moved, and clutched at 
her as if frightened. With the exception of three faint 
ecchymotic spots on front of left tibia, which might be due to 
former injuries, no rash was observed. Examination revealed 
nothing abnormal in chest or abdomen. The bowels had been 
acting freely up till the illness commenced ; but no very correct 
account could be got of their condition since then. I found 
the gums swollen and tender over the two first molar teeth, 
and also some appearance of tonsillitis. I lanced the gums 
and ordered the following mixture : — 

R. 



Tinct. aconiti, . 


gtt. XVj. 


Tinct. belladon., 


gtt. XXX 


Potass, citrat., . 


oj. 


Potass, bromid., 


o ss - 


Syrupi simplic, 


3ij. 


Aquam ad., 


. 3ij- M. 



Sig. — A teaspoonful to be given every hour for six hours, and after- 
wards every three hours. Also to have a mild sinapism applied 
over the stomach. 

£9th March, 10 a.m. — The child appeared to be much better. 
Had not vomited since the previous evening. Temperature 
98° F. ; pulse 100. Ordered a calomel purge, to be followed in 
the afternoon by castor oil if necessary. The child was so 
much better that I did not think it necessary to see it again 
in the evening. 

30th March. — Was called to see the child at 3 a.m. on account 
of convulsions having occurred. Found it still having convul- 



Epidemic Cerebro-Spinal Meningitis. 33 

sive seizures. The pupils were dilated but not widely, and 
during the seizures the right side of the mouth was drawn 
outwards and downwards, and both eyes drawn into the right 
corners of the orbits. Both sides of the body were similarly 
affected. I administered 3 grains of chloral at the earliest 
opportunity, had the hair cut short and ice cloths applied to 
the head, and had cloths wrung out of hot water applied to the 
feet and legs. The attempt to administer anything by the 
mouth seemed to induce the convulsive seizure. I found on 
enquiry that the child had become worse about the same time 
as on the previous days, that attacks of retching had been 
frequent, and that it had vomited some milk and water which 
had been given to it. The bowels had been moved freely 
during the previous day, and again during the night — the 
motions being dark and offensive. The pulse was about 160, 
temperature 103° F. The first dose of chloral not having the 
desired effect of staying the convulsions, I repeated it in about 
half-an-hour, and again in another half hour, after which the 
child fell into a quieter condition, and I left, giving instructions 
to repeat the dose on the first appearance of the convulsions 
recurring. At 9 "30 a.m. the child was lying quietly, but 
breathing heavily and rapidly, pupils moderately dilated, eyes 
squinting occasionally. Tache cerebrale could be produced 
distinctly. Pulse weak, quick, and irregular ; temperature 
103*3°. Another dose of chloral had been given about 6 a.m., 
because of a threatened renewal of the convulsions. At 1 
p.m. the general condition was unaltered, but it appeared to be 
sleeping soundly ; pupils contracted. The face was flushed, 
but every few minutes a deathly pallor overspread the counte- 
nance, even the lips becoming pale — the pulse becoming very 
rapid and weak, and the breathing quicker and shallower. 
This pallor lasted for about half a minute, and the flush grad- 
ualty returned again. At 8 p.m. I found that it had been lying* 
quietly since the former visit, but woke up occasionally and 
asked for a drink. There had been no vomiting or retching 
since the convulsions appeared. A dusky congested hue now 
pervaded the countenance, the pupils were contracted almost 
to a pin hole, and squinting was still observed occasionally. 
No rash to be seen ; pulse, 160 ; T. 104*5° F. Dr. Macfarlane 
of Kilmarnock, who saw the case with me then, made an 
ophthalmoscopic examination of the eyes after dilating the 
pupils with atropine. There was distinct hyperemia, but no 
evidence of neuritis. The. bowels continued to move freely. 
A further dose or two of chloral had been given during the 
day to restrain the convulsions. Small doses of potassium 
No. l. D * Vol. XXII. 



34 Me. Frew — Report of a Slight Outbreak of 

iodide were also added to the mixture formerly prescribed, 
which was to be given as opportunity offered. 

80£h Mardi—8'30 a.m. — The child appeared to be quite 
insensible, the pupils were widely dilated (due to atropine), 
and the eyes insensitive to the touch. There was some 
twitching of the muscles at the corners of the mouth, and 
squinting. The abdomen was tympanitic. Had passed two 
motions since last night, of a .similar character to those 
formerly spoken of. Had not swallowed anything since 
5 a.m. Had one dose of chloral during the night, when 
there were some symptoms of the convulsions returning. 
Death occurred about 11'30 a.m. I saw the body at 5 p.m., 
when rigor mortis was extremely well marked. A post- 
mortem examination was persistently refused. 

The foregoing six cases are in my opinion so typical of this 
disease, that the diagnosis in any one of the cases hardly 
admits of a doubt. As I have formerly remarked, however, 
besides these six cases there occurred in the district at the 
same time a few other cases that presented some of the 
features of this disease, but where the course of the disease 
terminated abruptly after lasting for a few days, and con- 
valescence rapidly ensued. I have notes of five such cases, 
and there may have been one or two more. I will relate 
shortly one of these cases as an example : — 

W. M'C, aged 2 years, had a sudden seizure of vomiting on 
the 19th March, which recurred again on the following day, 
and continued until I saw him in the evening. He was then 
hot and flushed ; his mother informed me, however, that the 
flush was not constant, but was occasionally replaced by a 
condition of pallor. He starts frequently, and cries " Sair, 
sair." The head is slightly retracted, and if an attempt is 
made to bring it forward, he resists and cries. The pulse was 
quick ; tongue coated ; condition of bowels uncertain. This 
condition persisted until the morning of the 22nd, when I 
found the temperature normal, and the child looking much 
better, and in a day or two he seemed to have quite recovered. 

i 

Etiology of the Outbreak. — The town of Galston at the 
present time is undoubtedly in a deplorable sanitary condi- 
tion. In my opening remarks I referred to the causes of this, 
which are its natural low lying situation and the unsatisfac- 
tory state of the drainage. A closer relation, however, can be 
shown to exist between the unsanitary conditions and the 
different localities in which the cases occurred. Close beside 



Epidemic Cerebro-Spinal Meningitis. 35 

the row of miners' houses where the first case occurred, a 
large subsidence of the soil occurred early last summer ; the 
flow of sewage in the open ditch referred to was thus inter- 
fered with, and the ground around became soaked with 
sewage which gave off a most offensive odour. Even the 
walls of some of the houses, which are built of brick, were 
saturated with it. To add to this, the habits of most of the 
tenants are not what they might be in regard to hygienic 
measures. In a field to the rear of the house in which Cases 
II and III occurred, a similar state of matters existed, part of 
the field being so bad that it could not be ploughed. In both 
of these cases the " sewage morass " lay in the direction of the 
prevailing winds. Cases IV and VI occurred in a notoriously 
filthy row of houses, and where I had noticed that for many 
weeks the principal sewage drain had been choked, and 
quite a small lake of sewage lay frequently for days in 
front of the row. The case, however, which occurred in 
Darvel, occurred in a house which was a model of cleanliness, 
and where the surrounding sanitary conditions seemed fault- 
less. In this case a possible source of infection could be made 
out which will be afterwards referred to. 

The majority of writers on this subject have looked upon 
the question of the relation of the disease to unsanitary 
conditions as a very difficult problem. In the present 
instance there is no lack of prima facie evidence in sup- 
port of the theory that these conditions bear some causative 
relation to the disease. Infection, which is often a much 
more difficult cause to trace, may of itself account for the 
occurrence of some of the cases, and also be one factor in the 
causation of others. In the first case no source of infection 
could be traced. No other cases of the disease had occurred 
in any of the surrounding villages or towns so far as I could 
ascertain ; and Dr. Finlayson, who kindly interested himself 
in the cases, put himself in communication with Dr. Russell, 
the medical officer of health for this city, with the view of 
finding out whether any such cases had been reported to him, 
but the enquiry resulted negatively. After the first case, 
however, a source of communication could be established 
between all the other five cases, and, in a country district, this 
is a question which is capable of being examined with a 
greater chance of success than in large centres of population. 
Communicability could be traced betwixt Case I and Case II, 
a sister of the former patient being in the habit of calling 
daily at the house in which Case II occurred for their milk 
supply, which was taken in there for them. The patient in 



36 Mr. Frew — Report of a Slight Outbreak of 

Case III was a sister to the patient in Case II. Case IV 
occurred in the person of a girl who had visited Case III, and 
been in close contact with it three days before her own 
seizure. Case V occurred at a distance of four miles, and in 
this case the evidence of communicability is perhaps the 
weakest, but such as it is I will place it before you and leave 
you to draw your own conclusions. A near relative of this 
patient has a butcher's shop in Galston, which is situated in 
the same street as the house in which Cases II and III occurred, 
and almost directly opposite to it. The mother of the children 
affected with the disease was a daily visitor to this shop 
for her meat supplies. The butcher visited Darvel two days 
before the boy's illness commenced, and took the boy with 
him in his cart while making the round of the village. The 
case was the only one which occurre 1 in Darvel, and no other 
possible source of communication with Galston could be traced. 
Case VI occurred, as I have said, in a house in close proximity 
to where Case IV had occurred, and I know that there was 
frequent communication between the two houses. 

From the facts just mentioned, I am strongly inclined to 
believe in the infectious character of the disease ; but that 
some special soil is necessary for the reception of the infective 
material seems likely, from the fact that many people came 
into contact with these cases who escaped. 

I may also mention that I could discover no evidence in 
support of the theory which has been advanced in this 
country by Dr. B. W. Richardson, and in America by Dr. 
Baker, that eating; diseased grain is the cause of the disease. 

The diagnosis of the disease is not a matter of much 
difficulty after one is on the outlook for it, except in the case 
of young children, and especially in the absence of some of 
the prominent features of the disease, such as the herpetic or 
petechial eruptions and the retraction of the head. The 
general aspect of the case is, perhaps, as reliable a guide as 
any ; you can generally observe that the system is under the 
influence of a disease which is producing a powerful impres- 
sion upon the principal nervous centres, as evidenced by the 
uncontrollable vomiting, the "tremblings" or "quiverings," 
and the implication of the respiratory and circulatory nerve 
centres, as manifested in the breathing, and the alternate 
flushing and pallor of the countenance. 

The loss of hearing, which occurred in Case I, is a well 
known sequela of the disease. It is sometimes attributed to 
inflammation of the middle ears, but in this case it must have 
been due to implication of the auditory nerve in the brain. 



Epidemic Cerebrospinal Meningitis. 37 

The staggering gait, which persisted for a length of time, is 
interesting in connection with this. 

With reference to treatment, I do not feel that I can venture 
an opinion as to the value of any of the drugs administered, 
because they were administered very irregularly during the 
critical stage of the illness on account of the delirious con- 
dition of the patients. Some good was, perhaps, got from the 
external application of leeches and ice to the head, &c. If the 
present belief as to the disease being of the nature of a fever 
which runs a definite course is correct, we can only hope to 
moderate some of the symptoms and support the patient's 
strength until the crisis is passed. Most good is to be hoped 
for from preventive measures directed to the hygienic and 
sanitary conditions of the district, and, where possible, cases 
should be isolated, especially from other children. 



Since reading above paper, I believe that I have seen 

another case of this disease. It occurred in a girl 5 years of 

age. She went to bed in her usual health on the evening of 

27th May. About 5 a.m. of the 28th, while her father was 

preparing to go to his work, she awoke, complained of having 

a headache, and almost immediately thereafter vomited. The 

vomiting and headache (which her mother thinks was chiefly 

confined to the left side) continued up to 1030 a.m., when 

she had a convulsive seizure. I was then sent for, but not 

beino- at hand, I did not see the case until two o'clock. She 

was then in a condition of complete unconsciousness, and 

having convulsive seizures every few minutes. I was informed 

that she had continued so since the commencement. Each 

seizure lasted about half a minute, and they recurred every 3 or 

4 minutes. The pupils were moderately dilated. During the 

seizure both eyes were turned to the left, and both arms were 

affected with choreic-like movements. There was some rigidity 

of the muscles of the leg, but the legs were not moved about 

in any way. There was grinding of the teeth and frothing at 

the mouth. In the intervals between the convulsive attacks 

she lay quietly, but breathing heavily. The pulse was about 

84 in the quiet intervals, but rose considerably during a 

convulsion. The skin did not feel hot, but cold cloths had 

been applied constantly to the head since the first occurrence 

of the convulsions. The bowels had been opened twice of their 

own accord. There was no eruption or rash anywhere on the 

body. I tried to administer some chloral and bromide of 



38 Current Topics. 

potassium in solution, but none was swallowed, and the 
attempt seemed to hasten a convulsive seizure, as also did 
touching the skin anywhere on the upper part of the body. 
The child continued in this condition until death, which 
occurred about 7 p.:m. on the same day ; the whole duration of 
the illness being only 14 hours. I examined the body on the 
following morning. There were then visible some petechial 
spots aromid the mouth, one of considerable size on the left 
thigh, and a few smaller ones on the front of the legs above 
the ankles. The forehead looked slightly swollen, and pitted 
on pressure. A further 2>ost-mortem examination was not 
asked on account of the highly excited state of the girl's 
mother. No direct source of communication was traced, but 
the case occurred in the same part of the town as Cases 
II and III. 



CURRENT TOPICS. 



Berlin Polyclinic. — The following has been sent to us 
for publication : — Clinical courses, comprising all the different 
special branches, for practical physicians, are held every 
month in the Polyclinic at Berlin (Germany), Carlstrasse 30. 
The courses always commence on the first week-day of the 
month. They last a whole month and are held every working 

da y- 

The number of participants is limited to six for every 
course. Should more than six apply for the same course, 
an extra or parallel course will be formed. 

To all those physicians wishing to perfect themselves in a 
special branch, the opportunity is given to serve three months 
as assistants in that particular branch. Those gentlemen 
having served as assistants will be allowed, in appropriate 
cases, to conduct the extra or parallel courses. 

It is intended to constitute the Berlin Polyclinic an inter- 
national medical school for the improvement of physicians 
of every country. In order to have the courses conducted in 
foreign languages, assistantships will be conferred also on 
foreign physicians. 



Correspondence. 39 

CORRESPONDENCE. 



The Proposed Medical Section of the Postal 
Microscopical Society. 

To tlie Editors of the " Glasgow Medical Journal." 

Gentlemen, — I beg you will allow me the opportunity of 
stating briefly the object which I hope to attain by the forma- 
tion of this new section, which is this : — 

The means of furnishing members of the medical profession 
with such slides as they are naturally most interested in, and 
such notes in relation thereto as will not only anatomically 
describe the slides under observation, but will, where practi- 
cable, give a full history of the cases whence they were 
taken, duration of the disease, the methods of treatment 
adopted, and every other matter of interest likely to prove 
of any educational value to all succeeding members. 

To accomplish this, it is proposed that every member shall 
send to the hon. secretary for circulation six slides (or any 
multiple of six), with full descriptive notes thereon, to be 
written in the book or books provided for that purpose ; and 
each member receiving the same will be asked to add all 
that he can in further elucidation of the various subjects 
under discussion. 

Boxes containing twelve slides will be circulated at regular 
dates, and in such a manner that each member should receive 
one at fortnightly intervals. 

When each set of slides has been seen by all the members, 
it will be returned to the original contributors, who will be 
asked for a fresh supply ; and that each series (or set) may 
circulate for a whole year it is necessary that at least 
fifty members be enrolled. Several have already sent in their 
names. As the fees for the medical section (separately) will 
be the same as for the general section, it is thought desirable 
that the two sections shall run concurrently. The first year's 
subscription, therefore, will carry on to the 30th September, 
1885, and will, after the first year, become due on the 1st 
October in each year. 

The first session will commence as soon as a sufficient 
number of slides have been received. 

Members of the medical section will be at liberty to join the 
general section also on paying half annual subscription extra. 

A copy of the Journal of Microscopy is presented to every 
member quarterly as published. — I am, very faithful]}' yours, 

ALFRED ALLEN, Hon. Secy. 



40 Revii ws. 



REVIEWS. 



Medical Education, Character, and Conduct: Introductory 
Addresses, deliix red to Students of Medicine in Edinburgh 
and Glasgow, 1855-1866-1882. By W. T. Gairdner, M.L>. ; 
Professor of Medicine in the University of Glasgow, and 
Physician in Ordinary to the Queen in Scotland. Glasgow: 
Jas. Maelehose v.v Sons. 1883. 

Address: Delivered to Students of Medicine in the University 
of Glasgow after Graduation, Session 1882-83. By W. T. 
Gairdner, M.D.. LL.D. Glasgow : Jas. Maelehose & Sons. 
1884. 

In these two pamphlets we have four Introductory Addresses 
by the distinguished Professor of Medicine in our University, 
and we call attention to them, even though it be some time 
since their publication, because they seem to us to exhibit 
many truths which the medical profession, as well as students 
of medicine, ought to bear perennially in mind. The whole 
tone of these Addresses is healthy and ennobling. The main 
idea which runs through all of them, and has been apparently 
the life-long doctrine of the writer, seems to be that while 
medical men are, in a certain sense, mere bread- winners, yet 
that they have, even in the details of their work, if rightly 
regarded, a high calling which gives them rank in the scientific 
world. 

Perhaps the most powerful of the Addresses is that delivered 
at the opening of the session 186G-67. The key-note of this 
is contained in this sentence — " The day of orthodoxies is 
over, the day of real sou nee has begun." The author gives a 
vivid sketch of medical orthodoxy and heresy in the olden 
time, instancing especially the century -long discussions over 
the admissibility of antimony as a medicine to be prescribed 
by regular practitioners. In 1566, the Faculty of Medicine of 
Paris passed a decree according to which " antimony is dele- 
terious, and to be counted among the simples which possess 
the quality of poisons. Xor can it be amended by any other 
preparation, so as to be taken without injury." After a hot 
controversy, extending throughout a hundred years, a majority 
of the Faculty came to the conclusion in 1666, that "anti- 
mony is to be numbered among purging medicines, and that 
it shall be in the power of every doctor to prescribe it." And 
yet all this controversy and voting concerned themselves with 
little else than words. It was not a dispute in which the 



Revieivs. 41 

results of observation were the essential elements in the 
argument, as there is no record that the combatants on either 
side added anything to the science of medicine. These days 
have happily passed, and men are now at liberty to try all 
means which may commend themselves to their judgment. 

The idea of modern medical science is contained in the 
dictum of John Hunter — •" Don't think, but try" — in other 
words, do not expend your energies in idle and ignorant 
speculation, but bring all to the test of facts. Our author 
insists repeatedly and strongly that medical practice must 
have a scientific basis. He emphasises the importance of the 
study of Natural History in its various departments as a 
preliminary to the more directly medical studies, because it 
forms a habit of mind " which is now-a-days not less than 
essential for success in every medical inquiry." Biological 
.science, including pathology as one of its departments, is the 
essential basis of medical learning, and cannot be safely 
divorced from it. Professor Gairdner takes some credit to 
the Scottish Universities and Schools of Medicine for having in 
anticipation of the march of medical legislation kept in advance 
in this matter. Quoting an article in the Times of October 
1882, in which the education of the English medical man as it 
existed 25 years ago is referred to, he contrasts the training 
in England with that of the Scottish student of the same 
period. The English student was educated essentially by the 
apprenticeship system, with at first one year of hospital 
training, afterwards gradually increased to two or three years. 
As the medical schools were connected with hospitals the 
years of hospital training were those of systematic scientific 
study. This system prevailed till the passing of the Medical 
Act in 1858, when the system was approximated to that 
which had existed for many years in Scotland. 

We suspect that the English schools have still a good deal 
to learn in this direction. We believe that the separation 
between scientific and practical medicine, although greatly less 
in distance than formerly, is still flagrantly present. This is 
brought out rather humorously in the latest of the Addresses 
under notice, in which Dr. Gairdner refers to an interview 
which he had with an enthusiastic devotee of physiology in 
Cambridge University. This gentleman repudiated the idea 
that physiology is to be studied as a branch of medical science; it 
belongs to pure biological science, and the medical physiologist 
is a mere object of contempt. When we find in the London 
schools of medicine that natural history hardly enters into the 
curriculum, while physiology, anatomy, and pathology are taught 



42 Reviews. 

entirely by men who are directly aiming at practice, we see 
some reason for this attitude on the part of the scientific 
physiologist. We are far from saying that men who are on 
the threshold of practice are not capable of doing good work 
both as investigators and teachers in the scientific branches, 
but surely these branches are sufficient for the whole energies 
of a few men, and the perpetuation of the system in the 
London schools of medicine is obviously a survival of the 
older views of medical education. It may be added that the 
most recent appointment in Cambridge University seems to 
indicate that medical science, if we may give this designation 
to the study of human pathology, is to have no place inside 
the walls of that venerable institution, and that even pathology 
is to be studied as a branch of pure biological science. 

Our traditions in Scotland are happily different, and at each 
of the three great medical centres we find men devoting; their 
whole time to the study and teaching of natural history, 
anatomy, physiology, and pathology, while the students are 
required to make these subjects a serious part of their curri- 
culum. In these admirable Addresses of Prof. Gairdner, we 
see much of the spirit of those who have been wise enough to 
make our Scottish Universities real- teaching schools for 
medical students, aiming to give to practitioners of medicine 
a truly scientific interest in the problems which meet them in 
their everyday work. It is hardly too much to say that this 
has, in great part, been the secret of the amazing success of 
our Scottish Universities and medical schools. They have 
kept a high ideal before the medical profession, and the 
answer has been that a high value has been put upon their 
teaching. We venture to think that it is only by preserving 
this high ideal, and by keeping in the front in the scientific 
as well as the more directly professional teaching, that our 
universities and medical schools will prosper. It may be said 
that the curriculum must not be over-weighted, especially in 
the purely scientific departments, but it is exactly in these 
departments that our universities cannot afford to fall behind, 
and rather than sacrifice them it were better to add another 
year to the curriculum and make it, what students nowadays 
frequently do, a five years' course. If under the old English 
system a student could serve a five years' apprenticeship and 
take a year additional at a hospital, surely five years is not 
too much for the modern requirements of the medical student. 

We regard these Addresses, whose spirit we have endeav- 
oured to give, as a valuable contribution to the history of our 
Scottish medical schools, and commend them to the consider- 



Reviews. 43 

ation of all who are interested in medical education in 
Scotland. We have only further to remark on the pleasure it 
gives us to find a man of Prof. Gairdner's attainments giving 
expression to such genuine and modest religious sentiments as 
he does in all these Addresses, from that delivered in 1855 to 
the latest. 



Practical Pathology: A Manual for Students and Prac- 
titioners. By G. Sims Woodhead, M.D., F.R.C.P.E. With 
136 Coloured Plates. Edinburgh: Young J. Pentland. 
1883. 

The very great advances which have been made in the teach- 
ing of practical pathology in recent years have rendered it 
necessary that the student of medicine should have at his 
command text-books which will aid him in his study of this 
very important and difficult subject. The volume at present 
under review is therefore of interest as being probably the 
first book in the English language exclusively devoted to the 
subject of practical pathology. The book is one of consider- 
able size, and has been very beautifully and expensively got 
up. Perhaps the most striking and novel feature of it is the 
great beauty and artistic merit of the illustrations, which 
have been executed in colours. We doubt, however, if the 
very extensive use of coloured illustrations is of such value 
as would at first sight appear. Outside of the pathological 
laboratory, the student would find it difficult to prepare and 
stain his specimens in the way that can be done in the 
practical class, and therefore it is of the very greatest impor- 
tance that he should be able to recognise morbid appearances 
without the aid of staining reagents, which can only be done 
by careful and prolonged study of sections mounted as they 
have been cut. This is a circumstance which has to some 
extent, though not altogether, been overlooked in preparing 
the present work. 

The plan adopted, as the author states in his preface, is to 
follow the tissue from the body to the microscope, and cer- 
tainly the plan is a good one. With this object in view, the 
writer first of all describes the instruments necessary for and 
the method of making a post-mortem examination. Then 
follows a very careful and good account of the apparatus 
necessary for and the methods of preparing, mounting, and 
staining sections for microscopic examination. The different 
organs are next taken up in detail, and the appearances of the 
various affections to which they are liable described. The 



44 Reviews. 

last three chapters of the book deal respectively with tumours, 
parasites, and the vegetable parasites. The scope of the 
work is thus seen to be great, and it now remains for us to 
indicate our opinion of its utility for the purposes which the 
author has in view. 

There are many good points in the work, but also we think 
some serious defects. Perhaps one of the best parts is the 
careful and comprehensive account of the histological methods. 
In this regard the volume is likely not only to be of great 
utility to the student, but also to be of much service to the 
professed pathologist as a work of reference. A much more 
unsatisfactory chapter, however, is that which describes the 
method of performing a post-mortem examination. The 
impression we received in reading it was that it probably had 
been written by one who had had no very extended experience 
in this department of pathological research. It may be 
remembered, too, that in teaching students to perform post- 
mortem examinations, the most careful attention to every 
detail, even the most minute, is of the utmost importance. 
We may refer to a few points. After describing the median 
incision necessary for opening the body, the author advises 
that the abdominal wall should be divided from within out- 
wards to avoid injuring the organs. From a very considerable 
• ■xperience in post-mortem work, we can say that it is much 
more convenient, and even safer, to divide the abdominal 
parietes from without inwards, if care be taken to drag well 
■ in the edge of the abdominal incision. The writer, in the 
next paragraph, says, " remove the sternum thus " — not a 
word having been expressed as to how the soft tissues are to 
be reflected from the ribs. The author then says that great 
care must be taken not to open the pleural sacs — we would 
ask is this in the majority of cases possible ? He advises that 
the sternum should be sawn beneath the level of the first rib, 
and the entire bone removed only in those cases where a more 
complete dissection of the neck is desired. We think that the 
former method is essentially bad, and that the latter should 
always be adopted. Surely a difficult operation like that of 
opening the sterno-clavicular joints deserves more notice than 
— " Divide the sterno-clavicular ligaments, and turn the 
sternum backwards." The method described of dealing with 
the heart is also very unsatisfactory. For example, it is said 
— " it (the heart) is rotated from left to right, so that the right 
border of the heart may come to the front, and an incision is 
made into the right ventricle." Such a procedure would have 
the precisely opposite effect, as it would bring the left border of 



Reviews. 45 

the heart to the front ; this is, in fact, the direction for opening 
the cavities of the left side. We are not told how to rotate the 
heart in opening the left side, and we are instructed to remove 
the organ by dividing the aorta and pulmonary artery at some 
little distance from it. Is it not also necessary to divide the 
veins ? There are other inaccuracies to which we might refer, 
but those we have given will suffice to show that this article 
requires revision. It may seem that our criticism on this 
portion of the book is somewhat severe, but a considerable 
experience in the conduct of post-mortem classes, in which each 
student has an opportunity of making an examination for 
himself, has taught us the value and importance of minute 
directions. 

The pages dealing with morbid histology are much more 
satisfactory. This part of the book shows that Dr. Wood- 
head is an accomplished and skilled pathological histologist, 
and well up in all the details of microscopic work. Our 
chief objection to this portion is that there seems to be an 
effort to combine the systematic and the practical, which We 
think should as much as possible be kept separate in a 
practical text-book. However, this is a point on which 
difference of opinion may legitimately exist. 

Notwithstanding the defects to which we have referred, 
the book is likely to prove of much value and service both to 
the student and practitioner, and we have pleasure in recom- 
mending it to the notice of those interested in the study and 
teaching of practical pathology. 



Life History Album. Prepared by the Directors of the 
Collective Investigation Committee of the British Medical 
Association. By Francis Galton, F.R.S. London: Mac- 
millan & Co. 1884. 

The Parent's Medical Note-Booh. Compiled by A. Dunbak 
Walker, M.D., CM. London : H. K. Lewis. 1884. 

It was hardly to be anticipated that even the authority of the 
Collective Investigation Committee of the British Medical 
Association would free Mr. Galton's Life History Album from 
criticism. It was still more likely that imitation, which is the 
sincerest flattery, would be attempted; but it remained a 
problem whether improvement could be effected, otherwise 
than by eliminating such queries as failed to obtain satisfactory 
or reliable answers. If this be a fair statement of the general 
opinion, a book like the present will not be received with 



46 Reviews. 

favour. In the "directions for use" prefixed to the Life 
History Alburn, it is specially recommended that all details of 
medical history should be entered by a medical man ; care 
being taken to note physical signs and their permanence, also 
idiosyncrasies as to drugs. Dr. Dunbar Walker does not 
forbid that the entries in his Note-Booh should be made by 
the medical man, but he provides material to induce parents to 
accept the responsibility themselves. This is a most undesir- 
able direction to give parental zeal. 

The recent fashion to popularise medical science has too 
much forgotten the old proverb concerning a little knowledge. 
It is easy and interesting to teach a little, and were human 
kind perfect it would be desirable. But to prove an acceptable 
teacher a semblance of completeness must be given to the 
subject taught. The apparent completeness courts reliance, 
and in matters of medical direction, reliance on imperfect 
knowledge means disaster. 

Mr. Galton, in his Enquiries into Human Faculty, records 
a previous and considerable experience of the value of answers 
to questions propounded to the laity at large. His Life 
History Album is in many respects a selection of what appear 
to him to be the most useful of such queries. They are calcu- 
lated to stimulate a rational and attainable interest in the 
growth and development of children, and will no doubt ulti- 
mately have an important bearing upon education equally as 
regards direction and extent. This use of a Life History 
Record has been previously suggested by Dr. Percy Boulton. 

Dr. Dunbar Walker's Note-Book is, in all but its form, a 
contrast rather than an imitation. Its very title reverses the 
judgment already given by Mr. Galton and his experienced 
coadjutors that on all medical matters a skilled opinion should 
be obtained. 

Note the difference of standpoint. Mr. Galton says, page 2, 
" Variations of weight are the surest guides to variations of 
health. Arrested increase, or a gradual or sudden loss of 
weight, often occurs before any other symptom of disease can 
be detected, and may be the first to give the alarm, and call 
attention to the health of the child. Insidious diseases may 
thus be met early and checked ; dangerous illnesses may be 
avoided, and even life preserved, by a careful attention to this 
indication." 

Dr. Dunbar Walker says, page 14, "Rheumatic Fever. — A 
fever characterised by severe inflammation and pain in the 
larger joints. Duration, two weeks to two months. Sequelae 
(after effects), heart disease, stiffened joints." Mr. Galton's 



Reviews. 47 

advice will lead no one astray. Can we say the same of Dr. 
Walker's ? We do not think that rheumatic fever in children 
is "characterised by severe inflammation and pain in the 
larger joints." On the contrary, the joint symptoms are more 
usually trivial, and the heart affection, developed by neglect, is 
too often the first characteristic sign of rheumatism. 

Mr. Galton thinks parents should take alarm at the first 
indefinite sign of failing health. Dr. Walker encourages a 
looking for, and inferentially a waiting for, characteristic signs 
of disease. Even had Dr. Walker's descriptions of disease 
been full and accurate, which they are not, his Note-Book, in 
so far as it is medical, would be objectionable. It is per- 
missible, perhaps it is even a duty, to teach the layman to 
gauge the standard of health ; but is not the main reason for 
so doing to ensure that skilled advice should be sought for the 
slightest deviation. It is then in truth that medicine is most 
surely protective and preventive. 

That such qualities of the curative art should be fostered is 
conspicuously suggested, and by Dr. Walker having deemed it 
necessary to translate the word sequelae (after effects) no less 
than seventeen times in the course of his small Note-Booh. 
That any disease should leave sequelae other than the physical 
changes coincident with its invasion is ajiopprobrium medicines. 
Whether such relics of barbarism will be more effectually 
extinguished by the partial education of the laity, or the early 
supervision of the profession, we leave all intelligent men to 
decide. 



Medical Fashions in the Nineteenth Century, including a 
sketch of the Bacterio- Mania and the Battle of the Bacilli. 
By Edward T. Tibbits, M.D. Lond. London: H. K. 

Lewis. 1884. 

This is a small book of lamentations written in a somewhat 
lively and interesting style. The author frets over the fickle- 
ness of medical fashions. A man does not need to be " more 
than a quarter of a century " in practice to feel annoyed at 
the universal see-saw ; but grumbling at this human weakness 
is hardly likely to lessen it ; and, so long as it results in some 
little progress, it is possible to possess one's soul in a certain 
amount of patience. Dr. Tibbits seems to have comparatively 
little faith in many of the " new things," and he is inclined to 
discourage that failing in others, though he is good enough to 
admit that medical fashions have often some value before they 
reach the fashionable sta^e. 



48 Mevit ws. 

After some remarks on the reign of fashion in all depart- 
ments of life, he proceeds to consider two matters, which vex 
him much. The first of these is the wholesale abuse of many 
valuable remedies and methods of treatment. This is illus- 
trated under a series of separate headings, the first of which 
is Bleeding. In common with many others, he would like to 
see this again used judiciously, and, in common with many 
others, he seems to be waiting for some one to set the 
example. After a few lines on Mercury comes the subject 
of Large Doses. Here it is noted with satisfaction that 
English medical men are ceasing to charge for medicines. 
The custom of making large profits on "bottles" excite- 
mingled feelings in Scotch graduates, who spend their first 
year "out" assisting some English practitioner. After this 
we have Small Doses, or Homoeopathy, the most consistent 
of expectant methods, " a meditation upon death." The 
author is so generous as to believe that no true homoeopath 
now exists. After Hydropathy conies Mesmerism, with which 
are classed Metallo-therapy and Massage. Then follow Alco- 
hol, Anaesthetics, and Chloral. He has heard that chloroform 
was used a few years ago in London " to produce a kind of 
intoxication, and sometimes complete insensibility," during 
child-birth. Regarding- digitalis, he states that at the begin- 
ning of the century it was hoped that, with the use of this 
drug, consumption would very soon cease to be the opprobrium 
of our art. The sphygmograph he considers to be of little 
practical value, and its prototype is mentioned as a contriv- 
ance of Dr. Herrison about fifty years ago. He condemns 
the phrase " arterial tension " for its vagueness, and holds the 
view that digitalis is a sedative and depressant, and not a 
stimulant. Then follow some strictures on mineral waters 
and health resorts. 

The second woe is the evil result of an unreasoning 
adherence to theories in etiology. To sewer gas he would 
not attribute so very much blame. " Scavengers do not 
appear to suffer in any special manner." Nearly half of the 
book is devoted to the " Bacterio-mania and the Battle of the 
Bacilli," the position taken being that " such organisms hav- 
ing anything whatever to do with disease is pure hypothesis.' 
" These organisms have been and still are regarded, I venture 
to think, without sufficient evidence, the veritable cause and 
essence of disease." A sketch is given of the history of the 
germ theory. The identity of anthrax and woolsorter's 
disease is denied, and a case of what was called by the latter 
name, but which was really cardiac disease, is described. The 



Revieivs. 49 

tubercle bacillus is scouted as the cause of consumption, and 
this disease is said not to be infectious. As to the bacillus of 
cholera, " Koch went to Egypt to look for it, and has been 
successful, as might have been expected." Suspension of 
judgment in the matter of germs is asked for. 



A Guide to the Study of Ear Disease. By P. M'Bride, M.D. 
Edinburgh: W. & A. K. Johnstone. 

Taken as a whole, we would be inclined to characterise Dr. 
M'Bride's book as one of the best introductions to the study of 
the subject, if not the best, that has lately appeared in this 
country. In calling it an introductic/n we notice that the 
author himself characterises it as such, both in his preface and 
at the beginning of his first chapter, and it seems almost a 
pity that he has chosen the more ambitious title of a guide, for 
the book seems to lack the completeness and fulness of detail 
that we find in the larger works on ear disease. 

The first chapter of the book is taken up with consideration 
of points in the anatomy and physiology that are of most 
practical importance to the aural surgeon : even while recog- 
nising that we should not expect in it a minute anatomical 
description of the ear, or the physiological facts or theories in 
full detail, still thirteen pages of large print seem all too little 
to treat even of the points referred to, and we are apt to think 
the chapter "scrappy" and unsatisfactory, at times perhaps, 
because the points are put shortly and distinctly. We may 
also draw attention to the anatomical illustrations at the end. 
In plate I, we have represented four dissections from different 
view points of the middle ear, printed in colour. These four 
plates, however artistic they may be considered, do not give a 
clear view of the parts, and the explanations under each are 
decidedly meagre ; we doubt if any one who has seen the 
parts in reality would compare their value with that of a 
good wood engraving. While we notice this as another failure 
of coloured lithographs or chromos to depict anatomical speci- 
mens, we may point out that the other plates, which perhaps 
from their nature may more readily lend themselves to this 
treatment, are good and likely to be useful. A and b in plate 
V and b and c in plate VI, appear to be specially good, and in 
the representation of the normal membrana tympani and in 
that of the thickened membrane with patches of opacity, the 
artist has been quite as successful as in any book that we 
have seen containing such illustrations. 
No. 1. E Vol. XXII. 



50 Reviews. 

This notice would be of undue length if we were to remark 
on the various chapters in detail, but we may mention that on 
Chronic Suppuration of the Middle Ear and its Complications, 
that on Disturbance of the Nervous System resulting from Ear 
Disease, on Tinnitus Aurium, and that on General Diseases 
which affect the Ear, as not only giving a clear idea of the 
subject in hand, but as being suggestive both as to treatment 
and as to the probable etiology. 

Throughout the book we find distinct statements as to the 
strength of solutions and of other materia medica recommended 
— an important detail frequently omitted in larger and more 
pretentious works. 

We were rather surprised to see that Dr. M'Bride recom- 
mends the trial of a solution of acetate of lead when there is a 
discharge of pus through the drum membrane: but in this 
instance he does not give the strength of the solution, so we 
may hope that he has not been in the habit of using lead in 
such cases. At least, since Hinton wrote condemning the use 
of lead in otitis media, we thought it was generally recognised 
that in ulcerative processes in the ear, as it doubtless is in 
similar cases in the eye, the use of lead was to be avoided, as 
it tends to form a deposit that in the one may clog parts that 
should be movable, and in the other obscure parts that should 
be transparent. 

In concluding this notice we take the liberty of making a 
rather long quotation from the chapter on Chronic Suppuration 
of the Middle Ear, because we feel sure, if laid to heart by 
practitioners generally, it would go far to prevent the miser- 
able results we often see from a disease that is most amenable 
to treatment in its early stages. 

"This affection is often set down to struma. It is more 
than likely that scrofula plays an important part in prevent- 
ing the action of the vis medicatrix naturae, but it also must 
be remembered that an ulcerated discharging surface may be 
enough to account for the presence of enlarged glands, which 
may then caseate, and lay the seeds of tubercular disease. 
Chronic middle ear suppuration is peculiarly apt to give rise 
to complications (e. g., granulations and polypi, mastoid disease, 
caries, pysemia, cerebral abscess). 

" The patient is often brought to the surgeon on account 
of a ' running ear,' or perhaps more frequently on account of 
a bad smelling discharge which annoys those who are brought 
in contact with the sufferer. Often these cases have been 
long neglected, and if asked for an explanation, the statement 
is generally made by parents or patient that it was considered 



Reviews. 51 

dangerous to interfere, or even that the otorrhoea was believed 
to be salutary by the family physician. Apropos of this 
subject, Roosa naively remarks that the Creator would have 
made us with discharging ears if they were necessary for our 
well-being. Any one who notes the histories of a number of 
cases of neglected ear disease — suppurative or otherwise — will 
find strange revelations as to medical ethics. The observer 
will meet with patients incurably deaf, or perhaps the victims 
of caries of the temporal bone, threatening life itself, as a 
result of disease curable in its early stages. Such patients 
will often tell how the doctor was consulted, and how in one 
case they were told that the discharge was beneficial, or in 
another that the deafness would disappear at puberty. From 
no line of argument founded on rational data of pathology 
could such conclusions be arrived at, and I hesitate to apply 
the proper epithet to such empirical statements and prophecies 
coming from medical men in whom patients place confidence." 



The Medical Annual and Practitioner's Index: a Yearly 
Record of useful information on subjects relating to the 
Medical Profession. 1883-84. London : Henry Kimpton. 

This is a remarkable gathering together of facts which may 
be useful to the medical practitioner, and is intended to lie on 
his table for ready reference. It commences with short notes, 
giving the essence of the more important contributions to the 
medical journals in the past year. These are followed by a 
notice of some of the inventions of the year, some particulars 
of the health resorts of Great Britain, France, Germany, and 
Austria; sanitary memoranda, and a concise account of the 
medical schools, universities, and licensing bodies, with par- 
ticulars of the nature of the examinations, and the dates on 
which they are held. Next come jottings as to the medical 
societies in the metropolis and the London hospitals, and a 
gazetteer of Great Britain and Ireland, " showing the popula- 
tion, distance from London, number of practitioners, hospitals, 
dispensaries, medical and scientific societies, lunatic asylums, 
&c, in the most important towns in Great Britain." This is 
followed by a medical, official, and trade directory, a summary 
of the Medical Act Amendment Bill (1883), and facts and 
figures on such widely diverse subjects as consultations and 
digestion, assistantships and antidotes ; weights and measures, 
postal information, books of the year; new drugs, private 
asylums, hygienic homes, nursing institutions, and a list of 



52 Revieivs. 

medical and surgical periodicals bring the book to a close ; 
and when it is stated that all this matter occupies only about 
three hundred pages, it will be understood to be a marvel of 
condensation. Where so much is attempted we must expect a 
few errors, but these are neither numerous nor very impor- 
tant, although it is certainly a little startling to find that 
the only local nursing institute mentioned is the Glasgow 
Maternity Hospital, and that is described as situated in 
London. The compiler, Mr. Percy Wilde, M.B., has very 
decided notions on many matters, and does not fail to express 
them, but we think it a little unfair to assert that " General 
Practitioner is a favourite designation utilised by men with 
single qualifications ; " nor do we believe it to be just to Mr. 
Thomas Cooke to say that the physiological instruction at his 
school " barely amounts to a pretence." No doubt there is a 
germ of truth in the following sentence : — " But if the student 
wishes to obtain the medical degree of an university, it will be 
prudent in him to take out the majority of his lectures under 
the Professor who will be later on his examiner ; the sound- 
ness of this policy is best recognised in the Scotch universities;" 
but we doubt if the writer improves his position by the rather 
virulent foot-note he has appended to it. A little enquiry 
among students who have tried the preliminary examination 
of the Faculty of Glasgow would have satisfied him of the 
slight ground he has for the statement — " This Prelim, has 
the reputation of being among the least exacting in the king- 
dom." We would suggest that in future years Mr. Wilde 
would do well to avoid passing summary judgment on matters 
with which he is imperfectly acquainted. 



Histological Notes for the Use of Medical Students. By W. 
Horscraft Waters, M.A. Manchester: J. E. Cornish. 
London : Smith, Elder & Co. 1884. 

This little book has an attractive outside and a satisfactory 
inside. It is an enlarged version of sheets supplied to the 
students in the classes of practical histology in Owen's College, 
Manchester, during the summer sessions of 1882, 1883. Its 
object is simply to aid a student in the examination of speci- 
mens, and for this purpose a short account of the chief points 
to be observed in the specimens is given. The book goes over 
the whole matter, which so many students now study every 
summer in all medical schools, and it should be found admirably 



Revieivs. 53 

suited for saving the labour of taking notes during the class 
hour, when time is so precious. It is very much what a good 
student would endeavour to put down in his note-book, 
during the brief description usually given by the demonstrator, 
before he goes round to assist the students individually. 

It bears manifest evidence of having been composed to meet 
actual and not imaginary needs, and every one accustomed to 
conduct classes of practical histology will recognise that the 
writer has put down every word for the definite object of say- 
ing once what he has had to say a hundred times. 

After a few paragraphs on Focussing, the Cell, the Applica- 
tion of Reagents, Testing, Foreign Bodies, Preventing Drying, 
and Mounting, Histology proper is taken up. The tissues are 
carefully considered, each supposed section or specimen receiv- 
ing a concise description. After this comes a list, with notes 
as to preparation, of Hardening Agents, Staining and 
Mounting Reagents, and then there are definite instructions 
for the preparation of each tissue. 

Specimens of ossification, softened tooth, and mammary 
gland seem to be omitted, although these are all easily procured 
and prepared for class purposes, and form instructive objects. 
Pancreas is rarely satisfactory for class work, and is, perhaps, 
rightly omitted. The branchiae of the oyster or mussel form 
usually a more convenient source of living ciliated epithelium 
for a large class than the mouth of a frog. It would surely be 
difficult to get a specimen of cellular cartilage from the ears of 
mice for each student. The external epithelium of the cornea 
is thinner, not thicker, than that over the conjunctiva, with 
which it is continuous, and it is generally impossible to make 
out separate cells in the pigment layer over the ciliary pro- 
cesses, the mass of pigment here resembling the uvea of the 
iris in this respect. 

Considering the size of the book, it is singularly complete, 
and should prove quite sufficient for the purpose for which it 
is written. It is handy, accurate, and thoroughly practical. 
It can therefore be recommended with confidence. 



The General Practitioner's Guide to Diseases and Injuries of 
the Eye and Eyelids. By Louis H. Tosswill, B.A., M.B. 
Cantab., M.R.C.S. London : J. & A. Churchill. 1884. 

The reasons which have induced Mr. Tosswill to venture into 
the field of medical literature are no doubt sufficiently weighty 



54 Reviews. 

in his own eyes to justify the production of this little book, 
but as he does not state them in his preface we are somewhat 
at a loss to find a reason d'etre for it. The general practitioner 
has in his surgery text-books descriptions of the diseases and 
accidents herein described, in most cases written by oculists of 
high standing and wide experience ; if, therefore, he requires 
aid in this department of medical practice, it is in regard to 
subjects not touched on in those treatises ; but the author of 
this book, instead of going beyond, invariably falls short even 
of their restricted limits. Notably in regard to cataract his 
information is so meagre as to be absolutely misleading ; while 
as to the ophthalmoscope, he is silent as to the existence of 
such an instrument, although as an aid to the diagnosis of 
many diseases it is admittedly of great value to the physician 
and general practitioner. If, however, we put aside these 
objections, there is little fault to be found with the execution 
of the work. The descriptions are perspicuous, accurate, and 
brief ; the treatment is generally judicious, and the author 
does not forget to point out the necessity for early consultation 
with the specialist. 



A Handbook of the Diseases of the Liver, Biliary Passages, 
and Portal Vein. By Henry R. Buckley, L.RC.P. Edin., 
L.RC.S.I. High Wycombe: F. Westfield. London: W. 
Kent & Co. 

This book is intended to "supply concisely the kind of 
information required by that large class of men of which I 
am an individual — namely, students and general practitioners. 
. . . I have endeavoured to be as concise as the clear state- 
ment of facts will allow, to avoid ambiguities of technicality 
and nomenclature as much as possible, and above all things to 
eschew dogmatism, which ought to have no place in medical 
literature." With the author's object we cordially sympathise, 
but we regret that we cannot say his endeavours have had a 
successful issue. Facts not clearly stated, ambiguities of style, 
and dogmatic statements on subjects still sub judice, are not 
infrequent in his pages. We cannot, therefore, recommend 
this work to our readers. 



Medico- Gh irurg ical Society. 



MEETINGS OF SOCIETIES, 



MEDICO-CHIRUKGICAL SOCIETY. 



Session 1884-85. 
Meeting V — loth February, I884. 



Dr. Gairdner, President, in the Chair. 

I. Trephining of the Spine for Paraplegia. 

Dr. Macewen showed a patient who had been operated on by 
him for the relief of complete sensory and motor paraplegia, 
and who has now quite recovered. He was admitted under Dr. 
Macewen's care with a very marked angular curvature in the 
middle and upper dorsal region, of some years' duration. 
This was accompanied by complete motor and sensory para- 
plegia. The latter had been present to a modified extent for 
nearly nine months, but within the last six had been very 
pronounced, the bladder and rectum being paralysed at a 
somewhat later date. The limbs were in a spastic condition. 
Patellar reflex and ankle clonus were present and slightly 
exaggerated. 

The spinal column could not be straightened by extension. 

The spinal column was operated on for the relief of this 
state. Dr. Macewen described the operation and subsequent 
treatment. The patient was then shown to the Society. He 
was able to walk and run about quite well ; the movement and 
sensation of his limbs were perfectly restored. 

Dr. Alexander Robertson said that, as Dr. Macewen had 
mentioned, he had consulted him in this case, and he could 
corroborate the description of the child before the operation as 
given by Dr. Macewen. Certainly, his physical condition was 
then pitiable in the extreme, and his mental condition was 
equally wretched. If touched he began to cry. Sensation, at 
all events below the knees, there was none, and the motor 
power was also in abeyance. The tache ce're'brale was well 
Drought out by merely drawing the finger over the trunk, 
this leaving a red mark. With regard to the legs, there was 
the spastic rigidity spoken of by Dr. Macewen. When the 
nurse lifted the boy his limbs stood rigid, and when the 



56 Meetings of Societies. 

legs were separated they went together with a snap. Urine 
was expelled on the slightest attempt to raise him. With 
regard to the cause of the condition, looking at the sharp 
angle at the curvature, the cause of the pressure was fully- 
evident. Charcot had indeed described cases without curva- 
ture ; but from reading these cases he doubted whether 
paraplegia would have been produced except in a bony canal. 
He would anticipate that by trephining and allowing the cord 
to expand backwards relief would be obtained, as it certainly 
was in the present case. He should say, however, that it was 
an operation which should not be performed unless all other 
treatment had failed. These cases sometimes recovered by the 
use of medical measures. But as this case had been under 
observation and treatment for some time previously, and no 
satisfactory result attained, the operation seemed to him 
justifiable. He would congratulate Dr. Macewen on the 
success of what was practically a new operation. 

Dr. Neiwnan, in reference to the operation itself, suggested 
that by the use of a chisel the procedure would have been 
facilitated. 

Dr. Cameron said that he had had much experience of 
caries of the vertebras, and especially, perhaps, in the 
treatment of abscesses associated with it ; but, of course, 
he had no experience of any such operative procedure as that 
which Dr. Macewen had brought under the notice of the 
Society. Nevertheless, he could join his congratulations 
to those of the President and others who had spoken in 
regard to its very successful issue in Dr. Macewen's hands. 
But to pass from this individual cure to contemplate the 
practice becoming at all general, required at the outset that 
they should pause and carefully consider what the tendency 
of paraplegia as a clinical fact in this disease was. He was 
of opinion that the usual course of the paralysis was that if the 
case otherwise did well, it tended to recovery. It was not 
common to find a patient who had presumably recovered, and 
had anchylosis, with permanently palsied legs. No doubt 
they saw now and again a poor cripple with a hump on his 
back and another on his breast, with square and high 
shoulders, and his neck looking as if it grew out of his 
sternum, wagging himself along on crutches, with two pendu- 
lous and absolutely helpless legs ; but it was astonishing, con- 
sidering how frequent palsy of the lower limbs was at some 
stage or other of the disease, how seldom this occurred. He 
could recall many cases of marked and continued paraplegia 
which recovered as the disease recovered. This led him to 



Medico-Chirurgical Society. 57 

believe that it was really due in the vast majority of cases to 
the fact that, at the part, the cord was in the focus of a severe 
inflammatory disorder of hone, and so might be pressed on by 
inflammatory products. The posterior excurvation took place 
because the anterior wall of the canal had been removed ; and, 
on account of this latter fact, the cord escaped being nipped 
in the majority of cases. Pott himself pointed out the' 
peculiarities in the character of the paraplegia in this disease. 
It was accompanied by rigidity and spasm (spastic), at least 
in many cases ; whereas, in fractured spine, where the cord is 
lacerated, cut, or pressed on by the fragments, it was charac- 
terised by flaccidity of all the muscles and joints. The 
success of this case was great and satisfactory, and the 
improvement took place in response to the operation. Still, 
it seemed to him that it was difficult to say what cases 
required such an operation, and what cases might be safely 
left to nature. 

Dr. Hugh Thomson said that he had seen a case in which, 
as the effect of an accident, a man had complete paraplegia from 
the neck downwards. There was severe injury at the junction 
of the cervical with the dorsal vertebrae. Not only was he 
unable to move hand or foot, but sensation was almost gone, 
and the breathing was purely diaphragmatic. He proposed 
trephining the spine, but this was objected to by the medical 
consultant in the case, and it was not done. They both 
expected a fatal termination to the case before morning. He 
was at the time they saw him unable to expectorate. Yet the 
man completely recovered, with anchylosis of the bones at the 
neck. 

Dr. Whitson corroborated Dr. Macewen's description of the 
case before the operation, and the means employed before 
operative interference was resorted to. The operation he held 
to be proper in the circumstances ; and its successful result 
left no reasonable ground for doubt as to its being perfectly 
justifiable. 

Dr. Macetven, in reply, said that in operating on one of the 
cases he used a trephine which was more easily worked than 
that in ordinary use in this country. In the second case he 
used^a saw. It was possible that with a chisel one might 
drive a little bit of bone in. In regard to Dr. Cameron's 
remarks no doubt it was true that in a number of instances 
paraplegic cases did recover. He had seen a case of para- 
plegia from lateral curvature, where it was the acute curva- 
ture which caused the paraplegia. No doubt it was quite 
true also that they came in the streets on persons with bent 



58 Meetings of Societies. 

spines who were not paraplegic ; but one does not expect to 
come on many cases of paraplegia in the streets. Surgeons 
had not such a good chance as physicians had of judging in 
such cases as to the probability of recovery ; but not a few 
cases he believed did not recover, the paraplegic condition 
going on till death. They would see in the Hunterian Museum 
curves in which the lumen of the canal had been narrowed by 
malformation, due to osseous irregularities. Was it an advis- 
able thing to leave pressure on nerves for months or years? 
If they could relieve such pressure would the nerves not be 
benefited thereby ? Changes took place in the brain, owing 
to pressure, which were permanent. Loss of memory and 
injury to the intellectual powers resulted from such pressure 
if long continued. But the question will present itself in 
many cases whether the clot would be absorbed, or whether 
the brain tissue would suffer in consequence of the pressure 
occasioned by it. A bullet in the brain might lodge a long 
time without doing damage, but in other instances it very 
speedily did so. No doubt the question of discriminating the 
cases of pressure on the spine on which to operate was one 
of very considerable difficulty. He thanked the President 
and the Society for the manner in which his observations 
had been received. 



Saturing of the Patella. 

Dr. Macewen showed two patients who had been the 
subjects of transverse fracture of patella, and who had been 
operated on by elevation of the fibrous and aponeurotic 
structures, which intervened between the fragments, and then 
by uniting these by suture. The one was a case of recent 
fracture ; the other an ununited fracture of nine months 1 
duration. 

The two patients were shown. Both patellae were firmly 
united. The patients felt their limbs strong and sound. Both 
were slaters by trade, and they were able to carry out all the 
duties of their hazardous occupation, their lives depending on 
their steadiness of limb. They could walk many miles with- 
out fatigue. 

The discussion on these cases ivas postponed till the next 
meeting. 



Medico-Chirurgical Society. 59 

Meeting VL— 7th March, 1884- 



Dr. Gairdner, President, in the Chair. 

Suturing of the Patella. 

Mr. Maylard said that he had seen the case to which Dr. 
Macewen had referred, which presented features supporting to 
some extent the theory of Dr. Macewen in regard to feeble 
union. This man (who died of aneurism of the aorta) showed 
a separation of the fragments of nearly a quarter of an inch, 
the only union being in the posterior part. This case pre- 
sented a good illustration of the interposition of the fibrous 
and aponeurotic structures preventing the process of osseous 
union as referred to by Dr. Macewen. The man was aged 
between 30 and 40. 

Dr. Hugh Thomson said that this notion of aponeurotic 
tissue between the surfaces checking union was certainly new 
to him. One great difficulty in promoting union was that of 
maintaining the bones perfectly steady. The slightest con- 
traction of the muscles must exert some influence on the 
fragments, and disturb the process of ossification. He had 
seen Malgaigne apply his hooks many years ago, and up till 
now he had not seen anything more effective for the purpose 
of keeping the surfaces in complete apposition. It must be a 
hazardous procedure in most cases to open the joint, and the 
introduction of wires would, he feared, in some cases be 
followed by serious results. He would accordingly be disposed 
to adhere to the older practice of Malgaigne. 

Mr. M'Carron said that in his experience of cases of 
fractured patella it had often occurred to him that it would 
be a good thing to have the fragments sutured. He had 
found a particular mode of bandaging, which he described — 
an alteration of the direct and oblique bandage — most ser- 
viceable in keeping the surfaces together. 

Mr. H. E. Clark said that Dr. Macewen had referred to the 
two views at present held as to the cause of non-union — viz.. 
that of distension of the joint and muscular action. With 
regard to the first he did not think that this was to any 
extent an active cause of non-union. He had seen cases of 
great distention of the joint where there was little or no 
separation, and, on the other hand, cases of separation where 
there was no distention. Muscular action, however, must 
very materially interfere with the process of union. Muscular 
action was found even to separate ligamentous union. Mr. 



60 Mi el ings of Societies. 

Clark then described a case which he had treated, in which 
there was a separation of three inches between the surfaces 
of the fragments. The lad, a sailor boy, had been treated 
on board H.M. Training Ship " Cumberland," neither bandage 
nor splint having been used. He cut down on the joint, and 
sutured the fragments with complete success. But they must 
face the fact that they could not attain this desirable result 
without running some risks. For long ununited fractures 
suturing appeared a very suitable procedure ; but for recent 
fractures it presented a doubtful aspect. 

Dr. Morton said that the aponeurosis at this point was 
undoubtedly periosteal, and a continuation of the tendons of 
the extensor. It was much thicker than ordinary periosteum, 
and covered the bone more completely. In a recent case he 
observed that it had got slightly over the edges, and it seemed 
to him likely enough that this aponeurosis getting between 
the fragments might cause difficulty of union. But it must 
be allowed that there were cases in which this explanation 
of non-union would not hold good. He had a case lately in 
which the ends of the bone crepitated quite easily. The 
results of suturing operations, however, were as yet not very 
satisfactory ; but if this cause, suggested by Dr. Macewen, was 
found to be operative in many cases, it would be necessary 
to have recourse to this procedure much more frequently 
than at present. 

Dr. Fleming said that it was conceivable that fracture of 
the patella might be limited sometimes to the anterior portion 
of the capsule, leaving intact the posterior portion. This 
would account for the fact that some cases recovered so 
easily, while in others the difficulty of union was great. 

Dr. Macewen said that where they had fracture of the 
patella without rupture of the aponeurosis, there was, as a 
general rule, osseous union. He had himself seen several 
cases of this kind. This was another argument in favour 
of the hypothesis that rupture of the aponeurosis had some- 
thing to do with non-union. He would not propose to suture 
in a case in which the aponeurosis was intact. No doubt 
many would prefer to leave these cases without operation, 
or operate only as a dernier ressort. Dr. Thomson had 
mentioned the success of Malgaigne's practice, but probably 
he had never had an opportunity of examining these cases 
after they left the hospital. Again and again he had seen 
cases dismissed from hospital as cured, and on examination 
the fragments were found very loose, showing a feeble fibrous 
union after all. 



Medico-Chirurgical Society. 61 

Dr. Macewen showed a patient from whom the right 
kidney was extirpated. — The patient was admitted into 
Dr. Macewen's Wards in an emaciated, semi-delirious con- 
dition, with high temperature and weak pulse. The history 
available at the time was of the most meagre description, and 
to the effect that he had been troubled with a urinary 
affection for about a year previously. His urine was loaded 
with pus. On examination microscopically, a few tube casts 
containing pus corpuscles were seen, along with numerous 
crystals of phosphate of lime. There was dulness and 
swelling in the right renal region, which was painful on deep 
pressure. The diagnosis was renal calculi with abscess of 
the kidney. 

Within the first twenty -four hours of his admission into 
the hospital, it was evident that he was sinking, and that 
something would require to be done at once for his relief. It 
was thought that the renal calculus might be removed while 
the abscess could be opened and drained. (Dr. Macewen 
described the steps of the operation.) The renal calculi were 
removed ; one from the pelvis of the kidney of irregular form, 
one of its projections situated in the ureter : the other from 
the substance of the gland. The kidney was found to be 
riddled with abscesses, and as it was apparent that it could 
no longer perform its secretory functions, it was removed. 

The patient recovered from the operation with remarkable 
rapidity. Such was the change that had taken place in his 
appearance within three weeks that some of the gentlemen 
who had been present at the operation, and had not seen him 
in the interval, could scarcely believe that the emaciated 
weakling, whose life was then trembling in the balance, was 
the same lad with rounded form and plump appearance now 
before them. From the second day after the operation there 
were no tube casts seen in the urine, and from the third day 
after there was no pus. 

Dr. Alex. Patterson said that the subject of operating in 
surgical kidnej' was a very interesting one. The initial 
difficulty was to determine whether the other kidney was 
diseased. If the patient was passing the normal quantity of 
urine, it was probable that the opposite kidney was sound and 
doing double duty. In most cases where there was tuber- 
culous kidney there was also in connection with it abscess in 
the body of the kidney, and its function nearly destroyed. 
The operation of removal was first performed by Simon of 
Germany in 1869, and since that period about thirty cases 
had been recorded, about one-half of them being successful. 



62 Meetings of Societies. 

In a number of these cases the diagnosis turned out to be 
inaccurate. Dr. Macewen's case was evidently entirely 
successful and performed in the very nick of time. Dr. 
Patterson exhibited a stone which he had a few days before 
removed from the kidney of a woman with success, and 
described the steps of the operation. 

Dr. Robertson said that the difficulty of determining the 
exact condition of the organ constituted the most serious 
difficulty in these cases. In the Glasgow Medical Journal of 
last month was described an instrument by means of which, 
when introduced into the bladder, the orifice of one ureter 
could be occluded at a time, and the flow of urine thus 
dammed back. By its means it was therefore possible to 
ascertain the condition of each kidney by itself. It was 
interesting to note that it had now been beyond doubt that, in 
case of all double organs, one-half could be dispensed with. 
Even the brain was not an exception, as the one-half of it 
could be destroyed without any marked impairment of the 
intelligence. In the case of the kidney, however, it was clear 
that the risk of life, from the action of outside agencies, was 
considerably increased by one kidney having to do duty for 
two. In the case of a chill, for instance, the increased work 
thrown on the single organ would be a matter of serious 
consequence. 

The President said that the course of events in these cases 
was something like this. Along the ordinary channel pus 
was discharged for a considerable period for a greater or less 
period, this going on interminably. If the patient does not 
succumb, then there came a time when the kidney was 
structurally and functionally destroyed. If an opening were 
now made externally, pus was discharged in this way, and this 
might go on indefinitely. The next step was that of waxy 
degeneration or Bright's disease. It was perfectly clear that, 
if they were satisfied that the kidney was permanently 
disabled, they might save the patient's life by having recourse 
to the operation for its removal. 

Dr. Whitson bore testimony to the accuracy of the descrip- 
tion of the case before the operation, and to the critical 
position from which the operation timeously saved him. The 
result thoroughly justified the procedure adopted. 

Dr. Macewen thanked the Society for the manner in which 
his communication had been received. 



Pathological and Clinical Society. 63 

GLASGOW PATHOLOGICAL AND CLINICAL SOCIETY. 



Session 1883-84. 
Meeting XL— 8th April, 1884. 



The President, Professor M'Call Anderson, in the Chair. 

Dr. Alexander Patterson showed a unique specimen of 
a urinary calculus, and read a paper on the subject, which 
will be found at page 409, vol. xxi. 

Dr. Alexander Robertson showed a patient affected with 
unilateral hallucinations, and remarked that he had 
brought the subject of unilateral hallucinations before the 
profession in a paper read at the Edinburgh Meeting (1875) of 
the British Medical Association,* and also in a communica- 
tion to the International Medical Congress of London.-f- 
These papers were based on observations made on a large 
number of people, most but not all of whom were more or less 
insane. It was shown that one-sided hallucinations were very- 
far from being rare, and that in his experience they were most 
frequent in the forms of mental disorder which were due to 
alcohol. He had found that in the great niajotuty of cases the 
imaginary impressions were on the left side ; still there were 
exceptions to this general rule. They were mostly associated 
with the sense of hearing, but those of sight were of occa- 
sional occurrence ; a few had been noticed in connection with 
touch ; no clear case had been found in relation with taste or 
smell. 

Reference was made to their pathology. It was considered 
probable that in cases of marked hallucinations, whether 
bilateral or unilateral, the highest centres, those, namely, on 
the surface of the brain, were specially involved. If it hap- 
pened that the hallucinations were the earliest phenomena of 
disturbed mental action, then it seemed reasonable to think 
that distinct morbid action had begun in these centres. Where 
the morbid fancies were on one side it was held that the special 
centre involved, which would be on the surface of the opposite 
hemisphere, was weaker than the corresponding one of the 
same side. The weakness might be due to a cause either con- 

* Published in Glasgow Medical Journal for 1875, page 496. 
+ Transactions of Congress, vol. iii, page 632. 



64 Meet i rigs of Societies. 

genital or acquired, and such an agent as alcohol in the blood 
would act with special virulence on the defective part. 

Dr. Robertson stated that the patient — a woman, age 59 — 
whom he now showed to the Society, was an excellent illus- 
tration of hallucinations of the left side, implicating the 
senses of sight and hearing. She states that she had a 
"stroke" in the beginning of the summer of 1883, affecting 
her left extremities. This had passed away almost entirely 
in a few days, but from that time onwards till August last, 
when she came under Dr. Robertson's care, and for some 
months afterwards, she was troubled with imaginary voices 
and forms. They were seen and heard both day and night, 
but were most troublesome during the day. Sometimes both 
men and women would come to her bedside, and occasionally 
only women ; they would look at and bend over her, but when 
she gazed intently at them they disappeared. These figures 
never spoke ; the " voices " that she heard were of people she 
did not see. The hallucinations of hearing have always been 
on the left side, but at first those of sight were occasionally 
bilateral, though after a week or two they also became left- 
sided and continued so. For some months she was puzzled to 
know whether the voices and figures were real or imaginary, 
but generally she considered them real. When questioned on 
this point she would say, " They have the form of real people, 
and are real to me." At that time they gradually disappeared, 
and she remained free from them for about two months ; but 
about six weeks ago they returned, still confined to the left 
side, though their stay was only for a few days on this occa- 
sion. At present she holds them to have been imaginary, and 
the result of the disturbance in her brain caused by the 
" stroke." When they first troubled her they were associated 
with a smell like that of brimstone, and a very peculiar taste, 
quite unlike anything she had ever felt from disordered 
stomach. 

Hearing is found to be a little dull on the left side, the 
tick of the watch ceasing to be heard at more than 3 inches 
from the ear, as compared with 12 inches on the other side. 
The sight of the left eye is also a little defective ; this, how- 
ever, she says, existed long before she had the " stroke." She 
can distinguish colours fairly well with both eyes. No motor 
or sensory defect is observable in any other part of her body, 
except a slight weakness in the grasping power of the left 
hand. 

In reply to questions by members of the Society, the 
patient stated that, at the time she was troubled with these 



Pathological and Clinical Society. 65 

imaginary forms, she saw a chariot with a crowd of people, of 
a blood -red colour; at other times the persons were of 
ordinary colour. She further said that she had tested them 
by closing first the one eye and then the other, but that had 
made no difference, as she did not see them with the right eye, 
always with the left. 

Dr. Robert Scott Orr said that he had only met with one 
case at all similar to Dr. Robertson's. The patient was an old 
gentleman aged 80 years, whose mind was distinctly weakened. 
He imagined that he saw a man come into his bed-room, walk 
round the bed, and then disappear. At other times he 
thought that the ceiling was going to fall upon him. He had 
numerous other hallucinations of a similar character. 

Dr. Francis Henderson remarked that Dr. Robertson's case 
was of special interest to him, because he had a patient under 
his care presenting well marked unilateral hallucinations. 
This case differed from that of Dr. Robertson's in that the 
patient at the time of the hallucination was quite clear in his 
mind. He was a gentleman 70 years of age, who had slight 
cataract in his left eye. At one time the hallucination was 
present in the shape of a printed page before the left eye ; 
the words of the page were single and not suggested by any 
association. Three or four weeks ago it was present in the 
form of a crowded street, and the old gentleman amused him- 
self while lying in bed by watching it. He saw the images 
for a short time after he closed the left eye ; but on keeping 
it closed it disappeared. The attacks were generally associated 
with some excitement. 

Dr. Robertson, in reply, said that cases such as that related 
by Dr. Orr were not at all uncommon in his practice ; but 
that given by Dr. Henderson was quite of the order of the 
one he had shown, the difference being in the state of the 
patient's mind. Dr. Robertson then referred to several similar 
cases. 

Dr. Newman showed specimens from a case of almost com- 
plete OCCLUSION OF THE PORTAL VEIN BY THICKENING OF ITS 
walls for a distance of about two inches, causing ascites, and 
distension of the veins of the abdomen without oedema. The 
patient was a boy 7 years of age, and had his abdomen tapped 
on two occasions, each time about 100 ozs. of fluid being 
removed. Post-mortem. — The peritoneum was greatly dis- 
tended with gas, and the stomach and intestine were also 
inflated, so that when the abdomen was opened they bulged 
forward considerably. The peritoneal cavity contained about 

No. 1. F Vol. XXII. 



6 6 Mee t i rigs of Sou ieties. 

three pints of clear straw coloured fluid. The thoracic organs 
were normal. The liver was dark in colour, firm in con- 
sistency, and its surface smooth. The abdominal organs were 
normal, except that the veins and capillaries contained an 
unusually large quantity of blood. This was most marked on 
the anterior wall of the stomach aud at the pylorus. The 
portal vein appeared as a firm cord, and on section its walls 
were seen to be considerably thickened, so that it was with 
difficulty that a bristle could be passed through it. The con- 
stricted state of the portal vein was seen to extend into the 
substance of the liver for nearly two inches, and then gradually 
the calibre of the vessel became increased, and it assumed to 
the naked eye its normal appearance. The portal veins 
throughout the organ were empty. 

Microscopic Examination. — The portion of the portal vein 
described above to be almost completely occluded was found 
to present the following appearances : — The connective tissue 
around the vein was seen to be increased in amount, and 
infiltrated with fat, containing numerous crystals of margarine. 
The increase in thickness was almost entirely limited to 
the external coat. The external measurements were not 
augmented. The external coat was seen to be so thickened 
that the internal coat was pressed inwards, and the calibre of 
the vessel reduced. The external coat was composed of con- 
nective tissue, infiltrated with fat, and supplied by a large 
number of blood-vessels with thickened walls, which here and 
there were surrounded by groups of leucocytes. The internal 
coat was very granular in appearance when examined by the 
low power, and was found to be composed mostly of round 
and spindle-celled tissue. 

The liver presented the following appearances : — Around 
the radicles of the hepatic vein the hepatic cells were greatly 
atrophied, and the capillaries in this part of the lobules were 
observed to be distended with blood in some places, while in 
others they were almost entirely empty. The hepatic tissue 
throughout the organ was granular in appearance ; the most 
marked and significant change observed was the almost total 
destruction of the hepatic cells in certain localities. In some 
of the smaller branches of the portal vein, a thickening was 
observed, which presented almost the same features as those 
above described in connection with the main vessel. 

Dr. Nevrman remarked in connection with this case that 
during life there were only some of the symptoms of portal 
obstruction, and after death some of the lesions which one 
regards as characteristic of occlusion of the portal vein were 



Pathological and Clinical Society. 67 

found to be absent. There was no history of haemorrhage 
from any of the mucous membranes ; diarrhoea was not a 
prominent symptom. There was, however, dilatation of the 
veins which, when collected together, form the portal vessel. 
The spleen, however, was not enlarged, nor was jaundice 
present at any time. The cases where occlusion of the portal 
vein most commonly occurs are malignant disease of the 
duodenum, or head of the pancreas, inflammatory conditions 
extending to the portal vein from surrounding parts, or 
abscesses in the liver itself, or even more commonly the 
obstruction may result from thrombosis of the portal vein or 
some of its branches. In this case, however, the constriction 
is the result of an hypertrophy of the external coat, associated 
with an infiltration of fat. The middle and internal coats are 
unrecognisable as such, but differ from the external coat in 
containing inflammatory products and a few muscular fibres. 

Dr. J. Lindsay Steven showed specimens of the bacillus 
anthracis. He had prepared the specimens in Cohnheim's 
Laboratory at Leipzig, 18 months ago, and the tissues exhi- 
bited were from the lungs, heart wall, and liver of a rabbit, 
which had been inoculated with the anthrax virus. All the 
blood-vessels in the sections were seen to be crowded with 
large rod shaped organisms, and so abundantly were they 
present, that they almost served the purpose of an injection. 
Some of the sections were stained in gentian violet, and 
others were doubled-stained in gentian violet and picro- 
carmine, the result of this being to show the organisms as 
violet coloured rods lying in a tissue stained of a beautiful 
red colour by the picro-carmine. 

Dr. J. Lindsay Steven showed a specimen of enormous 
hypertrophy of the heart, an example of the so-called 
IDIOPATHIC hypertrophy, and made the following remarks : — 

I desire to bring this specimen under the notice of the 
Society for two reasons — (1), because it is one of the largest 
hearts I have ever seen ; and (2) because neither in the organ 
itself, nor in any part external to it, was any very obvious 
cause of the great hypertrophy to be discovered. The speci- 
men was obtained from the body of a man who was treated 
in the Wards of Professor M'Call Anderson, to whose kindness 
I am indebted for the following particulars of the clinical 
history : — 

John M., ret. 41, a soldier, was admitted to Ward II on the 
29th February 1884, complaining of dyspnoea, palpitation, 



68 Meetings of Societies. 

and dropsy of the legs, penis, and scrotum. He had suffered 
from dyspnoea and palpitation for a period of about 5 years. 
Dropsy, however, only made its appearance five weeks ago in 
the legs, and a few days before admission in the penis and 
scrotum. In 1879 he was at the Zulu war, and he blames the 
violent exertions of that period for bringing on his illness. 
Quite recently he was dismissed from the army, having served 
21 years. Since his illness commenced he has suffered from 
slight cough, his chief trouble, however, being the severe 
paroxysms of breathlessness with which he was frequently 
troubled. Latterly he has been passing his urine involun- 
tarily. There is no distinct history of rheumatism, although, 
while in Zululand, he suffered from slight pains in the neck 
and arms. 

On admission, there was great oedema of the parts men- 
tioned above, and there was also the most extreme orthopncea. 
The apex beat was displaced four inches downwards, and to 
the left, and the impulse was diffuse and heaving. There was 
a musical murmur following the second sound, heard most 
distinctly at mid-sternum, and over the second right costal 
cartilage. The pulse at the wrist was of the typical water 
hammer character. 

The most persevering treatment failed to relieve the ex- 
treme passive congestion, or to restore the balance of the 
circulation, and the patient died on 3rd April, 1884. 

A post-mortem examination was made on 4th April. The 
heart, on being opened and emptied of clots, weighed 33 
ounces, being more than three times the average weight of 
a healthy heart. The muscular tissue, though pale, was of 
firm consistence, and, on microscopic examination, presented 
healthy appearances. All the cavities and apertures were 
much dilated, the tricuspid orifice passing six, and the mitral 
five, fingers. Before opening the organ, the sufficiency of 
the aortic valve was tested, and it was found to be quite 
incompetent. This incompetency was seen to be due, not to 
any fixity or contraction of the curtains, but rather to an 
inability on their part to cover the orifice. And now, you 
will see upon looking at them that there is comparatively 
little wrong with the curtains — certainly, I think, nothing 
to account for the great hypertrophy with which we have to 
deal. They are perhaps slightly thickened, but quite freely 
movable, and on their ventricular surfaces are a few very 
small projections, but nothing of any great significance. With 
the exception that they failed to close the dilated apertures, 
the other valvular curtains also presented quite healthy 



Pathological and Clinical Society. 69 

characters. We failed then to find any sufficient cause of 
the great hypertrophy in the condition of the heart itself, 
and the state of the other organs yielded no explanation. 
The liver was nutmeg; the kidneys were engorged; but on 
microscopic examination, with the exception of slight granu- 
larity of the renal epithelium, were found to be healthy. 

In endeavouring to answer the question as to what has been 
the cause of the hypertrophy in this case, I would remark 
that perhaps the tendency of teaching and practice has been 
to regard cardiac hypertrophy and dilatation too much as the 
result of disease within or without the heart, and to leave 
out of view altogether an important group of cases in which 
simple hypertrophy is the first link in the chain of succeeding 
pathological conditions. Thus, Dr. Stokes, of Dublin, was of 
opinion that simple hypertrophy of the heart was very rare ; 
but if we consider shortly the writings of some other observers, 
among whom are a number of military surgeons, we will find 
abundant proof that a simple or idiopathic hypertrophy of 
the heart is by no means so rare as many would be disposed 
to think. Dr. W. C. Maclean, of Netley, in speaking of the 
frequency of irritable heart among soldiers, writes as follows: — 
" Again, I have often pointed out to you that nothing is more 
common than to see cases here of well marked hypertrophy 
of the heart without valvular disease. The obstacle is not 
at the outlets of the heart's chambers, it is one which inter- 
feres with the free and healthy play of the organ."* In the 
last sentence he refers to the accoutrements of the soldier. 
Surgeon Meyers, of the Coldstream Guards, states his belief 
that hypertrophy and dilatation per se may give rise to 
incompetency of the aortic valve, and relates two cases of 
disease (rare in the civil population, but not uncommon in 
the army) where the aortic incompetency was secondary to 
an idiopathic hypertrophy and dilatation."-}- The same views 
were advanced by Dr. Moinet, of Edinburgh ; J and, in a paper 
in Virchow's Archiv, Dr. Frantzel gives an account of similar 
diseases among the young soldiers of the German army. This 
writer is of opinion that the cause of the affection is the 
deleterious effects of prolonged military exercises, especially 
in time of war.§ 

* "Diseases of the Hear-t in the British Army," Brit. Med. Journ., 16th 
February, 1867. 

t On the Etiology and Prevalence of Diseases of the Heart among Soldiers. 
London ; J. Churchill & Sons, 1870.' Pp. 60-62. 

\ The Ccmses of Heart Disease. Edinburgh : Bell & Bradfute, 1872. 
P. 88. 

§ Virch. Arch., vol. lvii, p. 215. 



70 Meetings of Societies. 

But we arc not without examples of this disease amongst 
the civil population. Thus, Peacock, in describing the preval- 
ence of heart disease among the workers in the Cornish 
Copper Mines, writes : — " In this way an hour or more is 
spent by the men in climbing, and when they reach the surface 
they are usually much out of breath, and their hearts beat 
violently. . . . The cardiac effect I conceive chiefly to 
arise from the distension and over-action of the heart in the 
prolonged exertion of climbing." * Friedreich also recognises 
in the working classes an idiopathic hypertrophy of the heart 
without valvular disease or mechanical hindrance, but the 
result of excessive bodily exertion.-f- In a communication 
entitled, " Das Tiibinger Herz," Miinzinger describes a form of 
hypertrophy of the heart due to overstrain, which is common 
among the labourers in the vineyards of Tubingen.]: A general 
review of the whole subject is given in a paper by Seitz.§ 

It will thus be seen that idiopathic hypertrophy of the 
heart has often been observed both at home and abroad ; and 
I think, from the histoiy of this case and the appearances 
observed after death, we can have but little difficulty in 
regarding it as an example of idiopathic hypertrophy. The 
patient himself regarded his exertions in Zululand as the cause 
of his disease, and complained that the marches they had to 
undergo were not so severe on the men as their having to dig; 
trenches and throw up earthworks around their encampments 
at night after a hard day's marching. The case, I think, is 
interesting, as showing a form of cardiac hypertrophy not 
very commonly observed in our Glasgow hospitals. 

Dr. Newman agreed with the remarks of Dr. Steven to a 
certain extent. This was a form of hypertrophy not common 
among the labouring classes of Glasgow. The cause of the 
condition was that incompetency of the aortic valve was set 
up, after which the hypertrophy could not recede. 

* Lectures on Valvular Disease of the Heart, p. 65. 

t Krankh. d. Herz., 2 Aufl., Erlangen, 1867. Virchow Jffandb., p. 160, 
169, c.f. 172. 

t Deutsch. Arch. f. Klin. Med., xix, p. 449. " Zur Lehre von der Ueber- 
anstrengung des Herzens." 

§ Deutsch. Arch. f. Klin. Med., xi, p. 485 ; xii, p. 143, &c. 



Pathological and Clinical Society. 71 

Session 1883-84. 
Meeting XIL—lSth May, I884. 



The President, Professor M'Call Anderson, in the Chair. 

Dr. Joseph Coats showed specimens of tubercular peri- 
tonitis, associated with tuberculosis of the Fallopian tubes 
and general tuberculosis. He first showed the intestines 
exhibiting tubercular peritonitis, in which the tubercles were 
somewhat smaller than usual. There were the usual adhesions, 
composed of vascular connective tissue. In connection with 
this he also showed the uterus and Fallopian tubes — in the 
latter there was a distinct tubercular affection, evidently set 
up by the tubercular virus passing down them. The tubes 
were greatly dilated and tortuous. This conjunction was not 
uncommon. Much more uncommon was the conjunction of a 
peritoneal and a general tuberculosis. In some cases a tuber- 
culosis of the thoracic duct had been found to account for the 
infection of the blood. 

Dr. Fleming showed a patient with an ulcer of large size 
ON the right forearm, in which there was no chance of 
healing without great contraction. He treated the case by 
dissecting up a flap from the skin of the abdomen, and 
stitching it to the ulcer, tying the arm down to the abdomen. 
In five days he divided the isthmus, when it was found that 
complete adhesion of the flap to the forearm had occurred. 
The case was doing exceedingly well. 

Dr. Joseph Coats showed specimens and drawings in 
cases of cerebro-spinal meningitis. He referred to the case 
which Dr. Finlayson had brought before the Society about a 
year ago, a drawing of which was again exhibited. Dr. 
Finlayson was much interested in the report of cases occurring 
lately in Ayrshire, and as a result of correspondence, specimens 
were sent from Dr. Frew, of Galston. A picture of part of 
the brain in one of these cases was shown, also microscopic 
sections of the soft membranes. A very abundant yellow 
exudation was present over the convexity of the brain and 
posterior surface of the spinal cord. This, under the micro- 
scope, showed a highly characteristic inflammatory character, 
the membranes being infiltrated with enormous numbers of 
round cells or pus corpuscles. In regard to the question of 



72 Meetings of Societies. 

micro-organisms, Dr. Coats did not give a very definite opinion. 
He stated that he thought he had observed micrococci in the 
midst of the inflammatory exudation, but he could not state 
that these had any specific characters. 

Dr. Frew, of Galston, read a report of a slight outbreak 

OF EPIDEMIC CEREBRO-SPINAL MENINGITIS, which will be found 

at page 21. 

Dr. F inlay son said that, since he showed his case, he had 
tried to find out if similar cases had been seen in Scot- 
land. He found that there had not been many. In 1878 Dr. 
Maclagan referred in the Lancet to cases occurring at Dundee, 
but there was, in his opinion, no real evidence of their being 
cerebro-spinal meningitis, and many thought that they were 
unusual cases of typhus. Dr. Gorman, of Rutherglen, had 
informed him that, about the time of the Dublin epidemic, 
about 1867, there were three cases of girls in Bridgeton and 
Rutherglen which were supposed to be of this nature. The 
patients were rag pickers. They were not verified by post- 
mortem examination so far as he could hear. 

Dr. Robertson said that when Dr. Finlayson showed his 
case of epidemic cerebro-spinal meningitis he referred to 
ordinary meningitis in so far as it related to this case. Since 
that he had had another case. In this one the cord was 
not affected. The brain alone was affected — its base was not 
involved, but there were the usual signs of lepto-meningitis. 
There were no convulsions, and the patient died exhausted. 

There was yellow lymph between the convolutions and on 
the upper surface of the cerebellum. 

The patient was a man, aged 44, of drunken habits. 

The following case was sent by Dr. Morrison, of Belvidere 
Fever Hospital, but was not in time to be read at the meeting. 

B. J., ast. 9, admitted 20th February, 1884. Patient took ill 
nine days ago with headache and vomiting ; bleeding from the 
mouth began the day before admission. 

When admitted blood was oozing steadily from the mouth, 
and it was found on examination that it was a general oozing 
from the gums that was the source of the haemorrhage. The 
child was extremely emaciated, lay in bed with her legs 
flexed ; cried out when touched, but when left alone lay as if 
quite unconscious of her surroundings. The eyes were fixed 
and the pupils irresponsive to light. Pulse weak ; tempera- 
ture 103-2°." 

On 21st February the child appeared somewhat better, and 



Pathological and Clinical Society. 73 

took milk more freely. The temperature was 103° in the 
morning. Towards evening there was a change for the worse. 
At 6*30 p.m. the temperature was 106'6 o . The body was 
.sponged frequently with tepid water and dilute acetic acid, 
and at 10 p.m. there was a fall of temperature to 104°. Bowels 
moved slightly. 

On the 22nd February the oozing had almost ceased, and 
the temperatures were 103° and 103 - 2°. 

On the 23rd it was noticed that the head was drawn back 
towards the vertebrae. This was so extreme that the occiput 
almost touched the spine. On attempting to restore the head 
to its natural position the child screamed as if in severe pain, 
and the rigidity was found to be extreme. Both upper and 
lower limbs were rigid and flexed. The pupils were dilated 
and irresponsive to light. Temperature 101-2° and 103°. 
Dark motion. 

The drawing back of the head and the patient's condition 
remained unaltered till the 25th of February. The tempera- 
ture on the 24th was 1026° and 106°; on the 25th, 102-4° 
and 102°. 

On the 26th, at 10 p.m., the child died. 

TEMPERATURES. 





Morning. 


Evening (6-30). 


20th Feb., 


- 


103-2° 


21st „ 


103° 


106-6° and (10 p.m.) 104' 


22nd „ 


103° 


103-2° 


23rd „ 


101-2° 


103° 


24th „ 


102-6° 


106° 


25th „ 


102-4° 


102° 


26th „ 


102° 


Died at 10 p.m. 



Dr. Finlayson showed a tumour in the brain of a 
child two years old, who had died at the Sick Children's 
Hospital on 23rd April. He likewise presented a drawing, 
made by Dr. Newman, indicating its exact position. The 
child was seen for the first time about two months before he 
died, when the following history was obtained. He had 
hooping-cough somewhat severely when 10 months old, and 
this lasted for six months ; since then he was supposed never 
to be right, being cross and irritable, without any definite 
symptoms. There was the history of a discharge from the 
left ear in January 1883, lasting for two months, and again 
in January 1884, lasting two days. The child had begun to 
stand at chairs in October 1883, when about 18 months; and 
in November he was said to have been frightened by some 



74 Meetings of Societies. 

child, and at that time had an attack of vomiting, but this 
was not repeated. Ever since then he had been unwilling to 
try to stand, and latterly was evidently quite unable to do so. 
In the beginning of January 1884 the left eyelid was noticed 
to droop, and about the same time the right side of the face 
appeared to hang somewhat loose, and the right arm became 
weak and unsteady. This condition was found to exist on 
the first examination at the end of February. The pupils 
were equal, but some deviation outward of the left eye was 
detected (the same side as that on which the ptosis existed). 
The child was sometimes a little feverish, and the bowels 
were confined. He often indicated when they were going to 
act, or when he was about to pass water. As a rule he slept 
soundly at nights. There had been no convulsions at any 
time, and no great screaming ; and, as already stated, only 
once had there been vomiting before admission. 

On admission to the ward on 1st April, the child was found 
in the condition already indicated, somewhat feebler, and 
quite unable to stand, or to use the right hand for grasping 
anything. He was noticed to have a tendency to fall over 
towards the right side, as if it were specially weak when made 
to sit up for a little time. He was at first very restless during 
the day, fretful and crying, and tossing, or swaying the body 
back and forward, but he usually slept well at night. His 
ears were examined by Dr. Barr, the aural surgeon to the 
Institution, but there was nothing wrong found, and so the 
discharges referred to seem to have been of little importance. 
The eyes were examined by Dr. Thomas Reid, the ophthalmic 
surgeon to this Hospital ; he confirmed the existence of ptosis 
and divergent strabismus, but found nothing of a very definite 
kind in the fundus of the eye ; but, of course, the examination 
of such a case was conducted under great difficulties. It was 
also subsequently ascertained that the child could see with 
either eye when tested with a piece of bread held up to him, 
the left eyelid being lifted up during the process ; but he 
always grasped the bread with the left hand, the right being- 
useless for such a purpose, and, when moved at all, being very 
shaky and tremulous. The child was the first of the family : 
there was also a baby three months old, quite healthy. No 
evidence of disease could be traced in the parents. 

On admission a mixture of iodide and bromide of potassium 
was ordered, and the restlessness became much less; but on 
11th April the bromide was stopped as it was found that the 
child had become very drowsy, and the iodide alone was 
resumed on 18th April ; but it subsequently seemed as if this 



Pathological and Clinical Society. 75 

sleepy state were due to the advance of the disease rather than 
the medicine. After admission another change occurred in a 
drooping of the right eyelid as well as the left, and the paraly- 
sis of the right side of the face became more marked. Within 
a few days of death the eyelids, which had both drooped so as 
to almost completely close the eyes, became wider. This was 
thought to be possibly due to the paralysis of the right orbicu- 
laris palpebrarum counteracting so far the paralysis of the 
levator palpebrse on the right side ; but as the left also drooped 
less, without any facial paralysis on that side, it was more 
likely due to some varying pressure within — perhaps to some 
change in the fluid in the ventricles which probably increased 
at the time the drowsiness supervened. A new feature devel- 
oped about this time was the turning of the head towards the 
right shoulder. This tendency was very pronounced, particu- 
larly when the child was made to sit up with assistance. It 
was exactly of the same kind as that seen to be so often 
associated with lateral deviation of the eyes ; but this feature 
could not of course exist along with the divergent squint 
already referred to. Two days before death a sudden change 
for the worse occurred, characterised by unconsciousness and 
some rigidity and even convulsive movements ; this state was 
interrupted by a short period of consciousness, during which 
he was able to swallow, but he soon relapsed and died on 23rd 
April. The temperature which, during the first three weeks of 
his stay in the hospital, only went up occasionally to 100° or 
101° ran up during the unconscious and convulsive stage to as 
much as 103°. Vomiting only occurred about twice during the 
time he was in the hospital. It could not be ascertained 
whether he had pain in his head ; he was noticed sometimes to 
put up his left hand to his head. 

The post-mortem examination was made by Dr. Newman. 
Nothing of note was discovered in the chest or abdomen 
except the minutest quantity of calcareous deposit in a gland 
at the bronchus. 

The surface of the brain seemed drier than usual, and a quan- 
tity of fluid was found at the base of the brain and in the ventri- 
cles which were much distended. A tumour was discovered just 
above the pons varolii, involving the left peduncle of the brain. 
It measured about 1-i inches from above downwards, and 
about f inch across. It was chiefly to the left of the middle 
line, but it extended a quarter of an inch to the right of it. It 
was separated from the lateral ventricle by about £ of an inch 
of apparently normal tissue, and from the floor of the fourth 
ventricle by not more than the thickness of a sheet of paper. 



7 6 Meet i rigs of Soc ieties. 

It extended also close up to and was just under the corpora quad- 
rigemina. The relationship to the nerves was examined : the 
trunk of the third nerve on the left side seemed as if it would 
be compressed by the tumour against the base of the skull. 
The tumour was of firm consistence and clearly denned from 
the brain substance, and it had a yellowish-grey colour. On 
microscopic examination it was found to have the structure of 
a round-celled sarcoma. The drawing made by Dr. Newman 
showed the tumour in position after removing the left hemis- 
phere of the brain and the whole of the cerebellum. 

Dr. Finlayson in his remarks said that the group of symp- 
toms observed pointed strongly to a cerebral tumour, and this 
became more certain when nothing was found in the ears 
likely to account for the symptoms. The complex character of 
the symptoms on both sides of the face and in the right limbs 
seemed to suggest a multiple cause, and this of course was 
quite consistent with the idea of scrofulous or tubercular 
growths in the brain, which are the most frequent in children, 
although nothing suggestive of this tendency could be made 
out in the examination of the child or in the history, unless 
indeed such had followed the severe hooping cough ; the sectio 
showed, however, a single tumour in such a situation as to 
account for the symptoms pretty satisfactorily. As to localisa- 
tion, the view was expressed during life that the tumour 
would be found to exist on the left side, involving the 
peduncle of the brain, and it was even thought the corpora 
quadrigemina might be involved. This idea was based on the 
very marked deviation of the head to the right shoulder. 

Dr. Newman showed sections of the tumour. 

Dr. George S. Middleton showed Cathcart's Microtome. 
He explained the purposes for which it is useful, and demon- 
strated the method of usincr it. 

Dr. Thomas Reid showed an orbital tumour about the 
size of a hen's egg removed from the left orbit of a girl 5 
years of age, the disorganised eye having been enucleated in 
October 1883. About twelve months before the vision of 
left eye was found to be defective, and a white reflex coming 
from behind the pupil. The eyeball was painful, the pain 
extending to the temple. There was a history of a blow on 
the forehead three months previously. 

On admission in September, the lens was seen to be opaque 
and partially dislocated, the cornea opaque at its lower aspect. 
Examination of the enucleated eye after hardening in MuLler's 



Pathological and Clinical Society. 77 

fluid showed complete separation of the retina, with a 
grumous fluid filling the cavity between it and the choroid, 
which coagulated in alcohol; no specific growth could be 
detected, and the optic nerve was quite healthy. 

Two months after, suffered from severe pain in the forehead 
and temple, which was followed by a swelling, occupying the 
bottom of the orbital cavity, and everting the lower lid. The 
swelling gradually increased and protruded between the 
eyelids. 

It was diagnosed as malignant, and there was some doubt 
as to the propriety of its removal. This was finally decided 
on, and under chloroform, the cavity of the orbit was 
thoroughly cleared out, 3rd May, 1884. There was no 
attachment except at the optic nerve entrance. The cavity 
was then washed out with chloride of zinc paste. There was 
very slight inflammatory reaction. 

A section of the tumour showed it to be a small celled 
sarcoma of a brain-like consistence, with the healthy stump 
of the optic nerve imbedded in it, the sheath being somewhat 
thickened and continuous with the tumour. 

Except the headache, there was no symptom pointing to the 
tumour being of intra-cranial origin. 

Note. — 24-th June. — The patient lost the vision of right eye 
about a week since, without any evidence of intra-ocular 
changes, pointing conclusively to the presence of a tumour at 
the base of the brain. 

Dk. Knox showed an eyeball enucleated for glioma 
of the retina penetrating the sclerotic and developing in the 
tissue of the orbit. The patient was a boy 2| years of age, 
and of a strumous habit. The usual yellow reflex from the 
fundus had been well marked, and his mother had stated that 
a sudden increase of size and some bulging forwards of the 
eyeball had taken place a few days before admission to the 
Eye Infirmary. The eyeball was enucleated, and all went 
well for about five weeks, when recurrence took place in the 
tissues of the orbit. This tumour grew rapidly, and in three 
weeks was of the size of a small apple, completely filling the 
orbital cavity, and distending the eyelids. Its conjunctival 
surface presented a slightly pigmented appearance from small 
extravasations of blood. Further operation was deemed unad- 
visable. On section the eyeball was seen to be distended by 
the tumour, the anterior part of which — very soft, had a dis- 
tinctly yellow colour, while the posterior part was firmer, and 
marked by numerous small extravasations. The optic nerve 



78 Medical Items. 

had been cut about § of an inch behind the sclerotic, and was 
considerably thickened. Microscopic sections of the tumour 
showed the characteristic small celled growth of a o'lioma. 
To the outer side of the optic nerve the choroidal tissue, both 
blood-vessels and pigment, was completely transformed into 
gliomatous tissue ; the sclerotic was infiltrated by rows of 
small cells lying between the layers of fibrous tissue ; outside 
of the sclerotic the orbital part of the tumour had the same 
structure as the intra-ocular, but no capsule or limiting mem- 
brane was found on this part of the tumour. The optic nerve 
was infiltrated similarly to the sclerotic, and presented a 
gelatinous appearance. The tumour therefore might be con- 
sidered a typical glioma springing from the retina, and passing 
outwards along the optic nerve, and through the choroid and 
sclerotic by infiltrating and partly destroying these tissues. 
There was no apparent rupture of the sclerotic. The rapidity 
of growth in all parts of the tumour was very marked. The 
whole history and appearances corresponded very closely with 
those of a case of glioma reported by Knapp in his book on 
Intra-ocular Tumours. 

Dr. J. Lindsay Steven showed two specimens of horse- 
shoe KIDNEY, which he had obtained within a day or two of 
one another in the 'post-mortem room of the Western Infirm- 
ary. They were the first that had been found in that institu- 
tion. One of them was the seat of tubular nephritis ; there 
were two ureters in each specimen. 



MEDICAL ITEMS. 

UNDER THE DIRECTION OF 

ALEX. NAPIER, M.D. 

Surgical Uses of Collodion. — Mr. Sampson Gamgee 
writes: Collodion is one of those therapeutic agents of which 
the value to the surgeon is admitted, without being adequately 
appreciated or utilised. Composed of ether, gun-cotton, and 
spirit, collodion is a powerful anti-putrescent ; and, by ready 
evaporation and contraction, it exercises the dual antiphlogistic 
power of refrigeration and compression. In acute orchitis I 
know no plan of treatment so simple, rapid, and satisfactory, as 



Medical Items. 79 

coating the cord and scrotum with layers of collodion, by the 
aid of a camel-hair brush previously clipped into it. The sensa- 
tion is momentarily sharp, the shrinkage rapid, and so is the 
subsidence of the inflammatory process — facts pointed out some 
thirty years ago by Bonnafont, but much doubted and almost 
forgotten. To swollen parts which cannot well be bandaged, 
collodion is especially applicable for the compression attending 
its contraction. I was lately consulted in the case of a good- 
looking boy considerably disfigured by a red and swollen nose, 
which became very pale and visibly contracted just after I 
painted it with successive layers of collodion. I repeated the 
application three times in the succeeding fortnight, with the 
effect of producing shrinkage of the organ to its natural size 
and colour. When the nasal bones are fractured, a very effec- 
tive mould for keeping them immovable, after adjusting them 
with the fingers, may be thus made: place over the nose a thin 
layer of absorbent cotton soaked in collodion; as it dries another 
layer of cotton and more collodion, taking care that the applica- 
tion extends sufficiently on each side to give buttress-like 
support. The patient compares the feeling to the application of 
a firm bandage on the nose, and the bones consolidate effectively 
under the shield, which may be renewed as it cracks and 
peels of. 

Other cuts than recent ones do well under collodion. A 
horse-breaker sought my advice for a grazed wound inflicted by 
a carriage step on the front of his right shin, ten days previously. 
He had applied water-dressing continuously. The surface of 
the sore had suppurated, and its edges, for some distance round, 
were red and tender. I raised the foot to empty the limb of 
blood, dried the surface of the sore with absorbent tissue, then 
brushed it over with collodion, and applied a smoothly com- 
pressing bandage over one of my pads. The part was easy at 
once, and with two more dressings at intervals of four days 
cicatrisation was perfect; the patient having continued his 
business of riding and driving without losing an hour. Bir- 
mingham Med. Review. Jan. 1884. 



Affections of the Eye-Muscles in Diseases of the 
Brain and Spinal Cord. — Disturbance in the function of 
the eye-muscles is observed in many forms of brain disease. 
This condition, as pointed out by Dr. Henry G. Cornwell, 
in an interesting clinical study in the April issue of The 
American Journal of the Medical Sciences, is brought about 
by intra-cranial diseases, which affect the innervation of one 



80 Medical Items. 

or all of the three motor nerves distributed to the eye — viz., the 
third, or motor ocidi, which supplies the levator palpebrarum 
and all the muscles of the globe of the eye except the superior 
oblique and the external rectus ; the fourth, or patheticus, 
which supplies the superior oblique; and the sixth, or abducens, 
which supplies the external rectus. The facialis is also to 
be included in the group of motor eye-nerves, as some of its 
filaments are disturbed to the orbicularis palpebrarum. 

Tonic spasm may affect the eye-muscles in some intra-cranial 
conditions, giving rise to strabismus. This is occasionally 
observed in the first or irritative stage of acute inflammatory 
affections of the brain, as, for example, in basilar meningitis. 
It may also be seen in epilepsy, at times in hysterical con- 
vulsions, and also in the convulsions of infancy due to teething, 
worms, &c. This form of spasm, in the greater number of 
instances, affects the internal rectus, the irritation giving rise 
to it being doubtless at the root of the third nerve in the floor 
of the fourth ventricle. The pupils are in most instances 
contracted, proving that the squint is the result of nerve 
irritation. 

Clonic spasm of the eye-muscles is a rare condition, which 
is seen in some cases of brain tumours, cerebral sclerosis, and 
tubercular meningitis. 

Strabismus, on the other hand, may be the result of 
paralysis of one of the recti muscles due to a disturbance 
in the innervation of the nerves supplying them. 

Instead of a complete paralysis of an eye-muscle due to 
intra-cranial disease, there may be only a paresis of the muscle, 
no deviation in its relation with its fellow being noticeable to 
an observer, further than, in marked cases, a halting or jerking 
in the movements of the eye toward the affected side. The 
subjective symptom of this condition is diplopia, or double 
vision, the distances of the images from each other being 
dependent upon the extent to which the affected muscle is 
enfeebled, and also upon the direction in which the eyes are 
turned. 

Paralysis or paresis of the eye-muscles, Dr. Cornwell points 
out, may be periodical in character, as has been observed in 
some cases of basilar tubercular meningitis, cerebral syphilis 
tumours, abscesses of the brain, and in the early stages of 
tabes dorsalis. 



THE 



GLASGOW MEDICAL JOURNAL. 



No. II. August, 1884. 
ORIGINAL ARTICLES. 



ON THE PATHOLOGY OF PSEUDOHYPERTROPHIC 
MUSCULAR PARALYSIS, WITH REMARKS ON A 
SO-CALLED DEGENERATION OF THE NERVOUS 
SYSTEM. 

By GEO. S. MIDDLETON, M.A., M.D. 
{Being his Thesis for the Degree of M.D. in the University of Glasgow.] 

Opportunities for making examinations of the tissues in 
cases of pseudo-hypertrophic muscular paralysis have been so 
infrequent, that I very readily undertook the investigation of 
the parts in two cases which died in Glasgow within the last 
two years, and were subjected to post-mortem examination. 
I was the more inclined to do so as the chief interest centres 
in the condition of the nervous system, and I had previously 
devoted a considerable amount of time to the microscopic 
examination of the brain and the spinal cord in cases in which 
these were affected. 

The cases to which I refer occurred in the practice of Dr. 
Robertson at the Town's Hospital, and post-mortem examina- 
tions were made, the one by Dr. Newman and the other 1 >\ 
Dr. Steven. To Dr. Robertson I am indebted for the clinical 
history of these cases, which will be found in the Appendix. 
Dr. Newman handed over to me the parts which he had 
removed for microscopic examination, and Dr. Steven also 
kindly supplied me with portions of the cord and muscle in 

No. 2. G Vol. XXII. 



s2 Dr. Meddleton — On the Pathology of 

his case, which had. however, been previously examined both 
by himself and by Dr. Coats, the latter having very briefly 
described in his Manual of Pathology the appearances met 
with. I have made a very detailed and minute examination 
of over 200 microscopic sections from these cases, and the 
results are recorded in the following pages. 

Report by Dr. X<> '-man of the Post-mortem Examination 
of Case I. 

"External appearance. — The body is greatly emaciated and 
almost perfectly free from adipose tissue, and is also very anae- 
mic. There is great atrophy of the muscles, particularly those 
of the extremities. 

"Muscular system. — Examination of the muscular system 
throughout the body gives the following results. The superficial 
muscles of neck are almost normal, with the exception of the 
sterno-mastoid, which is pale in colour, but does not present 
marked evidence of the changes which are so observable in some 
of the other muscles. The deep muscles at the back of neck 
and scaleni muscles are pale in colour, but otherwise present the 
characteristic appearances of healthy muscle. The superficial 
muscles of the back present very much the same appearances 
as the deep muscles of the neck, while the deep muscles of the 
back are very pale in colour, and in only some parts can any 
trace of muscular structure be seen. The intercostal muscles are 
not much affected. The deltoid, the flexor sublimis digitorum, 
and the ext. indicis are found to be greatly changed, so that it 
is with difficulty that any trace of fibrillation can be made 
out. The glutei maximus, medius, and minimus on both sides 
of the body are so much altered that there is some doubt as 
to their identity, so much so that the question is raised whether 
the tissue examined is muscular or adipose ; those muscles are 
very pale in colour, soft, but not oily in appearance. In the 
quadriceps ext. and gastrocnemius this change is not so far 
advanced as in the gluteal muscles, but still more marked than 
in other muscles of the body. 

" Nervous system. — The brachial plexus and the ulnar nerve 
do not present anything remarkable in their appearance, and 
the sciatic also appears to be normal. 

"Brain. — The dura mater is firmly adherent to the cal- 
varium, but is easily removed from the base of skull. Brain 
otherwise normal. 

" Spinal corcl does not present any change to the naked eye. 

"The heart is very small and the left ventricle is firmly 
contracted. There is no increase in subpericardial fat ; the 



Pseudo-Hype lii'opltic Muscular Paralysis. 83 

myocardium is very slightly paler than normal, and on care- 
ful examination with the naked eye no evidence of fatty 
or other changes can be detected ; all the valves are strictly 
normal. 

" The large blood-vessels are normal. 

"Lungs. — Both apices and posterior parts are firmly adherent 
by old fibrous adhesions ; both apices are firmly consolidated, 
and on section present the characteristic appearance of chronic 
catarrhal pneumonia followed by caseation. In the right lung, 
about an inch and a half from apex, there is a cavity the size 
of a walnut, containing soft caseous material. The lower lobes 
of both lungs appear to be normal. There are a few miliary 
tubercles distributed throughout the right lung. 

" Liver. — Practically normal. 

" Spleen. — Normal. 

" Kidneys. — Are slightly enlarged, capsules easily separated, 
and on section, beyond slight hyperemia, there is nothing to 
be made out." 

All the parts kept for microscopic examination were pre- 
served in alcohol, without the use of any other hardening agent. 
In preparing sections, the parts were soaked in water to 
remove the spirit, they were then put into a solution of sugar 
for several hours, and afterwards transferred to a solution of 
gum for some hours more. I found that the longer they were 
kept in gum the more easily they were cut. All the sections 
were made with Cathcart's * ether freezing microtome. When 
cut they were floated off the knife into boiled water, and 
allowed to remain sufficiently long to remove all trace of the 
sugar and gum. Sections of muscle were examined unstained 
in glycerine, in glycerine and acetic acid, and in acetate of potass 
solution ; stained with logwood, both in acetate of potass and, 
clarified, in Canada balsam ; and stained with methylaniline, 
in acetate of potass. Sections of the nervous system were 
examined unstained in glycerine and acetic acid ; stained with 
methylaniline, in acetate of potass, and, when clarified, in 
Canada balsam ; stained with logwood, carmine (Beale's 
solution), or picrocarmine, in Canada balsam. 

Muscles. — The muscles examined were those of the neck and 
the deep muscles of the back, the deltoids, the flexors and 
the extensors of the right forearm, the gastrocnemii, the left 

* Eilin. Clin, and Path. Journal, 9th Feb., 1884. — I have found 
Cathcart's microtome an exceedingly satisfactory instrument. Without it 
I could not easily have accomplished the work which this examination has 
entailed, and which lias all been done without trouble in myown house. 



84 Dr. Middleton — On the Pathology of 

gluteus maximus, and the tibialis anticus : the muscular tissue 
of the heart and of the bladder was also examined. 

The voluntary muscles presented the changes which have 
been described by all previous observers. These may be 
considered under four divisions. 

1. Variation in thickness of the muscular fibres. 

2. Hyaline or colloid degeneration, or coagulation necrosis 
of the muscular fibres. 

3. Increase of connective tissue. 

4. Fatty infiltration. 

In all the muscles examined the fibres were found to differ 
greatly in diameter ; and, in addition, many of them presented 
marked irregularity of thickness. Both of these conditions 
were much greater than in normal muscle, and were most pro- 
nounced in the muscles which had undergone least fatty infiltra- 
tion ; but the smallest fibres seen were in muscles which were 
almost totally replaced by fat. Thus, in the deep muscles of the 
neck, fibres were seen of normal size, about -^q inch in 
diameter, while most were much smaller, many being only 
Twm> inch ; in the gluteus maximus, on the other hand, where 
scarcely any muscular fibres remained, these did not measure 
more than tt^j inch in diameter. Irregularity in size was 
very apparent in some of the fibres, especially in those which 
had undergone hyaline degeneration. 

The condition variously designated as hyaline or colloid 
degeneration, or coagulation necrosis,* was met with in all 
the muscles, but chiefly in those in which fat was least 
abundant. Numerous fibres were affected, presenting a 
vitreous-like appearance when viewed by transmitted light 
with a low power ; the hyaline portions were broken up into 
clumps of considerable diameter, with an almost vitreous-like 
fracture. Only a few of these presented any trace of trans- 
verse striation, but many of the patches were the continuation of 
fibres which showed fairly well marked striation, and some of 
these were bifurcated. In other cases the remaining portion 
of the fibre presented only a granular appearance. Some 
fibres also presented this granular appearance without the 
hyaline condition. In sections stained with methylaniline, 
the hyaline masses had a reddish tint, suggestive of, but not so 
rosy or bright in colour as, that taken on by amyloid material. 
In many cases fibres so affected were broken across, the frac- 
tured ends being connected only by the sarcolemma. It is 
also noteworthy that this change was most marked in those 
muscles which otherwise presented least departure from the 

* For an illustration of this, see Coats' Manual of Pathology, p. 106. 



Pseudo-Hypertrophic Muscular Paralysis. 85 

normal. Can it be that this degeneration is the first stage in 
the disappearance of the muscular fibres ? The same degener- 
ation has been described by other observers, but not by all who 
have written on this subject. 

Increase of connective tissue between the muscular fibres, 
and between the various fasciculi, was very marked in all 
the muscles, but was most pronounced in those muscles 
which presented least of the fatty change. The fibres of this 
connective tissue for the most part lay parallel to the fibres of 
the muscle. In a few sections it looked as if degenerated 
muscular fibres were directly continuous with these connec- 
tive tissue fibres, but this cannot be stated with certainty. 
In this tissue were numerous nuclei, many of them very large, 
and corresponding to the description given by Clarke and 
Gowers in their case. The walls of the vessels were consider- 
ably thickened and surrounded by connective tissue, but the 
increase of connective tissue did not bear any distinct relation 
to the distribution of the vessels. 

Infiltration with fat was the most prominent feature in all 
the muscles. This reached its maximum in the gluteus, and 
in the deep muscles of the back (erectores spinas), was very 
extensive in the gastrocnemii, the tibialis anticus, the deep 
muscles of the neck, and the deltoids, less marked in the 
flexors of the forearm, and least marked in the extensors of 
the forearm, and in the superficial muscles of the neck. The 
fat cells were large, like those of a lipoma, and, where muscu- 
lar tissue still remained, they were arranged in rows parallel 
to the muscular fibres, and enclosed in tubes of connective 
tissue, so that a single row was frequently seen isolated from 
the other tissues. The cells nowhere contained fat crystals. 
In the gluteus maximus very few muscular fibres were seen, 
many of them granular, and all of very small size, as already 
noted. 

In the heart there was none of this infiltration, nor were 
any of the fibres affected with hyaline degeneration. Indeed, 
the only thing noted was increase of the connective tissue, 
and this was not very pronounced. 

The bladder was hypertrophied, measuring, when hardened 
in spirit, almost half an inch in thickness. Here also there 
was an increase of connective as well as of muscular (.issue, but 
there was no infiltration with fat. 

Nt rvous System. — The parts of the nervous system examined 
were the cord at various levels throughout its whole length, 
the medulla oblongata, the pons, the corpora striata, the 
ascending frontal convolution on both sides, portions of the 



86 Dr. Middletox — On the Pathology of 

brachial plexus, of the ulnar and the sciatic nerves, and of 
the lumbar sympathetic ganglia. 

In every section one's attention was at once drawn to the pre- 
sence in enormous numbers of small whitish glancing bodies, 
scattered everywhere throughout the tissues, but much more 
numerous in the white substance than in the grey. These 
bodies varied in size, the largest measured being y^- inch in 
diameter, and the smallest „J 00 inch. The smaller ones were 
rounded or oval in form, but the larger ones more irregular in 
outline, looking as if they were formed by the junction of 
several smaller ones. In some places they were so closely set 
as to present the appearance of a string of glancing beads. 
In unstained sections most of them were clearly demarcated 
from the surrounding tissue, but round many of them the 
nerve-tissue was darker than elsewhere, and into this deeper 
coloured tissue they shaded rather indefinitely. Under a low 
power they appeared semi-opaque and homogeneous, but under 
a high power (Hartnack's eye-piece No. 3 and objective Xo. 
7) they were less glancing and more granular-looking. Their 
distribution was quite indefinite, and bore no relation to the 
blood-vessels of the tissues, and when examined in longitudinal 
sections of the cord they were seen to extend longitudinally 
quite as far as transversely. In such longitudinal sections it' 
was evident that they pushed aside and compressed the 
fibrous structures of the cord. The smaller of these bodies 
might have been taken for corpora amylacea, though none of 
them presented concentric striation. It was impossible, how- 
ever, to make this mistake with regard to the larger ones, 
which corresponded more nearly with what have been 
described as colloid bodies. In order to make out their 
nature, various staining agents were employed. Methylaniline 
rendered them somewhat reddish, but this colour was dis- 
charged soon after the sections were mounted in acetate of 
potass. Iodine stained them of a pale yellow colour, and the 
addition of sulphuric acid did not make any change. They, 
therefore, cannot consist of amyloid material. Osmic acid 
rendered them brown ; a black colour was developed only in 
some of them, chiefly those which have been described as 
surrounded by a darker tissue than normal. With carmine 
and picrocarmine they were unstained, but they took on the 
colour of logwood. In sections coloured with logwood, deeply 
stained irregular patches were seen in great numbers, their 
centres being less stained than their peripheral portions. These 
patches looked almost like collections of round cells closely 
aggregated, but on more minute examination they were found 



Pseudo-Hypertrophic Muscular Paralysis. 87 

to consist of glancing bodies surrounded by irregularly con- 
densed and puckered fibrous tissue. Sections dehydrated in 
alcohol, and clarified with turpentine, showed these bodies 
less lustrous, and more opaque and granular. Ether had no 
effect on sections dehydrated with alcohol, save to render the 
whole section, including these bodies, more transparent. 

From the fact that I had seen similar bodies previously in 
sections of nervous tissue, I concluded, as I had done before, 
that they were merely an accident of the mode of hardening, 
an opinion strengthened by their irregular and wide distribu- 
tion. I could find no description of similar appearances in any 
of the text-books of Pathology or in works on the Diseases of 
the Nervous System which I consulted ; but, on commencing a 
perusal of the recorded pathological observations on pseudo- 
hypertrophic paralysis, I found Mr. Kesteven described a 
similar appearance, looking on it as an example of a lesion 
described by Dr. Batty Tuke and Dr. (now Professor) Ruther- 
ford.* On referring to their paper, I found their description 
corresponded closely with that above given. In a later paper,-f- 
while they unfortunately termed the lesion "miliary sclerosis'' 
they guarded "the reader against the assumption that this 
term indicates that this is a form of gray degeneration (the 
sclerosis of French writers). We adopt the term because it 
simply indicates rounded hardened patches." In order to de- 
termine whether I was dealing with the same bodies, I treated 
sections with fuming nitric acid and fuming sulphuric acid. 
These had the effect of determining a change fully described 
and figured by Drs. Tuke and Rutherford as occurring in their 
case. The glancing bodies lost their lustre and their homo- 
geneous or granular appearance, and were converted into 
masses varying in aspect, some looking like clusters of grapes 
arranged round a centre, others like rosettes made of tubes 
rounded or blunted at the ends, and very similar to tubes 
of myeline which I had often observed at the margins of 
unstained sections of brain-tissue when pressure had been 
applied to the cover-glass, and which reminded me of tubes 
of macaroni. When treated with turpentine this appearance 
was lost, and sections under the low power looked as if they 
were riddled with holes. On examination under a high power, 
these spaces were found to contain a very fine reticulum, the 
neuroglia, with here and there an axial nerve cylinder. This 

* "On a New Lesion observed in die T'>r;iin of an [nsane Person." 
Med. Jour., Sept., 1868. P. 204. 

t "On the Morbid Appearances met with in the Brains of Thirty I 
Persons." Edin. Med. Jour., October, 1869. P. 289. 



88 Dr. Middletox — On the Pathology of 

appearance of loss of tissue was still more pronounced in 
sections from which the acid was removed by soaking in 
water, and which were then stained with logwood, dehydrated, 
clarified, and mounted in the usual way. What were formerly 
deeply-stained patches were now clear spaces, contrasting 
strongly with the surrounding tissue. When stained with 
carmine this condition was not so apparent. Sections treated 
with nitric acid, and then washed and stained with osmic 
acid, showed none of those clear spaces, but darkened patches 
as in other sections not so treated. Strong ammonia had no 
effect on these bodies. These, therefore, have all the characters 
of the so-called " miliary sclerosis " of Tuke and Rutherford, 
and must be the condition described under that name. 

In further elucidation of the nature of these bodies, I 
examined all the microscopic specimens of nervous tissue in my 
possession, amounting to some hundreds of sections from over 
thirty different cases. In this large series of observations I 
found similar glancing bodies in a great many sections, but 
only in one or two cases as numerous as in this one. They 
were present only in those instances in which the parts had 
been primarily or wholly hardened in spirit, never where the 
parts had been first fixed by hardening in chromic acid 
or the bichromates and finally preserved in spirit. In the 
cases described by Drs. Tuke and Rutherford, and by Mr. 
Kesteven, the tissues had always been immersed for some 
time in alcohol before being finally hardened in chromic acid. 
Believing that the condition was due to the action of alcohol, 
I had alternate portions of a normal cord hardened in alcohol 
and in chromic acid : but, as I was in haste to get the work 
finished, they were in these fluids for only a week. On making 
sections I found that while the tissue hardened in chromic acid 
presented none of these bodies, that in alcohol was freely 
strewn with them ; indeed, fchey were quite as numerous as in 
the case under investigation.* As it so happened, the fact that 
the cord had been in alcohol for so short a time was an 
advantage; for in the sections numerous drops of myeline 
were seen everywhere, especially abundant in the white 
matter, and some of the glancing bodies presented the appear- 
ance already described as being brought about by treating 
sections with nitric acid. These latter looked just as if they 
were formed of drops of myeline run together. The conclusion, 
therefore, to which I have come is, that these bodies are simply 
the result of hardening in alcohol, and that they are formed 
by the action of the alcohol on the myeline of the nerve-tubules. 
* I have repeated and confirmed these observations in another case. 



Pseudo-Rypertro'pliic Muscular Paralysis. 89 

In this view I believe I am confirmed by a description of 
the lesions found in a case of paraplegia by Lockhart Clarke.* 
He does not state how the parts were hardened, but he 
describes and figures (as a lesion) bodies very similar to those 
found in this case. "Around the spinal canal, and in the 
transverse commissure, a large number of corpora amylacea 
were also observed. In the surrounding white columns, especi- 
ally the posterior and the lateral, many of the nerve-fibres had 
evidently suffered from either partial destruction or complete 
disintegration of their white substance. At the lowest roots 
of the same pair of nerves — the fourth cervical — the principal 
lesion was in the neighbourhood of the posterior commissure 
— in which were observed two or three small spots of trans- 
parent granular disintegration — and in the anterior decussating 
commissure, the front of which, at the bottom of the anterior 
median fissure, was partially replaced by a heap of fat 
globules; but many of these bodies were changed from the 
perfectly spherical form by compression against each other, 
and in this shape bore a strong resemblance to aggregated 
particles of the white substance of nerves. In other regions 
of the cord similar particles were found in different parts 
of the grey substance, collected into groups, or arranged in 
strings like beads, and appearing like nerve-fibres composed 
of series of particles of their own white substance." 

Drs. Tuke and Rutherford did not consider their lesion 
the same as Clarke's ; nor did the}" lose sight of the possibility 
of their " miliary sclerosis " being the result of the agents 
used in hardening, but they negatived this idea because 
they had "subjected healthy brains to precisely the same 
treatment, and other observers have done the same, and no 
such appearances have been produced. Further, in the case 
described, this lesion was found only in the white matter of 
the atrophied half of the cerebellum, although the half that 
was not atrophied was treated and examined in exactly the 
same way." *f* I cannot reconcile their statement with my 
own observations, nor can I say whether they are still of 
the same opinion. 

I do not profess an intimate acquaintance with all that 
has been written on the pathological appearances met with 
in lesions of the nervous system, but, holding the view that 
this particular appearance is merely the result of the action of 
alcohol on the tissues, and must therefore be of frequent occur- 

* "Pathological Investigations in .-i < lase <>f Paraplegia." Brit, and For. 
Med.-Chir. Rev. 18G4. Vol. xxxiii, p. 486. 
t Edit*. Med. Jour., Sept., 1868. P. 210. 



90 Dr. Middletox — On the Pathology of 

rence, I think it is strange that, in the course of my reading, 
I have seen descriptions of similar appearances only by 
Kesteven, Tuke and Rutherford, and Clarke. Possibly its 
infrequent mention is to be attributed to the facts that others, 
like myself at an earlier period, have attributed it to its true 
cause, and thought it unnecessary to notice it, and that, in 
recent years, workers in nervous pathology have discarded 
alcohol as a hardening ao-ent. 

But while alcohol has been justly condemned, I have 
nowhere met with a description of the reasons. Hence I 
have been induced to go into detail in regard to the appear- 
ances found in this case. Besides leading to confusion by the 
formation of these glancing bodies, alcohol destroys the fine 
structure of nervous tissues. In transverse sections of the 
cord, for instance, the tubular contour of the nerve-fil ►res in 
the white substance is almost entirely lost, the white columns 
presenting, both stained and unstained, the appearance of 
a fibrous network, with the axial cylinders dotted over it. 
In sections hardened in chromic acid or the bichromates, 
on the other hand, the tubular contour is beautifully 
preserved. 

Other objections to the use of alcohol are that cavities are 
formed in the tissues, and crystals deposited. In every case 
in which the nervous tissue had been hardened in alcohol, holes 
were veiy much more numerous in the sections than in cases 
hardened in chromic acid. Many of these are due to blood- 
vessels, the section of the vessel having dropped out of its 
cavity ; but a much greater number of them are due partly 
to the removal of the myeline to form glancing bodies, and 
partly to irregular contraction of the tissues. I therefore am 
very chary of accepting a hole in a section of nervous tissue as 
evidence of softening and disintegration. In various of the 
hitherto recorded cases of pseudo-hypertrophic paralysis such 
holes have been described, as they have been also in other 
diseases of the nervous system. In the case under investigation 
they were exceedingly numerous, particularly in the brain. 
They were frequently also constant in position; e.g., in almost 
every one of a dozen sections of the medulla a hole was seen 
just external to the nucleus of the hypo-glossal nerve ; but while 
this constancy is so far in favour of its being a lesion, I am 
of opinion that it is the result simply of an elongated spindle- 
shaped cavity formed as above described. The same explana- 
tion applies to the cavities or empty spaces frequently found 
around the ganglion cells and the vessels. In addition to such 
holes, which have regular margins, there were, of course 



PsevAo-Hypertropliic Muscular Paralysis. 91 

numerous irregular tears seen, the result simply of the manipu- 
lation of the sections. 

Crystals were much more abundant in the sections of the 
brain than in the sections of the cord. They are common in 
sections hardened in alcohol, and present various forms, many 
being only semi-crystalline. The most common form is a 
feathery one, which in sections of the convolutions mounted 
in glycerine frequently present an appearance suggestive 
of the flowering on a window pane in frosty weather. They 
are often so abundant as to obscure the structure of the 
tissue. With transmitted light they are dark, but in sections 
stained, clarified, and mounted in balsam, they are quite 
transparent. Besides these forms rhomboidal crystals, fre- 
quently in clusters, were often seen much more crystalline 
in appearance than the former. In order to remove the 
possibility of these being due to the sugar and gum in 
'which the tissues had been soaked, the sections as cut were 
floated off into boiled water, and allowed to remain in 
it for hours. Besides, they were seen in sections cut by 
the hand, and never exposed to either sugar or gum. Nor 
were they due to the staining agents, which, especially log- 
wood, frequently deposit crystals, with the appearance of 
which I am perfectly familiar ; for they were seen quite as 
well developed in unstained sections as above described. I 
cannot say definitely what these crystalline substances are, 
but they are soluble in ether, and insoluble in fuming nitric 
acid ; probably they are unusual forms of cholesterin, or of 
some fatty crystal. 

For the reasons above stated, therefore, I am opposed to 
a treatment of the cord and the brain for pathological investi- 
gations which is often recommended — viz., a preliminary 
immersion of the parts in alcohol for 24 hours or more, 
preparatory to hardening in Midler's fluid, &c. The structures 
of nervous tissue should be first fixed in their natural position 
by the use of chromic acid or the bichromates before they 
are preserved in spirit. The objections to these hardening 
agents are no doubt considerable, for they render the tissue 
both very brittle and difficult to stain with carmine (which 
is by far the best staining agent for nervous tissue). I have 
no experience to lead me to say which of them is the best 
fluid, but I think that with proper attention the parts may be 
examined before they become brittle, and removed to spirit, 
which will then do no harm. As to staining, 1 have found that 
sections hardened in the bichromate of ammonium give very 
good results when dehydrated in alcohol, and clarified with 



J2 Dr. Middleton — On the Pathology of 

turpentine, without any staining. In any case, it is better 
to have the natural appearance of the parts retained than to 
have beautifully cut and stained sections which do not show 
the structures in their proper condition. 

I now proceed to the description of the various portions of 
the nervous system examined. 

Spinal Cord, — Throughout the whole length of the cord 
the central canal was of normal size and well marked, except 
in the lumbar region, where its calibre was obliterated, its 
epithelial lining being in close apposition all round. This 
condition, however, is by no means uncommon in this situa- 
tion, and cannot be looked upon as abnormal. Numerous holes 
were seen in both grey and white matter, besides spaces 
around vessels and ganglion cells ; for the reasons above 
stated I do not look upon these as of pathological significance. 
The vessels in the pia mater were distended with blood, as 
also were some of those in the sections ; but there was 
nowhere any exudation of leucocytes around the vessels or 
elsewhere. The walls of the vessels were not abnormally 
thick. 

In the upper cervical region, the ganglion cells of the 
anterior cornua were well developed, both as to number, size, 
clearness of outline, and length of processes : none of them 
showed pigmentation. The largest measured about vrhjj inch 
in greatest diameter, and the smallest rather less than 10 1 6 o 
inch, the majority being between these sizes. They were 
gathered into groups quite in a normal manner. The cells 
of the internal group were much smaller than those of the 
other groups, throughout the whole length of the cord ; but 
this in my experience is the normal condition, and these cells 
did not present any appearance of granular degeneration or 
atrophy. A more striking fact was that in many sections, 
not only of the cervical region, but lower down, the cells of 
this inner group were not of the same size on the two sides, the 
largest on the one side measuring ifl x 00 inch, while on the other, 
cells of double that size were seen. As the ganglion cells are 
very irregular in form, and of considerable length, I think 
that this may be explained by the section of the cells on the 
smaller side representing not a section through their largest 
diameter, but through one of their smaller diameters. How- 
ever that may be, I am not inclined to look upon the con- 
dition as abnormal. In the postero-lateral group, the cells 
were somewhat smaller than in the anterior groups, and the 
posterior vesicular column was indistinctly represented by a 
few scattered cells, well developed. There was no evidence of 



Pseudo-Hypertrophic Muscular Paralysis. 93 

sclerosis anywhere. In a few of the sections the anterior 
commissure was traversed by fibres extending from the fibrous 
tissue in the anterior median fissure ; but this condition is 
described as normal by Lockhart Clarke.* 

In the cervical enlargement, sections coloured with picrocar- 
mine presented, scattered over the white substance, patches 
stained of a deeper hue than the rest, resembling somewhat 
the appearance observed in sclerosis of the lateral columns. 
When examined by the high power, the depth of staining was 
seen to be due to the meshes of the reticulum being thickened 
at various points. This thickening was very local, a small 
central nucleus with radiations being frequently observed ; 
possibly these were enlarged Deiter's cells. Otherwise the 
sections were much as in the upper cervical region. The 
ganglion cells were well developed in every way. 

Throughout the dorsal region the amount of grey matter 
was very small, the broadest diameter of the anterior cornua 
being only £ or £ of the same diameter of the white matter. 
The ganglion cells were much fewer in number than in the 
cervical and lumbar regions, and smaller in size, the largest 
often not measuring more than T cnro inch in its long diameter. 
The best developed groups were the antero-lateral and the 
posterior vesicular column. Occasionally the one side showed 
better development than the other. 

In the lumbar region the o-ano-lion cells were abundant, 
large, and well developed, those of the internal group being as 
usual smaller than the others, which measured from ? ^„ inch 
to xttoo inch in diameter. No difference could be detected on 
the two sides, and there was no evidence of sclerosis any- 
where. Here also the anterior commissure was occasionally 
traversed by fibres running from the anterior median fissure. 

Throughout the cord, sections stained with methylaniline 
showed some of the ganglion cells of a reddish tint, disappear- 
ing after being mounted for some time in acetate of potass. 

The medulla oblongata, the pons, and the corpora striata 
presented nothing to note save glancing bodies, frequent holes, 
and numerous ciystals. 

In the ascending frontal convolutions similar appearances 
were presented, and in addition, along the surface of the grey 
matter there were here and there very small patches more 
deeply stained than the rest of the grey tissue. These patches 
were found to contain more connective tissue than the other 
parts. 

* "Researches into the Structure of the Spinal Cord." — Phil. Trans, of 
the Royal .Society. 1851. Vol. cxli, p. 614. 



94 Dr. Middleton — On the Pathology of 

The portions of the brachial plexus, ulnar, and sciatic 
nerves, and of the sympathetic ganglion examined did not 
reveal anything abnormal. In the nerves, glancing particles, 
very much smaller in size than those occurring in the cord and 
brain, but evidently of the same nature, were seen dotted over 
the nerve-fibres. The tubular character of the nerves was 
lost, just as in the other tissues. 

The notes of the post-mortem examination which was made 
by Dr. Steven will be found in the Appendix, under Case II. 
In this instance the parts given me for examination were 
portions of the spinal cord at various levels, and a portion of 
the erector spinae muscle. These were hardened from the 
first in a four per cent solution of bichromate of ammonium, 
and afterwards preserved in spirit. The sections were made 
and mounted in the same way as in the preceding case. 

The muscular tissue presented a most marked fatty infil- 
tration, with some increase of connective tissue, and great 
loss of muscular fibres with diminution in the size of those 
remaining. None of these showed any appearance of hyaline 
degeneration. 

Spinal Cord. — In this case no glancing bodies were seen, 
and holes were much less frequent in the sections than in the 
preceding case. "With methylaniline some of the vessels and of 
the ganglion cells were coloured of a somewhat rosy or pinkish 
hue, but none were distinctly amyloid; the colour was soon dis- 
charged in acetate of potass. In all the various regions of the 
cord the white matter showed very clearly the tubular character 
of the nerve-fibres. The tubules varied very much in size, the 
largest ones being, of course, at the periphery of the cord. It 
was doubtful whether some of those were not abnormally 
large, as they were found to measure as much as ^rVo i ncn ^ 
diameter, the common size being about 10 „ 00 inch. All, how- 
ever, presented the axis cylinder quite distinct, and not 
enlarged. 

In the cervical enlargement the ganglion cells were 
abundant and well developed, save in the internal group, 
which, as usual, contained cells much smaller than those of 
the other groups, but not presenting any appearance of 
atrophy. The majority of the cells in the other groups 
measured about 5^ or -^-^ inch in diameter. 

In the dorsal cord the cells were smaller, few of them 
reaching in size T ^ inch. The vessels were distended with 
blood, but no hemorrhages, and no exudations of leucocytes 
were s;jen. 



Pseudo-Hypertrophic Muscular Paralysis. 95 

In the lumbar cord the conditions were very similar to those 
noted above ; but there was more of the appearance of 
deficiency of the cells of the one side as compared with the 
other. The ganglion cells varied in size from 10 1 00 inch to 
about y-tg- inch. One very minute haemorrhage was seen in 
the anterior commissure, pushing the fibres of the commissure 
before it in a knee-like bend. 

Illustrations of the cervical and lumbar enlargements in this 
case will be found in Coats' Manual of Pathology (p. 434), 
and in the text he gives expression to the opinion that the 
cells in the anterior and internal groups are probably deficient. 
As I have already stated, I believe the cells of the internal 
group are normally smaller than the cells of the other groups, 
and that the condition noted in this and in the other case is, 
therefore, not abnormal. With this view I believe Dr. Coats 
is now inclined to agree. 

In reviewing the literature of this subject I have found 
recorded seventeen post-TnorteiYi examinations, to the original 
reports of eleven of which I have found access. In seven of 
these the examination of the spinal cord and nervous tissues 
gave negative results — viz., in the cases recorded by Meryon,* 
Eulenburg-Cohnheim,-f" Charcot \ (Duchenne's case), Brieger,§ 
Schultze, and Ross. IT In Brieger's case there was congestion 
of the vessels of the white substance, with collections of 
leucocytes in the perivascular canals, in the brain and basal 
ganglia, but not in the spinal cord. Similar collections of 
leucocytes have been described by Bramwell and others, but 
I regard them as an accidental complication and not essential 
to the disease. In Brieger's case they are sufficiently explained 
by the presence of tubercular meningitis. Their significance 
was indicated by me in a previous paper ; ** such exudations 
are generally met with in cases which have been characterised 
by cerebral excitement. In Selmltze's case it is stated that 

* Med. Chir. Trans. 1852. Vol. xxxv, p. 7.3. On Paralysis. 1864. 
P. 202. 

t Verhandlungen der Berliner Med. Gesellschaft. 1866. P. 191. (Not 
seen). 

\ "Note sur l'etat ana&omique des muscles et de la moelle epiniere dans 
un cas de paralysie pseudo-hypertrophique." — .!/•<■/,. ,/,• /7///.W. 1872. P. 
228. Not seen.) 

§ Deutsches Arch. /'. Klin. Med. L878. xxii, p. 200. 
Virch. Arch. 1879. Vol. lxxv, p. 475. 

^1 Diseases of the Nervous System. Second Edition. Vol. i, p. 1017. 

** "On Vascular Lesions in Hydrophobia and in other Diseases charac- 
terised byCerebral Excitement." — Journal of Anat. and Phys. 1880. Vol. 
xv, p. 88. 



96 Dr. Middleton — On the Pathology of 

the connective tissue in the ulnar nerves was perhaps in 
excess. It is, I find, extremely difficult to say what amount 
of connective tissue is normal to the peripheral nerves, so 
that I am inclined to believe that, in his case, the nerves, like 
the other parts, were quite normal. 

The case recorded by Barth * is generally looked upon as 
having been amyotrophic lateral sclerosis, rather than pseudo- 
hypertrophic muscular paralysis. I did not, however, see his 
record of it. 

The next recorded case that I find is that of Kesteven, -f- 
who describes dilatation of the perivascular canals, and 
numerous circumscribed spots of granular degeneration. He 
figures very distinctly the glancing bodies described above, 
and the conditions met with in his case are to be ascribed to 
the action of the alcohol in which the tissues were preserved. 

The most important case hitherto recorded is that by Clarke 
and Gowers, ^ who describe extensive lesions mainly of the 
grey matter. The form of degeneration they describe is one 
with which I am not familiar. The tissues were preserved in 
chromic acid, but had they been exposed even for a short 
time to the action of alcohol, I should have been inclined to 
attribute the appearances found to the action of that agent, 
especially as it is distinctly stated that globules of myeline 
were accumulated in various situations. No inference from 
the facts is drawn in their conjoint paper, but more recently 
Gowers§ has indicated his belief that the lesion had probably 
little connection with the primary disease, being rather a 
secondary result of long-standing paralysis and frequent 
attacks of pulmonary trouble. 

Bag describes an abnormally transparent condition in the 
neighbourhood of the posterior cornua, and an increase of the 
interstitial tissue with rarefaction of the nerve-fibres in the 
whole length of the cord, similar in extent and form to that 
found in degeneration secondary to disease of the brain. I 
had access only to the extract of his paper in Virchow's 
Jahresberickb, and cannot say whether he substantiates his 

*"Beitrage zur Kenntniss der Atrophia musculorum lipomatosa." — 
Arch, der Heilh: 1871. Bel. xii. P. 121. 

+ "The Microscopical Anatomy of the Brain and Spinal Cord in a case 
of Imbecility, associated with Duchenne's Paralysis." — Towrnal of Mental 
Science. 1871. Vol. xvi, p. 503. 

t Med.-Chir. Trans. 1874. VoL lvii, p. 247. 

§ "Pseudo-Hypertrophic Muscular Paralysis." A Clinical Lecture. 1879. 
P. 42. 

|| "Tre Tilfalde af Pseudohypertrophia Muscularis." — Hospital Tidende. 
■2 R., Bd. 4, p. 441. Viivli. Jahresberichtder Mediein. 1877. Pt. II, p. 133. 



Pseudo-Hypertrophic Muscular Paralysis. 97 

statement with illustrations. It seems to me that he has 
quite probably mistaken for sclerosis a condition similar to 
that described in some of the cervical sections in my first case. 
When I first examined my own sections I was inclined to the 
belief that I was dealing with sclerosis, but subsequent 
experience of more perfectly prepared and coloured sections 
led me to alter that conclusion. 

Brigidi * found in his case in the sympathetic ganglia 
dilatation of the veins, atrophy and pigmentation of the nerve- 
cells, and sclerosis. No other observer who has mentioned 
the examination of these ganglia has described a similar 
condition. In the extract of the case in the Record there is 
no mention of the cord and other nervous centres. 

Ross-f- in his first case observed atrophy of the ganglion 
cells in different groups, at different levels of the cord. Not- 
withstanding this, however, after having had the opportunity 
of examining a second case with negative results, he has come 
to the conclusion that pseudo-hypertrophic paralysis cannot 
be attributed to disease of the nervous system. 

Drummond \ met with a case presenting a bulging of the 
lumbar enlargement, evidently congenital, and disintegration 
of the lateral grey network of fibres, somewhat similar to that 
described by Clarke and Gowers. The parts were hardened 
in spirit and Miiller's fluid. The illustrations from his case 
do not seem to me clearly to indicate a lesion. 

Bramwell § has recorded, with numerous illustrations, a 
somewhat similar case, with a bulging in the cervical region. 
Besides this bulgino- attributed to a cono-enital malformation, 
he describes collections of leucocytes round the vessels, and 
lacerations of the grey matter. I have already indicated my 
opinion of such conditions, but neither in Bramwell' s work, 
nor in the only clinical report of his case as yet apparently 
published || is there any note of the patient's condition and 
symptoms at the time of death. The sections of cord shown 
would, apart from the bulging, pass for normal. He states 
that some of the nerve cells appeared to be hypertrophied. 
I know of no standard size for comparison. 

Pekelharing "7 givrs n detailed description of lesions which 

* Impartiable, 28th Feb., L878. Lon. Med. Rec., October, 1878. 

t Diseases of the Nervous System, 1st Ed., 1881. P. 207. 

| Lancet, 1881. Vol. ii, p. 660. Diseases of tin- Brain and Spinal Cord, 
1883. P. 335. 

§ Diseases of the Spinal Cord, 1882. P. 201. 

|| Dr. Milner Moore, Lancet, 19th June, 1880. 

IF Bin Fall von Biickenmarkserkraakung bei Pseudomuskelhypertropliie. 
Virch. Arch. 1882. Vol. lxxxix, p. 228. 

No. 2. H Vol. XXII. 



98 Dr. Middleton — On the Pathology of 

he believes he has met with in a case of this nature. 
Among these are dilatation and irregularity of the central 
canal in the cervical and dorsal regions, with obliteration of it 
in the lumbar region, also an accumulation of nuclei round it 
in its whole length. Then there are enlarged vascular canals 
on either side of the central canal ; also a distinct atrophy of 
the anterior and median groups of ganglion cells, besides a 
condition similar to Clarke and Gowers' disintegration. In 
my experience the size of the central canal is exceedingly 
variable ; it is usually surrounded by nuclei, and on either 
side there is generally a large vessel which, in the process of 
hardening, frequently has shrunk away from the surrounding 
tissue. These conditions I therefore look on as normal, and 
the illustrations accompanying his paper show the ganglion 
cells to be perfectly normal in number and size. With this 
conclusion I am o-lad to find that Schultze * agrees, as he does 
also with the view that Drummond's and Bramwell's plates 
represent essentially normal tissue. 

Finally, in Pekelharing's paper there is found a synopsis of a 
case described by Goetz,-f- who observed congestion of the vessels 
of the cord, and throughout its whole length a gelatinous prolif- 
eration of the connective tissue, with atrophy of the nerve- 
fibres of the white substance, and a peculiarly sharp separation 
of the various cell groups, but no atrophy of any of them. 
Pekelharing believes, however, that Goetz's illustrations of his 
case support his own views by showing atrophy of the anterior 
and internal groups in the lumbar region. I have been unable 
to get the original report of this case, but the extract leads me 
to the opinion that it is a case the structures of which had 
been altered by hardening in alcohol. 

My own observations and an examination of the cases hitherto 
recorded, lead me therefore to the conclusion that no alteration 
of pathological significance has been met with in the nervous 
system. The lesions said to have been observed are either 
accidental conditions, or not characteristic of this affection. 
There is even less indication of disease in the nerves and 
cord than one would expect to be the secondary result of 
the pronounced muscular degeneration. The conclusion to 
which we are driven is that the disease is primarily one of the 
muscular tissue. That it is of a congenital nature is indicated 
by the disease being one of early life, and by its more or less 
hereditary character; but I cannot discover any basis for 
speculation as to the immediate seat of this inherent vice. 

* Virch. Arch. 1882. Vol. xc, p. 208. 

f Aerztliches Intelligenzblatt. Miinchen. 1879. P. 419. 



Pseudo-Hypertrophic Muscular Paralysis. 99 

The malformations met with in two instances in the cord are 
interesting as indicating a tendency to congenital malforma- 
tion. The cause of death in almost all instances, so far as I 
have seen, has been some affection of the lungs, generally of a 
phthisical nature. This may be accounted for to some extent 
by impaired respiration due to diminished muscular power. 

Xotf. — Since the above was in type my attention has been 
drawn to an extract from a monograph on " Muscular Pseudo- 
hypertrophy," by Dr. Gradenigo, * of Padua, who views the 
disease as one of a myopathic nature, and objects to the term 
paralysis being applied to it. The description given of the 
changes found by him in the muscles corresponds generally 
with that of the appearances in my own cases ; but he seems 
to have found dichotomous division of the muscular fibres 
much more commonly than I have, and regards it as perhaps 
characteristic of this affection. In the extract there is no 
mention of the condition of the nervous system, but it is stated 
that the pathogenesis of the disease, at first myopathic, is later 
on neuro-myopathic. It is evident, therefore, that he agrees 
with the view that the case in favour of an affection of the 
nervous system has not been made out. 



APPENDIX OF CASES. 
Reports by Dr. PiObertson. 

Case I. — "James S., age 16, admitted into Town's Hospital 
8th April, 1882. Father of drunken habits ; died from 
'lipase of kidney. Mother living; said to be of sober 
habits. Has a younger brother ill like himself, and another 
brother and two sisters, who are well. 

" Patient is fairly intelligent ; has cleft palate (posterior) ; 
no evidence of constitutional syphilis. Present illness began 
several years ago — cannot tell how many. He first felt his 
back sore when he rose from bed ; afterwards, in running, the 
right leg would suddenly give way ; at the same time calves 
of both legs got big ^ people looking at his 1 >ig legs wondered 
that he should be so weak in walking. About 3i years ago 
arms began to get weak, this being years after the legs. 

"Present Condition. — Special senses and mind correct. Lower 
extremities: both feet in associated position of talipes equinus 

Contribuzione alia Patogenesi delta Pseudo-ipertrqfia muscolare. 
Milano: Fratelli Rechiedei. 1883. London Med. Record, 16th June, 
1884. 



100 Dr. Middletox — On the Pathology of 

and varus; hamstrings contracted; legs moderately wasted; 
thigh muscles greatly so ; intrinsic muscles of feet a little 
wasted. He can flex both legs on thighs beyond their con- 
traction, but contractile power of the left thigh muscles weaker 
than that of the right ones. AVhen legs are fully flexed, the 
extensor power of muscles in front of thigh is noticed to be 
very weak ; he can flex and extend thighs on pelvis better ; 
can flex and extend toes — all these movements are feebler than 
normal. Anterior abdominal muscles also weak, but propor- 
tionately less so than the thighs. He can expand the chest 
fairly well, and the intercostals are observed to act. Chest is 
ricketty — chicken - breasted — attributed to fall when an 
infant. When lying on back he cannot rise to erect posture, 
but he can turn from the back to the sides, or from the sides 
to the back ; can flex and extend the head and upper part of 
the back pretty well. There is no appreciable change in the 
appearance of the back — neither fuller nor more wasted than 
normal. 

" Upper Extremities. — The forearms are small, but do not 
give the impression of much wasting ; a little wasting in the 
metacarpal spaces, and on the webs between the thumb and 
forefinger (state of thenar eminences not noted) ; upper arms 
(biceps, &c, and triceps) distinctly wasted; neither deltoid 
much wasted in appearance, but the left is smaller than the 
right ; both anterior and posterior axillary folds are greatly 
wasted. He can flex and extend both wrists and all the 
fingers of both hands ; can flex and extend left forearm but 
feebly ; camiot flex right forearm on arm ; while attempting 
flexion of latter, the forearm involuntarily pronates; can extend 
this arm ; can withdraw right arm from side, but cannot bring 
the right elbow close in to the side again. He can raise the 
shoulders by levator angulse scapulas ; and none of the actions 
of the scapula are lost, though they are rather weak. He 
registers 4 lbs. on dynamometer with right hand, and 7 lbs. 
with left (I register 56 lbs.). He can voluntarily pronate and 
supinate the forearm, but the supination, particularly of the 
right arm, is not very complete. 

" Face and tongue muscles seem normal ; swallows fairly 
well, notwithstanding palatal deficiency. Sensation normal 
in all forms. Reflex responses scarcely appreciable in legs ; 
better in belly ; cremasteric feeble but distinct. Response in 
legs to interrupted current weak ; effect of continuous current 
could not be clearly ascertained, pain so great in skin, even 
with 15 cells of Leclanche's battery. Feels heat by hot sponge 
quite well. 



Pseudo-Hypertrophic Muscular Paralysis. 101 

" Bowels and Bladder correct. Puberty distinctly reached 
since trouble began. 

" 5th January, 1883. — Legs much more wasted ; contraction 
much greater — legs upon thighs, and thighs on abdomen ; can 
move the feet only very feebly — cannot flex or extend them 
more than half an inch ; so with the legs on thighs, but if the 
thighs are withdrawn from the pelvis somewhat forcibly, he 
can bring them back on abdomen readily ; no apparent change 
in the state of arms, or hands, nor of back nor head ; can move 
head in all directions — he cannot raise his body when seated 
in the erect posture, should he bend forwards. He can swallow 
well, and there is no wasting of tongue. Intercostals act 
fairly well. Sensation nowhere impaired. General health 
weaker. Bronchitis and some phthisical indications." 

The post-mortem examination was made by Dr. Newman on 
11th January, 1883. The report is incorporated in the paper. 

Case II. — "Walter W., aged 13i, admitted into Town's 
Hospital 21st March, 1882. Patient's mother is living ; father 
is dead. Mother all her life has been subject to fits apparently 
hysterical. Two of her children died from inflammation of 
brain during teething ; another son is bow-legged, he being 
the only other child alive besides Walter. The latter, our 
patient, was never stout, and did not walk till he was three 
years old ; afterwards he was able to run about till he was 
ten. He then first complained of sore feet in walking, and 
was subject to sweating of the head. Soon afterwards he 
found it difficult to rise from the floor. At that time his 
mother had not thought his legs to be either thinner or 
stouter than they should be. He was able to walk fairly 
well till two years ago. His general health at that time, and 
previously, was not very good, appetite being indifferent. His 
arms began to get weak about a year after the legs, and for 
nearly two years he has been unable to take his food himself. 
Sometimes he had a difficulty in passing water, but he never 
wet the bed. Sense of feeling in no part of his body has 
been impaired. He. has had no pain anywhere except in his 
feet after walking, but he often complained of headache. 

" The following note was taken of his condition on the 8th 
April, 18 days after admission, there being little change, 
except increasing general weakness in the interval : — Upper 
extremities — He can flex and extend both wrists, though 
feebly, and can abduct and adduct fingers and thumbs, as well 
as flex and extend them ; cannot flex left forearm, but can 
extend it feebly by stages. He cannot pronate the left arm 



102 Dr. Middleton — On the Pathology of 

fully, but can supinate it better. The right arm is in much 
the same condition as the left, but rather worse. Thouo-h the 
forearms are small, the} r have not a wasted appearance, nor is 
there distinct wasting of the hands, except a little of the 
thenar eminences. He can very slightly ilex or extend the 
forearms upon the arms, and he has even less power of move- 
ment at the shoulder joints ; but he has a little power in 
raising the shoulders, especialty the right one, and in drawing 
them back to the spine. When the arms are put out from the 
side, he can bring them in again slowly, and by stages. The 
scapulas do not stand out prominently. There is great wasting 
of the deltoid muscles, and of the anterior and posterior 
axillary folds. Though he has a little power in the hands, 
they are so feeble that he is quite unable even to move in the 
least the index on the dial of the dynamometer. In contrast, 
a healthy boy, age 10, turns the index to 25 lbs. The full 
current (Faradic) of a Weiss' battery has no effect on the 
flexors, but a little on the extensors, particularly of the left 
forearm. 

" Lower extremities. — He can flex and extend toes, but has 
scarcely any power of movement at the ankles. He has a 
little, but not much, power of flexion and extension at the 
knee and hip joints. He cannot stand, nor put his feet on 
the floor, nor can he sit without support ; upon the whole, the 
left leg is worse than the right. The left calf measures 8f 
inches in circumference, the right 8J ; in a healthy boy, age 
11, they measure each about 9| inches. The bellies of the calf 
muscles stand out as small, soft, bulbar-like masses. The left 
leg is slightly contracted at the knee, and the foot is in the 
position of talipes equinus. The thighs, though small, have 
not a wasted appearance. 

" When the head is bent down on the chest, he can manage 
to raise it by an effort, but if it fall back he cannot bring it 
up should he at the time be leaning back, though if sitting 
quite erect he can manage to raise it with difficulty. There is 
no incurvation of the back, and the abdominal muscles have 
considerable power, and are fairly resistant to the finger when 
he is sitting up. He requires to be lifted into and out of bed. 
He seems to have full power in opening and shutting the 
mouth, and also of moving the tongue and eyes in all direc- 
tions. The intercostal muscles are weak, though some action 
is observable. 

" Reflexes. — The plantar reflex in both feet is distinct ; right 
cremasteric is obtained ; abdominal and epigastric are observ- 
able ; no deep reflex. 



Pseudo-Hype rtrophic Muscular Paralysis. 103 

" Sensation, <tc. — No impairment of general sensibility ; dis- 
tinguishes impressions of heat and cold perfectly. Special 
senses are correct, and is fairly intelligent. 

" Heart normal, but feeble in action ; urine correct ; some 
bronchitis, and probably diffused tubercle. 

" The day after the foregoing note was taken patient was 
shown to the Pathological Society of Glasgow. His general 
enfeeblement afterwards rapidly progressed, and he died on 
the 18th of the same month, the lung symptoms being the 
most prominent before death. 

"P. M. — 4& hours after death. — The spinal cord to the naked 
eye seemed healthy. The gastrocnemii, gluteal and deltoid 
muscles more particularly appeared to have been converted 
ip^o fat, even the striated character being scarcely traceable 
at many parts. The other muscles of the extremities and trunk 
were similarly changed, though generally in a less degree, 
especially the trunk muscles. Heart weighed 3 oz. ; wall of 
left ventricle and other muscular structures appeared to be 
quite healthy ; kidneys, liver, and spleen normal in aspect ; 
some pleuritic adhesions. 

" Specimens of the spinal cord, nerves, and muscles were 
removed for microscopical examination." 

The post-mortem examination was made by Dr. J. L. Steven, 
but he has no record of it. The above notes were made by 
Dr. Robertson. 

The two following cases were first seen in the Royal Infirmary, 
where they were under Dr. Perry's care, and afterwards at 
Motherwell, in May, 1884, by the kindness of Dr. P. C. Smith. 
Their mother, a fairly intelligent woman for her position (wife 
of a coal miner), gave the family history as follows : — 

Children of the family — 

1. James, died of scarlet fever : a healthy boy. 

2. John, set. 13, health y : at work in pit. 

3. Thomas, set. 11 : affected. 

4. Francis, set. 9: affected. 

5. William, died of infantile diarrhoea. 

6. Michael, set. or healthy. 

7. A girl, 8et.4, Uoth henlthv 

8. A girl, set. 14 months, j botJl nealtn 3- 

Mothers family. — Consisted of six sisters and five brothers. 
The sisters are all married, and all have large families, none 
affected with any paralytic lesion save the two cases under 
notice. Two of the brothers died young (4?, and 7) of bron- 
chitis ; another died in early infancy; none of these presents! 



104 Dr. Middleton — On the Pathology of 

any indication of this disease. Two brothers married (one 
.since killed) and had families ; all welL 

Father's family. — Nine brothers; and two sisters who died 
of fever. The only history of anything like nervous disease 
in any of the brothers or their families is that of a girl, set. 26, 
who had epileptic fits after an injury to the head, and is now 
in an asylum. 

Case III. — Thomas M., set. 11 years. In this boy's present 
condition it would be impossible to diagnose the case as one 
of pseudo-hypertrophic muscular paralysis, for there is no 
hypertrophy, and he is so helpless that none of the phenomena 
characteristic of the disease can be elicited. He is sometimes 
lifted out of bed into a chair, but he is utterly unable to 
assist himself. Even when supported on both sides he is 
i [uite unable to stand erect or to place his feet to the ground ; 
in that position his legs are flexed on the thighs, and the 
thighs on the abdomen. There is very little evidence of 
talipes equinus. He can sit on a chair, doing so with his legs 
bent under him, and kept somewhat though not very 
widely apart. Neither when seated nor when standing is 
there any lordosis ; on the contrary, there is well marked 
curvature of the spine with the convexity backwards. 

The bo}' is emaciated, but the emaciation is general, and 
does not strike one as specially affecting the upper limbs, as 
in his brother's case. The pectoral muscles are much less 
atrophied than in Francis, as are also the muscles of the neck, 
scapulas, &c. The muscles of the spine and the intercostals 
partake of the general emaciation. There is no apparent 
hypertrophy of the calves or of the thighs. The thenar and 
hypo-thenar eminences are emaciated, but not like the con- 
dition in progressive muscular atrophy. There is no claw- 
like deformity of the hands. Measurement of limbs : — 

Right. Left. 

9^ inches. 

HI » 
6| „ 
6| „ . 

No fibrillation of the muscles ; no mottling of the skin ; no 
gross impairment of sensation. The knee-jerk is absolutely 
lost ; plantar reflex very weak ; cremasteric reflex not exam- 
ined. There is no ankle clonus. The mental condition is 
quite normal. 

When about 13 months old, and just trying to walk, he had 
in succession hooping-cough, bronchitis, and diphtheria, which 



Calf, .... 


9^ inches. 


Thigh, .... 


Hf „ 


Forearm, 


H » 


Upper arm round deltoid, 


H » 



Pseudo- Hypertrophic Muscular Paralysis. 105 

kept him in bed for about 14 months. It was only when 1\ 
years old, therefore, that he really began to walk, which he 
did quite suddenly. When about 3 years old he had measles. 
He never had any convulsive attack. The weakness in his 
limbs was first noticed when he was between 4 and 5 years 
of age; his gait was observed to be rocking, and he had a 
tendency to fall all of a heap. His mother cannot say that 
she ever observed any increased muscular development in his 
limbs, which is still so marked in his brother ; but she says he 
had the same difficulty in rising from the ground, in going up 
stairs, or in climbing on a chair. This, and Dr. Robertson's 
second case, seem to indicate that in some of these cases there 
is no stage of apparent hypertrophy. The almost total help- 
U\ssness has come on only since March; he was then able to 
walk a little ; he can now scarcely turn himself in bed without 
assistance. 

Case IV. — Francis M., set. 9. Up to between four and five 
years of age he was a healthy boy. He had measles when he 
was about 14 months old ; he never had convulsions ; and has 
had no other illness. He was somewhat slow in learning to 
speak ; but he never evinced any mental inaptitude. The first 
symptom noted was " rocking " gait, which was attributed 
to his stoutness. The waddling was so marked that his 
mother was advised by some of her neighbours to chastise the 
boy to cure him of what was looked upon as a bad habit. 
It was only after this had lasted for a considerable time that 
the weakness of the limbs was observed. 

He is now typically the subject of pseudo - hypertrophic 
paralysis, exhibiting the characteristic phenomena in walking, 
rising from the ground, and in ascending a stair. He can 
climb on a chair only with assistance. He is still able to 
attend school. The muscles of the upper limbs are much 
atrophied ; the deltoid and triceps are excessively small, and 
there is almost no pectoral fold; the trapezius and other 
muscles about the clavicles and scapulae are much emaciated. 
The muscles of the forearms are not so markedly wasted. 
The thenar and hypothenar eminences are small. The spinal 
muscles are firm -and full. There is well marked lordosis. 
When lying on one side he can abduct and adduct the leg 
with difficulty, moving it only a little way. The thighs and 
calves are relatively very large, and are quite firm to the 
touch. He stands with his feet several inches apart, and 
prefers having something to lean upon. There is no tendency 
to talipes equinus : indeed, he is flat-footed. There is no 
griffe des orteils. 



106 Mr. Nairne — Abdominal Section as Pert of the Surgical 
Measurement of the limbs : — 





Right. 


Left. 


Calf, .... 

Thigh, .... 

Forearm, 

Upper arm round deltoid, 


10| inches. 
12 „ 

H „ 

6 „ 


10 inches. 

114 » 

6$ „ 
6i „ 



No fibrillation : no mottling of skin : no loss of sensation : 
temperature not tested, but legs are said to become cold very 
easily. Knee-jerk absolutely lost: plantar reflex weak: 
cremasteric not made out as the testes are not fully descended. 
No ankle clonus. Mental condition quite good. 

Since the above note was made this boy has unfortunately 
met with a fracture of the middle of the shaft of the left 
femur. It was induced by a very trivial cause, falling down 
two steps of a stair. It is not known exactly how he fell ; but, 
if the account of the accident be correct, it would almost seem 
as if there had been some degeneration of the bony tissue. 
This idea is, however, negatived by the fact that union has 
taken place readily, and I am now (16th July) informed by 
Dr. Clark that the fracture is healed, but the boy has not yet 
recovered the power of walking. 



ABDOMINAL SECTION AS PART OF THE SURGICAL 
TREATMENT OF SOME DISEASES OF THE AB- 
DOMINAL ORGANS. 

By J. STUART NAIRNE, F.F.P.S.G. 
(A Paper read before the Glasgow Southern Medical Society.) 

IV. — The Operation. 

Preliminary Preparation, — To get satisfactorily through 
an operation, the operator ought himself to look after every 
detail beforehand. Should he leave this to be done even 
by an experienced nurse or assistant, he will frequently find 
himself short shipped in some emergency, for which he will 



Treatment of some Diseases of the Abdominal Organs. 107 

hardly be able to forgive himself. He may find that his 
pressure forceps will not work, that the silk ligatures have 
been cut too short, that there is not a sufficient supply of 
them, that the needles are blunt, that the whip cord is twisted, 
that some of the screws of the clamp have slackened, that 
there is not a screw driver or a pinching screw. One is 
amazed at the multitude of little things that require 
attention — little, but not unimportant, without which the 
operation is sure to drag, and the operator perhaps to get 
confused. I have seen one of the most distinguished 
surgeons of the day sweat over the brow at finding that 
the suture needles had been put so carelessly up that the 
threads were ravelled, and that time was lost in putting them 
right. 

]No one can successfully tackle an ovarian case, or open 
the abdomen for any purpose, who has not at command 
a good armamentarium. Instruments do not make an opera- 
tor; but he is the best operator who can use his tools 
best. 

For every operation, even for an exploratory incision, I 
invariably write out a list of instruments which are to be 
made ready and taken to the operation ; and I always choose 
as many instruments as I think will tide me over every 
difficulty, because one never knows what may turn up. I 
have known an operation for ovariotomy undertaken when 
the operator carried only his ordinary pocket case and a 
borrowed Spencer Wells trocar. I would be the very last 
to stand in the way of any one beginning a surgical career ; 
but I am sure, looking back only over the last dozen 
years, and seeing how much there has been in it of sorrow, 
that no one ought rashly to launch himself on such a course 
without having counted the cost in more ways than one. 
Dexterity and success in operations are bought at a great 
price ; and I refer not so much to the price of instruments 
as to patients' lives. Life is a holy thing, and the longer you 
live, and the more you take people's lives into your hands, the 
more careful you will become of your charge, and the more 
earnestly will you seek every means to save or prolong the 
life of your patient. 

In the matter of this preparation and arrangement of 
instruments I have copied from everybody that I thought 
was worth copying from, to whom I here tender my sincere 
thanks ; and I have quite as freely discarded the things I 
thought unnecessary or cumbersome. 



108 Me. Naibne — Abdominal Section as Part of the Surgical 

List of Instruments. 

Thirteen sponges in tin can. 

Fifteen pairs small pressure forceps. 

Three pairs large pressure forceps. 

Wire clamp, with screw driver and pinching screw. 

Two pairs bull clog pattern artery forceps. 

One scalpel. 

Whip cord. 

Ecraseur with thick cord. 

Chinese twist silk. 

Catgut. 

Horsehair. 

Twelve silk sutures — needle on each end. 

Two handled needles, with thick silk. 

Hand mirror. 

One pair broad pointed forceps. 

Catheter. 

One aspirator. 

One small trocar. 

One large ovariotomy trocar. 

One small tin can for needles. 

One pair cyst forceps. 

Wire cutting forceps. 

Glass drainage tube and exhauster. 

India rubber drainage tube. 

Ether or chloroform. 

Brandy. 

Morphia and subcutaneous syringe. 

Operating apron. 

To have all these things put in proper order will take, as a rule, 
an hour or two — sometimes longer; but this time is well spent. 

The Boom. — In regard to the room to operate in, if it is in a 
private house, as mine have mostly been, whether it has a 
north or a south, or any other light, you frequently cannot 
help ; but the table must be placed so that the patient's feet 
may be towards the window, and the light then falls forward 
on the abdomen. I put a small table in at the window, and at 
right angles to it a longer one whose side is in a straight line 
with the end of the small one. The operator stands in the 
rectangular space between the two tables and the assistant 
opposite. On the small table are placed the tin can with the 
sponges, and several flat basins containing the instruments, 
covered with lotion. If the spray be used, it is placed on its 
own stand at the assistant's left : and so everything is quite 
within reach. 



Treatment of some Diseases of the Abdominal Organs. 10!) 

The patient's night dress should always be split up in front 
before she comes to the operating table. Whenever she is 
sufficiently anaesthetised, a piece of water-proof sheeting is 
slipped below her, and soft warm towels stuffed on each side, 
so that there is no soiling of her night dress. A warm towel 
is then put over her thighs, and a broad band fastened round 
them below the table. The arms are fastened in a similar 
way. I have discarded the water-proof sheeting with the hole 
in it for operating through. I found it dirty and disagreeable. 
It is usually best that the patient should not empty the 
bladder before the operation. 

Position of Incision, — This must be determined by the 
nature of the case. Should circumstances demand it, it may 
be made anywhere in the abdominal walls. In a large 
hydatid tumour treated by abdominal section and drainage 
which I attended with Dr. M'Leod, of Kilmarnock, the 
incision was made on the left side ; and in a lady on whom I 
operated for gall stones, the incision was on the right side. 
The middle line is, however, generally the best as avoiding 
any large vessels, although some of the largest superficial 
abdominal veins I have ever seen lay in one case at right 
angles to the middle line, and were of necessity divided. 

In cutting, it is absolutely incumbent not to haggle, but to 
cut cleanly and sharply. The first incision ought to go, as a 
rule, through skin and subcutaneous cellular tissue. If there 
is much thickness of cellular tissue, and if it be cut with 
several strokes of the knife, it is very apt to be cut unevenly, 
and you may look for suppuration. Haemorrhage is often 
very free when the adipose tissue is thick, and this makes it 
all the more necessary to cut cleanly and sharply through it. 
so as to secure the vessels Math as little disturbance of the 
parts as possible. 

The length of the first incision should generally be about 
two inches, sufficient to let in two fingers. The sheath of 
the rectus is then taken up with a pair of broad pointed 
forceps, and you will sometimes accurately hit the middle line. 
If not, you must just go deeper. If you are in the middle 
line, the tissues divide so evenly and neatly that j'ou get to 
the peritoneum in a moment. If you are to the side and 
amongst muscular tissue, you must cut with great steadiness 
down, as the fibres have a tendency to interlace and lead you 
to the side rather than down. The peritoneum is then 
pinched up, and may be opened by the point of the knife. 
or a pair of blunt-pointed scissors. In cases where the 
abdominal walls are flaccid, and the bowels lie closely 



110 Mr. Natrne — Abdominal Section as Part of the Surgical 



subjacent, there is always a risk of wounding them, and such 
a thing has happened in the most experienced hands. 




H 



The total length of incision is a matter of expediency ; one 
sufficiently long to admit two fingers will frequently do for 
exploration, and let you know what is the 
condition of parts ; but often you have to 
make it much longer. In distended ab- 
domens you may make a formidably long- 
incision between the umbilicus and the 
pubes, while in an undistended one a two 
inch incision may take up almost the 
whole available space between these two 
points. If the incision requires to be 
prolonged, it is better to prolong it to the 
left, and so avoid the ligament of the 
liver ; at any rate, you can prolong it 
much higher on the left than on the right 
side without interfering with the reflexion 
of the peritoneum from the diaphragm. 

To prolong the incision you may use 
either the knife or blunt-pointed scissors. 
The quick, sharp bruise of scissors has 
a capital tendency to close the vessels and 
prevent hemorrhage. 

The scissors may thus advantageously 
be employed instead of the knife in 
separating adhesions. Some say the knife 
should never be used in the abdomen. 
This is nonsense. You must use every- 
thing and anything that is the best. For 
separating adhesions, the fingers are the 
best if they will do ; but they will not 
always do, and then you must use either 
the scissors or the knife. 

If the tumour should present at the 
opening, it should never be omitted to 
puncture it, or attempt to puncture it, 
with an aspirator or a small trocar to 



Treatment of some Diseases of the Abdominal Organs. Ill 



determine clearly what kind of tumour it is. From neglect 
of this very simple precaution, I have known a uterus re- 
moved in toto for tumour when it was only distended with 
hydatid fluid. 




112 Mr. Xairne — Abdominal Section as Part of the Surgical 



If it is a tumour filled with fluid, it may be emptied by an 
ovarian trocar, and pulled out gently either by the clutches on 
the side of the trocar, or by a pair of cyst forceps. 

Mr. Tait's trocar is not so generally known as Sir Spencer 
Wells', but it has some special advantages, and also some 
disadvantages. It is smaller and narrower and better for very 

fluid cysts. That of Sir Spencer 
Wells is less liable to get out of 
order. It makes a larger cut into 
the cyst, but this is really a matter 
of small moment when the cyst 
has to be removed. 

For simply puncturing, or for 

withdrawing fluid from a small 

cyst, a much smaller trocar than 

any of these is more serviceable, 

and one after the following shape 

2 (see accompanying figure), but 

f longer in the canula and smaller in 

Z its parts, which I have had made 

| for me, suits me admirably. 

& As soon as possible, a soft clean 

n sponge is put into the abdomen 

r r and left there till the tumour is 

~ cut away, and the pedicle tied or 

o whatever is to be done to it, done. 

"2 Then the sponge is taken out and 

| put in again if necessary, till it 

£ comes out clear from blood. 

This toilet of the peritoneum, as 
it is called, cannot be too gently 
performed, and yet it is of no use 
unless it is done effectively. To 
pour gallons or kettles of water 
over it, with the purpose of wash- 
ing it, as some say, is the height of 
folly, except under special circum- 
stances. If a cyst should burst 
in its extraction and discharge 
its contents into the abdomen, 
it may very reasonably be washed out clean in this way. 
I have had to do this twice in the case of burst cyst, 
with a recover}' in the one and a fatal result in the other 
case. But the less of this sort of soaking the better. Sponges 
are not a bit better for the peritoneum if they are plunged 




Treatment of some Diseases of the Abdominal Organs. 113 

into the abdomen soaking with water or carbolic acid lotion, 
but rather worse. Sponges should be used moist — squeezed 
nearly dry out of warm water and then gently and firmly 
pressed, not rubbed, over the parts. After a sponge has been 
applied two or three times and squeezed by the operator, 
it is soiled pretty well through, and it should be given to a 
nurse or assistant to squeeze hard and clean out of hot water 
while a new one is taken. Some rub away with a sponge as 
if they were painting, and plunge it again and again into the 
abdomen, dipping out of lotion and deluging the whole 
abdominal cavity, giving themselves an infinite amount of 
trouble to soak it all up again. The less the abdominal cavity 
is deluged with water or other fluid, and the cleaner and 
dryer you can leave it, the better it will be for the progress of 
the case. 

Sutures. — The tumour being removed now and the bleeding- 
checked, and the last clean sponge being still in the abdomen, 
the sutures are passed through the abdominal walls. I always 
use silk. Each piece of silk has a needle on each end, and the 
sutures are passed from within outwards. They are put 
through without being tied as you go on. Then the assistant 
on the opposite side gathers the ends on his side in his hand, 
and you gather yours. By holding them forward you can see 
that nothing is caught beneath. The sutures are then pushed 
aside by two fingers of the right hand and the sponge 
removed. The sutures are then tied, and usually as firmly as 
possible. The whole substance of the abdominal wall ought 
to be included as a rule, although there is great authority 
against this. Sir Spencer Wells says it ultimately comes to 
union only of peritoneum and skin. This question has been 
discussed at large over and over again; what we have to do 
with in the meantime is fact, and it is a fact that if you 
get union by first intention ail along the line, the tissues 
opposite each and all unite, peritoneum with peritoneum, muscle 
with muscle, cellular tissue with cellular tissue, and skin with 
skin, and this is what has always to be aimed at. The union 
of peritoneum usually takes place with great rapidit}', so that 
in the course of-twenty-four hours there may be not the 
slightest indication of an incision. 

If drainage is required, the drainage tube is placed fairly in 
the pelvis, behind the uterus or stump if there has been a 
clamp required. The dressings are then put on and a warm 
flannel bandage pinned over all.* 

* It is now usually judicious to empty the bladder by means of tin- 
catheter, and your mind is ;it rest for four or six horns. 
No. 2. I Vol. XXII. 



114 Mr. Xairxe — Abdominal Section as Part of tJie Surgical 

Directions to the Nurse. — The nurse must have the bed in 
readiness, a good firm bed in which the patient will not sink 
down, and a plentiful supply of hot water bottles properly 
closed and sufficiently protected with flannel, so that the 
patient may not be scorched. In one case I had, the brass 
head of the hot water bottle was so hot and unprotected as to 
make a deep wound in the leg, which was far longer of 
healing than the abdominal incision. The nurse must also 
have ready a basin and a supply of towels, for you never can 
tell whether a patient will be sick or not. A water bed is not 
usually required. 



A 



Mr. Lawson Tait's Wire Clamps and Screw Key. 

The figure in the middle represents a soft nickled loop of 
wire, which is made to encircle the base of a tumour. The 
first collar is then pushed on as far as possible through holes 
in each side. 

The figure to the left represents a screw with another 
collar through which the screw passes. This second collar is 



Treatment of some Diseases of the Abdominal Organs. 115 

passed on the legs of the loop close up to the first collar, and 
pinching screws on each side fasten this collar securely on 
the wires. 

When the handle of the screw is turned, the second collar 
remains fixed, and the first must travel up, till sufficient 
constriction is obtained. When the operation is finished, the 
first collar is pinched down on the wires, and the screw and 
second collar are removed. 

The figure to the right is a screw for turning the pinching 
screws. 

V. — HEMORRHAGE. 

I have been present at operations where one might truly 
•ay that it was only by the grace of God the patient did 
not die on the table from haemorrhage, as there were neither 
right nor ready means at hand for controlling it ; where there 
was nothing better for tying the stump of a pedicle than a 
piece of whip cord tightened by the hands ; and any one who 
has seen this method of securing a thick stump will not be 
very ready to try it. By no amount of manual pulling could 
you safely compress a vascular stump, say from an inch 
upwards in diameter. The vessels in the centre would be 
sure to bleed sooner or later, and I have seen one fatal case 
from this cause. In this case the operator had neither clamp 
nor compressing forceps, nor wire ligature to be screwed up ; 
nor even the loop of an ecraseur to control the haemorrhage. 
In one public institution I saw a death on the table. The 
uterus was amputated at the cervix, while the stump was 
grasped by the hand in order to tie a ligature on it. Before 
this could be done, the patient was dead. It is right to state 
that this death was attributed to shock, and not to the loss of 
blood. If this was a death from shock, it is the only sudden 
death I have ever seen from that cause ; I do not believe that 
death can ever possibly occur from that cause — viz., shock — 
unless some of the vital nerve centres be directly implicated, 
ahvays taking for granted, however, that the 'patient is properly 
under the influence of an anaesthetic. Under these circum- 
stances, and also when no anaesthetic is used, death may occur 
from the most trivial shock. You will remember a recent case 
when a highly respected surgeon of this city, examining a 
patient with inguinal hernia, found it suddenly slip from his 
fingers, and on announcing this pleasant fact abruptly to the 
patient, she immediately died. This was a death from pure 
nervous shock, and could not possibly have occurred under an 
anaesthetic. I do not believe a death ever occurred under 



116 Mr. Nalrne — Abdominal Section as Part of the Surgical 

an anaesthetic, unless from the anaesthetic itself, or from some 
kind of blunder in the operation. Some years ago I assisted 
an operator, a quiet, bold man, now laid in his grave, in the 
extirpation of some deep seated glands of the neck on the left 
side. The pneumogastric of that side was cut ; its inhibitory 
action ceased, and the pulse and respiration rushed at un- 
countable speed, bringing death in less than ten minutes. Be 
mortwis nil nisi bonum. It was a blunder, we all said so, 
four of us then, and the two eminent of us since then laid in 
their graves ; and this statement, a truthful little cross 
elevated over the one's tomb in no spirit of animosity, but 
as a valuable warning to us who remain. This is the kind of 
sudden death then that occurs under operation — error of 
judgment in doing, a slip, incapacity to control haemorrhage 
or surmount difficulties, or extinction of life by the anesthetic. 

In a case narrated in a recent number of the British 
Medical Jbwrna?, Knowsley Thornton, who assisted the operator, 
passed his hand into the pelvis and held the stump of the 
uterus, which had been removed till Koeberle's serre-noeud was 
applied. The case recovered ; but such a course is not to be 
imitated. An experienced operator may do almost anything ; 
but no one has the right to place the life of a patient in 
jeopardy either through temerity or carelessness, far less from 
a desire to show off his dexterity. Every drop of blood that 
you save«is a gain to your patient. 

I am sure many of you must remember as well as I do 
when an operation in our Royal Infirmary resembled, to a 
large extent, an exhibition of so many artificial fountains ; 
I and my fellow-students have frequently been bespattered 
with blood as we sat in the benches. I remember an opera- 
tion for ovariotomy in the Chapel, the" old operating theatre 
of the Glasgow Royal Infirmary. The general circumstances 
are as fresh and horrible in my mind as yesterday. The in- 
cision — the uselessly long incision — into the abdominal parietes 
was followed instantly by torrents of ovarian fluid and blood, 
the operator thrusting his hand into the interior of the cyst 
and breaking up smaller loculi, which discharged themselves 
in the same way. Everybody and everything around was 
soaked. Xons avons change tout cda. 

Pressure Forceps. — There need be no such display. De- 
liberation, quietness, the application of pressure forceps 
immediately you cut, or, when possible, before you cut, 
and your "operation will be conducted with the greatest 
cleanliness and the least risk to your patient. 

The ordinary artery forceps are absolutely worthless for the 



Treatment of some Diseases of the Abdominal Organs. 117 

immediate suppression of haemorrhage. You have frequently 
neither time nor room to throw a ligature over a bleeding 
vessel in the usual manner ; and, as I have seen, at a later 
stage of the operation the ligature and end of the artery may 
be cut off by accident. You can never make such a mistake 
with pressure forceps ; for if you have to cut a little beyond 
or above them, you are bound to know what you are doing ; 
you see the forceps attached, but you may not in your hurry 
notice the loop of silk or catgut. 

In an operation shortly since, which I had the pleasure of 
doing for Mr. Gilmour, eleven pairs of these forceps were 
attached at the same time to various bleeding vessels and 
surfaces ; and I may refer to that gentleman and to Dr. 
Pollok, who was also present, to say if there could have been 
more than two ounces of blood lost in an operation that lasted 
for an hour and ten minutes. 

The use of these forceps is not limited to abdominal surgery; 
they are far too seldom used in general surgical work. Your 
President kindly assisted me the other day at an operation in 
private for amputation above the knee-joint. With the 
limited use of an elastic tourniquet, and the rapid application 
of half-a-dozen pairs of forceps to the bleeding vessels, I think 
Dr. Park will bear me out in saying that there could not have 
been lost more than half-an-ounce of blood. In a long opera- 
tion, by the time you are ready to tie the vessels, you will 
frequently find the bleeding has ceased, and you will require 
fewer ligatures than you could have anticipated. It is a little 
difficult to slip a ligature on a vessel over the points of these 
pressure forceps, and you may require occasionally to put on 
an ordinary pair of forceps for this purpose, but very rarely 
indeed. 

These scissor or pressure forceps are of various sizes and 
makes, concerning which more particulars a little farther on. 
Those used by Sir Spencer Wells are admirable instruments ; 
Lawson Tait's form is sharper in the nose, and he claims for 
them that their point is not so readily entangled in a ligature ; 
the bulbous extremity which I have put on them, however, 
prevents any possibility of this happening. Pressure forceps, 
then, are a perfect sine qua non in any abdominal operation. 
It is important that there should be as little blood lost as 
possible, and it is also important that as little blood as possible 
should escape into the abdominal cavity. 



118 Dr. Robertson — On a Peculiar Case of 

ON A PECULIAR CASE OF CONGENITAL ANTI- 
FLEXION OF THE RIGHT KNEE-JOINT. 

By JOHN KEITH ROBERTSON, M.D., CM., Greenock. 

On the 13th February, 1881, Mrs. B. was duly and naturally 
delivered of a female child, good sized, healthy, and strong. 
This was her second child ; the first being a large and every- 
way healthy child also. There was just one peculiarity 
strikingly noticeable. This consisted in the appearance and 
position of the infant's right leg. It was bent upon the thigh, 
not in the natural position — backwards, but in the unnatural 
and ordinarily impossible position — forwards. The skin on 
the posterior aspect of the knee-joint was smooth and even, 
no marks indicating flexion of the joint posteriorly at any 
previous time being visible. On the contrary, the marks on 
the skin of flexion of the joint were all situated anteriorly. 
There the skin was thrown into lurks and folds, answering to 
their cause in the anterior bending of the tibia upon the 
femur. This caused an appearance as if the popliteal space 
were wanting, or filled in, on this limb : arising, of course, from 
the absence of the prominence of the hamstring tendons, 
which, in extension of the leg upon the thigh, lose their great 
prominence on the skin, while in this peculiar condition of 
parts they were still less observable. 

It is curious to what an extent this position of parts grates 
upon our sense of the appropriate and the beautiful, and 
begets in us that repugnancy which we always associate with 
deformity. Not merely that the case involved asymmetry ; for 
it is difficult to conceive that limbs capable of anti-flexion 
alone and merely straightening on the thigh in extension, 
could be beautiful or graceful, even supposing they were 
anatomically and physically sound and strong and perfectly 
useful, and even convenient. But the deformity rendered the 
limb useless for locomotion, or would doubtless do so when 
trial was possible. 

On trying to reduce the position of the limb to the normal 
state I found it rather difficult to do anything more than 
bring the tibia into a straight line with the thigh, in the 
ordinary state of extension. It sprang back to its old position 
by preference. 

Getting the father to hold the child, I forcibly bent the leg 
upon the thigh till it was flexed posteriorly. It came into 
the new position of retroflexion with a " snap," such as one 



Congenital Anti-Flexion of the Right K nee-Joint. 119 

often experiences in reduction of dislocated joints. It can 
scarcely be doubted that there was subluxation of the joint : 
and that besides the usual difficulty experienced in reduction 
of old standing subluxations, arising from the firmness 
acquired in the abnormal position by new formed co-aptations 
of bone surfaces, by the accompanying tightening of ligaments, 
strengthened also by the accommodation of tendons to their 
altered circumstances, we had probably also to displace the 
spine of the tibia from a posterior to an anterior normal 
position, which, while increasing the difficulty of reduction, 
would also tend to fix the limb in its newly acquired normal 
position, after reduction. It was temporarily fixed in its new 
position by a splint. A consultation with an elderly medical 
gentleman was held. His opinion was that no attempt should 
be made with the view of obtaining motion of the knee-joint ; 
but that ankylosis of the joint should be sought for by fixing 
it immovably. Fenced with this premonition in case of 
eventual failure to procure a useful limb, we could the more 
readily afford to try the alternative, in the way of aiming at 
a useful movable joint. This latter was agreed to. The limb 
was fitted with a hinge-jointed splint in front of the thigh 
and leg, the joint of the splint being adjusted to the knee- 
joint. This splint readily admitted of retroflexion of the leg 
upon the thigh, and also of extension, but not of the previous 
abnormal anti-flexion. 

The affected knee-joint is smaller than the opposite normal 
one ; and the muscles of the leg are also less developed. The 
breadth of the knee in front is markedly less, and being of a 
more rounded shape, contrasts with the square front of the 
other knee. After a few months the splint was cast aside : 
and when the child came to use its limbs, the gratifying result 
was that it did so perfectly, though not so early, nor in such a 
firm and free manner as would otherwise have been expected. 
There was an evident weakness about the limb which made 
her very cautious, notwithstanding which she often fell. 
Even yet it is apparently less able than its fellow, but it will 
doubtless strengthen with time and growth, and become for 
practical purposes as good as the other. 

So far as the joint itself is concerned it has behaved 
admirably. The normal movements of flexion and extrusion 
are now apparently perfect; and no relapse to its former 
abnormal state has ever occurred. And as time has proceeded, 
the motions have become better: for while at first the leg 
could not be flexed on the thigh to anything like the ordinary 
extent, the difference is only observable by a strict test of the 



120 Dr. Robertson — Congenital Anti-Flexion of Knee- Joint 

two limbs. To-day, 29th January. 1884, I so tested the two 
limbs, and found that the right leg could be flexed on the 
thigh, so far as to come to about an inch or so of touching the 
hip of the same side, while the left leg is easily flexed so as to 
bring the left heel to touch the left hip completely. 

One peculiarity in her cautious mode of progression when 
not walking on a plain level surface, is the circumstance that 
she invariably places the weaker limb in front. In climbing 
on chairs, tables, &c, which she is much inclined to do in 
response to the example and precept of her more robust and 
older sister, as well as in climbing up stairs, the right foot is 
tirst raised, planted, and secured, and the left then follows. 
In coming down stairs, or from any height, the right foot 
again is the pioneer. The weaker limb makes the tentative 
effort. I should have expected it otherwise. Some people, I 
think, are given to placing their best foot first, and cautiously 
dragging the weak limb after. The philosophy of either 
mode is good, doubtless, if both are equally the result of 
natural promptings. 

In September 1882, when she was 19 months old, a little 
hernial profusion was observed, also on the right side, and in 
the usual position of inguinal hernia : she was then with her 
mother in the country, and on coming home in October, we 
had a little ordinary spring truss fitted, which she still wears 
as a precaution, though no descent is now ever observed. 
This would point to a muscular deficiency of the right side 
generally, as well as of the right limb : but this is not at all 
obvious. I have been led to compare the right arm and left 
arm, but I cannot decidedly state that they are unequal as to 
muscularity. Her parents state that she was not willing to 
set her feet on the ground for a long time ; that she never 
crept or sat on the floor as other children ; and that she first 
stood to a chair : she commenced to walk in November, 1882, 
being about 21 months old. 

Congenital dislocations are sometimes the result of mal- 
formation of the joints, but in this case, though there is certainly 
a marked difference between the two knee-joints, there is 
nothing deserving the name of malformation. The differences 
are probably referable to the effects of compression interfering 
with the nutrition, and consequently with the development of 
the affected joint and limb, so as to make the limb and joint 
smaller in circumference, though not in length, than their 
neighbours : and lessening the muscular bulk and ability. The 
position of the limb also, though abnormal, was one of which 
one might well doubt that it had been long in duration in 



Mr. Miller — Operation for Displacements of the Uterus. 121 

utero, while the position itself was such that it was unlikely 
that the proper development of the joint and limb could have 
been permitted. The abnormal approximation of the anterior 
surfaces of the head of the tibia and the condyles of the 
femur would most likely check the development there, and 
might perhaps account for the smaller size of the patella. 
How the unfortunate position of these parts was primarily 
caused is not clear; nor is the time in which it took place 
much clearer. It is supposable that by some means the limb 
was prevented from assuming the flexed condition ordinary to 
the limbs of the foetus in utero : and that in the extended con- 
dition some hard or resisting part of the foetus itself impinged 
against the knee in front, whilst the strong muscular walls of 
the uterus, pressing against the posterior surface of the leg, 
gradually caused the position of parts at birth. In this case 
the position of the limb would not be seriously interfered 
with daring the earlier months of pregnancy: and only the 
increasing size of the foetus with the maturing growth of the 
womb would cause that serious compression of the limb which 
brought about the results. To this we are the more inclined 
to subscribe as the position of parts was not, as it afterwards 
proved, too fixed to admit of reduction ; or too much altered 
to refuse to retain the normal position after reduction. 

The little patient being healthy and strong, is very happy, 
and often gives vent to her exuberance of spirit by jumping 
anl dancing on the level floor: and it is gratifying to her 
parents and to all, to have such ocular demonstrations of a 
most useful and natural limb and knee-joint. 



TWO CASES OF THE ALEXANDER-ADAMS' OPERA- 
TION FOR DISPLACEMENTS OF THE UTERUS. 

Reported by ROBERT MILLER, M.B., 
Senior Resident Medical Officer, Town's Hospital, Glasgow. 

This operation for the cure of displacements of the womb 
being a novel one, and the cases operated upon in this Hospital 
having previously resisted the usual recognised methods of 
treatment, I have thought a brief report of their progress and 
results worthy of being placed on record. 



122 Mb. Miller — Two Cases of the Aleaxmder-Adams' 

The operation, as described by Dr. James A. Adams, of this 
city, in the Glasgow Medical Journal for June 1882, and by 
Dr. Alexander, of Liverpool, in the same year, consists in 
making a simple skin incision over the external inguinal ring, 
gathering up the ends of the round ligaments and drawing 
them sufficiently out to restore the womb to its normal 
position. Finally, the ends of the ligaments are stitched to 
the edges of the wounds. 

The first case is that of A. B., a domestic servant, aged 24 
years, who was admitted to the house a year ago, pregnant for 
the third time. There had been nothing abnormal about any 
of her labours. The head presented in each, and no instru- 
ments had been used. Her last confinement was, however, 
prolonged and severe. 

The girl, after her second child was born, had an attack of 
metritis, and was ill for four weeks. She then noticed that the 
womb had fallen a little. On leaving the Hospital she went 
out again to service, and she attributes her ultimate condition 
to the fact that the work was very severe, and she had often 
to lift and cany considerable weights. 

The distress occasioned by the displaced organ compelled 
her to throw up her situation, and shortly afterwards she 
again became pregnant. AVhen the last child was born the 
prolapse became so bad that a slight lift caused the os uteri 
to protrude between the vulva, while involuntary micturition 
often occurred during the act of couo-hino-. On account of the 
misery she was enduring she gladly consented to an operation. 

On the 20th March, under chloroform, Dr. Adams operated 
upon her and secured the round ligaments with chromicised 
catgut, while the external wounds were closed with wire 
sutures. Antiseptic precautions were taken, and the incisions 
were covered with protective and gauze dressings. There 
was almost no haemorrhage and no drainage tubes were used. 
The same evening the temperature was 99'2° ; pulse, 80 ; and 
patient complained of some pain, but was otherwise well. A 
half grain morphia suppository was given. 

21st March. — Morning temperature, 101'6°. Patient had 
thirst, but pain was much decreased. Light food and soda 
water given. Evening temperature, 101'6° ; some vomiting. 
Ice by mouth and suppository repeated. 

22nd. — Morning temperature, 101 "4°. Vomiting still trouble- 
some. Given ice, soda water, milk, and bismuth. Wounds 
dressed and looking remarkably well. No pus. Evening 
temperature, 1012° ; pulse, 92. Vomiting less and sleep 
obtained by suppository. 



Operation for Displacements of the Uterus. 123 

23rd, — Morning temperature, 101-4°. Wound on right side 
healthy, but the left has an angry look, and a suspicious 
blush extends for some distance above it. The left groin is 
also painful. Evening temperature, 102-6°. Erysipelatous 
blush on left side commencing at wound and extending along 
groin as high as costal cartilages. Painted with ext. bella- 
donna and glycerine (equal parts). Suppository repeated. 

24th.— Morning temperature, 102-6°; pulse, 120. Distinct 
bagginess above wound. Incision made and exit given to a 
considerable quantity of pus, which afforded great relief. 
Evening temperature, 102-4°. Patient much easier. Quinine, 
iron, wine, and nourishing food given at short intervals. 

25th. — Morning temperature, 102-2°; pulse, 112. Patient 
much easier. Considerable flow of pus, which was syringed 
away with carbolic lotion (1 in 20). On right side the wound 
looks well and appears to have united by first intention. 
Evening temperature 101 "8°. 

26th. — Morning temperature, 101-8°. Patient much better, 
and taking food freely. The incision made to give exit to pus 
is still discharging, but the original wound on same side is 
completely closed. Evening temperature, 100°. Patient very 
well. 

27th, — Morning temperature, 99°. Patient in good spirits, 
and the evening temperature is 98*6°. After this date the 
temperature remained normal, and the wounds were quite 
healed by first week in May. The girl has now none of her 
troublesome symptoms. 

The uterus is slightly antiverted, but there are none of the 
symptoms of that condition present. The bladder is now able 
to retain the urine and there is no desire for frequent mictu- 
rition. Menstruation has occurred twice since the operation, 
and the discharge has been normal and unaccompanied by 
pain. A Hodge's pessary was used during the time the 
wounds were healing. 

The second case is that of E. B., a woman, aged 42 years, who 
had been compelled to discontinue all work and reside in the 
House on account of the distress occasioned by a prolapsed 
condition of the womb, which a pessary failed to relieve. The 
os uteri came outside the vulva, and severe leucorrhoea very 
much aggravated her distress. 

On 14th March, Dr. Adams operated upon her, assisted, as m 
the former case, by Dr. Robertson, Dr. Fred. Adams, and my- 
self. The wounds were treated as in the case of the woman 
Black, but drainage tubes were used for the first week. No 



12-1 Mr. Miller — Operation for Displacements of the Uterus. 

difficulty was experienced in drawing out the ligaments, and 
as they were pulled upon the os uteri was felt to recede from 
the vulva to its normal position. On the evening of the 
second day the temperature ran up to 101°, but after that date 
it gradually fell to normal and remained so. 

The patient stated that she felt as if " something was drawn 
across her belly in the inside," but she did not have any dis- 
tressing pain. She, however, was very sick for a few days, 
and complained of the pessary that was introduced hurting 
her. All these symptoms disappeared in a day or two, and 
during her confinement to bed she was very comfortable. 

The wounds healed in about four weeks, and there was none 
of the erysipelatous complications in this case that occurred in 
the former one. 

About ten days after the operation she stated that menstru- 
ation had taken place for one day. As, however, she had 
ceased to alter for about ten years, her statement was not 
credited ; but she has since that time menstruated in a normal 
manner on two occasions. This curious fact may probably be 
explained by the altered condition of the circulation in and 
around the uterus, now in its proper position. 

She is now perfectly well, has no distress or pain, and has 
left the hospital to resume her usual employment. 

Note by Dr. Adams. — These cases show the immediate 
relief that may be obtained from this operation in cases of 
prolapse. 

There is, however, some risk of the operation becoming 
discredited from two causes. Thus it requires considerable 
experience to recognise, catch up, and manipulate properly the 
ends of the ligaments. The least rough handling may tear 
them, and too much poking within the wound by unskilful 
exploration is apt to induce a condition favourable to hernia, 
and favourable to the induction of suppurative action. Then 
in cases of old retroversions or flexions, where the posterior 
portion of the fundus uteri has become more or less hyper- 
trophied, the operation will only yield partial immediate relief, 
and it is through time alone that the altered circulation will 
affect the dense uterine tissue, and alter for the better the 
nutrition of the organ. That it does do so is shown in the 
case of E. B., where menstruation has been re-established after 
a long lapse of years. 

It is better to cut off about one inch of the ligament, as the 
extremity usually sloughs. The manipulation required even 
in experienced hands is an obstacle to the chances of getting 



Corresponded, ce. 12 5 

the wound to heal by first intention ; but with more frequent 
opportunity I am becoming sure that this may be obtained in 
the majority of cases. 

The catgut used should be prepared to withstand the action 
of the tissues for ten days ; and in addition to stitching the 
ligaments to the pillars of the ring, the sutures bringing the 
external wound together should pass through the ligamentous 
tissue that projects from the ring. 



CORRESPONDENCE. 



Dr. M'Bride's "Guide to the Study of Ear Disease." 

To the Editors of the " Glasgow Medical Journal." 

Sirs, — I am aware that it is a somewhat unusual course 
for an author to criticise a review of his own book ; but 
I think that when he is accused of advocating a method 
of treatment which is not only spoken of by his Reviewer as 
wrong, but as notoriously wrong, then I think he has a right 
to be heard. 

The passage in your notice of my work to which I take 
exception is as follows : — " We were rather surprised to see 
that Dr. M'Bride recommends the trial of a solution of acetate 
of lead when there is a discharge of pus through the drum 
membrane ; but in this instance he does not give the strength 
of the solution, so we may hope that he has not been in the 
habit of using lead in such cases. At least, since Hinton 
wrote condemning the use of lead in otitis media, we thought 
it was generally recognised that in ulcerative processes in the 
ear, as it doubtless is in similar cases in the eye, the use of 
lead was to be avoided, as it tends to form a deposit that in 
the one may clog parts that should be movable, and in the 
other obscure parts that should be transparent." 

Now, it so happens that acetate of lead has, in spite of the 
drawback mentioned, retained its position as a useful preparn- 
tion in subacute cases, probably on account of its happy com- 
bination of soothing and astringent properties. 

Your Reviewer's idea that its use has been entirely aban- 
doned is quite erroneous: and to prove my point I would 
refer him to the following standard works, which have 



1 26 Correspondence. 

appeared within the last few years, but which, I fear, have 
escaped his attention : — 

Burnett, A Treatise on the Ear, p. 489. 1877. 
Urbantschitsch, Lehrbuch der Ohrenheilkunde, p. 376. 1880. 
Politzer, Lehrbuch der Ohrenheilkunde, p. 463. 1882. 
Field, Diseases of the Ear. 3rd edition, p. 163. 1882. 
Pomeroy, Diseases of the Ear, p. 223. 1883. 
Barr, Manual of Diseases of the Ear, p. 500. 1884. 

I have said enough to show that the treatment recommended 
by me has been also advocated by others ; and while your 
Reviewer is entitled to his own opinion, he is not entitled to 
make use of misleading phraseology. I need not, therefore, 
apologise for asking you to put the matter right either by 
note, publication of this letter, or by a note in your next 
issue. — Yours faithfully, 

P. M'BRIDE. 
16 Chester Street, 
Edinburgh, 3rd July, 1884- 

Note by Reviewer. — Dr. M'Bride does not seem to notice 
that in trying to maintain his own position by his letter, he 
makes my statement stronger than it is. He writes that he is 
accused of advancing a method of treatment that is not only 
spoken of as wrong, but as notoriously wrong. Without 
quoting the words, any one can, by simply reading over the 
portion referred to, see that the statement in the notice is not 
so strong as that. 

Dr. M'Bride has been unfortunate in his choice of authori- 
ties, as I shall try to show. Take Professor Politzer's book 
first, and here I am referring and quoting from the translation 
by the late Dr. Cassells, as I have not the German edition. In 
writing of the treatment of chronic purulent inflammation of 
the middle ear, and after discussing very fully three methods, 
that coming first being presumably of the most importance, 
Dr. Politzer takes up the subject of astringents. He says : — 
" Those most in use are solutions of sulphate of zinc and 
acetate of lead, and next to these solutions of copper — more 
rarely solutions of liquor ferri, of crude-alum, and acetate of 
zinc. In applying these remedies, the fact must always be 
kept in mind that the mineral salts form with the albumen of 
the muco-purulent secretions combinations soluble only with 
difficulty. Hence arise more or less firmly adhering deposits 
in the middle ear, which accumulate in the depressions of the 
tympanum, and cannot be removed even by the most forcible 
injections. The ill effects of such deposits is sufficiently shown 



Correspondence. 127 

by experience. For, by the deposition of such masses in the 
neighbourhood of the ossicula, not only is the vibrating power 
of the latter diminished, but when the suppuration has ceased, 
it may be set up again by the constant irritation of the 
mucous membrane, caused by the remaining precipitates. 

" In spite of the astonishing efficacy of many astringents 
(particularly acetate of lead) in reducing the secretion, I now 
instil astringents less and less in cases of chronic otorrhoea, 
and confine their application to those cases in which there is a 
small perforation in the membrana tympani, and the previous 
antiseptic or caustic treatment has been without result." 

Further on he notices that — " Lead and iron preparations 
form the strongest and most firmly adhering precipitates, 
which can be syringed out of the external meatus even, only 
after they have been mechanically loosened with the probe." 
The application of these quotations to the subject in hand 
seems sufficiently obvious. 

Although I have much respect for many of the opinions of 
Urbantschitsch, unfortunately I have not the book specified 
by Dr. M'Bride, and cannot refer to it now. 

Dr. Burnett's Treatise on the Ear, the first book referred to 
by Dr. M'Bride, is deservedly considered as of authority on 
the subject. At the page in it mentioned by Dr. M'Bride, the 
acetate of lead is noticed among other astringents that have 
been and are used in the treatment of chronic purulent inflam- 
mation of the middle ear. Had Dr. M'Bride turned to the 
next page, and read what Dr. Burnett has written on the 
application of lead in these cases, he surely would hardly have 
quoted him in support of his position, or if he had, he would 
not have put him in the forefront of his defence. At pao-e 
490, Dr. Burnett writes — " Preparations of lead, though 
admirable astringents, are open to the same objections in 
treating diseases of the middle ear as in diseases of the eye. 
The insoluble precipitates which they form have caused their 
almost total banishment from the treatment of chronic puru- 
lent otitis media. 

"Leadwater has been used by Wilde, Schwartze, and 
Politzer with asserted success, in checking suppuration from 
the ear. But they are very cautious in its use, for fear of the 
aforesaid tendency of it to form insoluble precipitates." 

In conclusion, let me say that I should much regret if it 
could be shown that in the notice of Dr. M'Bride's book, in 
the last month's Journal, the susceptibilities of the author 
were not sufficiently considered. 

Here and now, however, it may be well to state distinctly 



128 Reviews. 

that it was intended that the point of the stricture to which 
Dr. M'Bride takes exception should lie, not so much or chiefly 
on the fact that he advises the use of lead in purulent affec- 
tions of the middle ear, with rupture of the membrane, but 
that he does not even mention the very real dangers to which 
an ear so treated is liable ; and this too in a book specially 
designed for students and general practitioners, who, unfortu- 
nately for patients and for the present state of surgical educa- 
tion, if they do look into the ear frequently, cannot tell 
whether the membrane is perforated or not. 



REVIEWS. 



On Bedside Urine Testing : including Quantitative Albumen 
and Sugar. Second Edition. By George Oliver, M.D. 
London. London: H. K. Lewis. 1884. 

This handy little work, of 128 pages, treats of the detection 
and quantitative estimation of albumen and sugar in the 
urine. Much attention has lately been directed to urinary 
tests, and no one, so far as we know, has done so much in this 
field of inquiry as Dr. Oliver. He has hit on the novel idea 
of introducing test papers impregnated with the various test 
solutions to supersede such dangerous and troublesome liquids 
as nitric acid, Fehling's solution, &c. For those who re- 
quire to carry tests about with them, more especially, these 
little papers will be found simply invaluable. The solutions 
used for albumen are those of potassio-mercuric iodide, sodium 
tungstate, potassium ferrocyanide, and picric acid, all more 
delicate as tests than the old favourite nitric acid. We have 
tried Dr. Oliver's papers and found them easy of application 
and thoroughly reliable. Various objections to these tests 
have been raised, but there is no test for albumen free from 
sources of fallacy without certain precautions. A formidable 
one, urged against potassio-mercuric iodide, is the large 
proportion of cases in which Chateaubriand found albumen in 
the urine of healthy persons by its use. In trying these new 
tests, we certainly found that the potassio-mercuric iodide 
almost invariably produced a somewhat turbid zone at the line 
of junction of the test fluid with the urine, even in non- 
albuminous specimens of the latter, so that we do not think it 



Reviews. 129 

so applicable for very delicate testing as the others. This, 
however, could only mislead the unwary, and is no objection 
to its use in ordinary clinical work. Chateaubriand's results, we 
believe, can only be accounted for by faulty observation, for Dr. 
Oliver never finds albumen by one test (and, for our own part, 
we can say the same) but he can corroborate the result by the 
others, as well as by the use of the microscope. He is no 
believer in physiological albuminuria. We are convinced the 
busy practitioner will find it well worth while to study these 
new tests. Few are sufficiently acquainted with the fallacies 
which beset the use of heat and nitric acid. Dr. Roberts, in 
his Urinary and Renal Diseases, mentions instances in which 
large quantities of albumen failed to be detected on account of 
the sources of error incidental to this method of testing, even 
in the hands of medical men. Such failures, we believe, are 
still of frequent occurrence. How often have we seen the 
fuming acid added in the most haphazard way at the boiling- 
point, as if with the impression that the more the better. The 
total abandonment of nitric acid in testing for albumen would 
be a great step in advance, and such works as the present are 
likely soon to produce this result. 

For the detection of sugar, Dr. Oliver has introduced indigo- 
carmine test papers, and he gives the results of a laborious 
and painstaking comparison of this test with Fehling's 
solution, and also with the picrate of potash test, lately 
introduced by Dr. George Johnson, of London. No less than 
sixty-four substances, occurring in the urine normally, or in 
various conditions, were experimented on in comparing these 
tests. We have not gone into this wide inquiry, but have 
verified the author's statements that the indigo-carmine paper 
is a trustworthy test for glucose, and at the same time affords 
very good approximative results quantitatively. 

The author's method for the quantitative estimation of 
albumen is not the least interesting and important part of his 
little work. Its great recommendation is the extreme ease 
and rapidity with which it can be performed ; indeed, it is 
the only one ever likely to be attempted by the practitioner, 
except the old one of roughly judging from the bulk of the 
precipitate with heat. After a few careful trials, too, we are 
disposed to think that it is really more accurate than more 
elaborate processes, such as that by potassio-mercuric iodide, 
lately recommended, which we found liable to a considerable 
margin of error. Dr. Oliver's pamphlet is the result of careful 
and conscientious work, and should be in the hands of every 
practitioner. 
No. 2. K Vol. XXII. 



130 Reviews. 

Albumen and Sag",' Testing. By George Johnson, M.D., 
F.R.S. 1884. 

This pamphlet deals with the same subject as the foregoing, 
although it is more limited in its scope with regard to 
albumen, being confined to qualitative testing, and treating 
mainly of picric acid. The writer passes in review with 
admirable clearness the various methods of testing for 
albumen, noticing the fallacies which attend them, and how 
these are to be avoided. Apart from a few debateable points 
in connection with very delicate testing, and which we need 
not here discuss, we may say that we agree in the main with 
the author as to the picric acid test. Dr. Johnson has not 
only added to our knowledge of this subject, but by his 
pertinacious advocacy of the merits of the test in question, 
has succeeded in making it widely known amongst the 
members of the profession. We need hardly remind the 
reader that the delicacy of the test, and its method of applica- 
tion, were pointed out in this Journal several years before Dr. 
Johnson took up the subject. Incidentally the author drops 
some valuable hints of a practical kind in reference to 
albuminuria, and we would emphasise his advice to examine 
the urine for albumen in all cases of disease. 

The picrate of potash test for grape-sugar may be emphati- 
cally said to be Dr. Johnson's own. With characteristic 
modesty he claims for it a decided .superiority over every 
other test. And we are disposed to think favourably of it in 
some respects. It is beautiful, is valuable as a negative test 
more especially, and if the practitioner will take the trouble 
to master its details, may be applied with tolerable facility. 
In testing for sugar, two things may be widely distinguished ; 
we refer to what is necessary for clinical purposes, on the one 
hand ; and those minute and delicate investigations directed to 
determining the question of the occurrence of a trace of 
glucose in the urine, on the other. With reference to the 
former, we have compared Dr. Johnson's test very carefully 
with others in a large number of cases, with results which 
may by and bye be published in some detail. Suffice it here 
to say that though Dr. Oliver has ascertained by his researches 
that the several sugar tests in use act unequally on different 
substances occurring in the urine, yet we have seldom found 
an indication of a grain or a grain and a half of sugar to the 
ounce by the picrate of potash, when Fehling's solution was 
not also reduced, thus showing the presence of something 
which acted on both tests. But with regard to the other 



Reviews. 131 

point referred to, that must still remain a questio vexata. We 
might observe, indeed, that the picric test, so far, furnishes 
another argument to those who maintain that the occurrence of 
glucose as a normal constituent of the urine is not proved. 
For, as was pointed out some time ago, this test acts on 
glucose only at a boiling temperature, whereas it gives 
invariably a certain degree of colour with normal urine in the 
cold. We have carefully examined this point, and generally 
found that the action in the cold amounted to nearly one-half 
of the whole, in cases where this was not above f, or 1 
grain to the ounce. It is evident, therefore, that we must 
deduct so much as not due to glucose, and a similar deduction 
must be made from the results of the ammonio-cupric process, 
since, on Dr. Johnson's showing, the two tests so closely 
correspond. Dr. Johnson admits no source of fallacy in 
connection with his test, and claims that it has no action 
on urates or colouring matters. We have washed urates red 
with uro-erythrine from the filter, and found them give a 
marked re-action with the test in quantities which were not 
affected by Fehling. 



Atlas of Female Pelvic Anatomy. By D. Berry Hart, M.D., 
F.R.C.P.E. Edinburgh : W. & A. K. Johnstone. 1884. 

The Edinburgh Medical School has long been famous for the 
prominence it has given to the study of obstetrics and diseases 
of women, and for the number of eminent men it has pro- 
duced in these departments — some to adorn its own halls, 
others to become ornaments of metropolitan or provincial 
schools and hospitals. It is a healthy sign that there are not 
wanting among the younger men of the present day worthy 
successors to those pioneers in this branch of study whose 
names are familiar to us all ; and among these budding 
gynecologists none bears a better reputation as a careful 
observer and able recorder of scientific fact than the compiler 
of this Atlas. Dr. Hart's monograph on the Structural 
Anatomy of the Female Pelvic Floor was so admirable and 
so interesting, that we could not but have high expectations 
of the present work when we knew it to be in course of 
preparation; and we are glad to find those expectations in 
every respect realised. 

As the name implies, the work consists of plates (37 in 
number), and of accompanying descriptions, but the latter are 
not limited to mere references such as usually elucidate 
anatomical plates ; they are full and complete accounts of the 



132 Reviews. 

female pelvic structures in their macroscopic and microscopic 
aspects. That these descriptions are somewhat scattered and 
disjointed is a defect inseparable from the character of the 
work, and one which, therefore, we are not disposed to 
criticise. 

The plates are excellent specimens of lithographic art, and 
satisfy us that we have in Scotland workmen capable of 
producing anatomical plates little if at all inferior to the 
best specimens issued from the French press. It is a little 
unfortunate that each plate bears the inscription — " Drawn 
from nature," seeing that fully half the diagrams are copied 
from other works ; if the statement had only been made 
on such as were actually so drawn, it would have had real 
value, and would have been a stamp of the accuracy and 
genuineness of the appearances figured ; as it is, it tends 
rather to throw suspicion over them all. 

Dr. Hart is unnecessarily severe on anatomists for their 
error in representing the vagina as an open canal, and for the 
mode in which they have always displayed the bladder and 
uterus. He forgets that their plates have never pretended to 
be anything but diagrams, and that they have preferred to 
show the bladder as partly distended and the uterus as lying 
in the axis of the inlet, because this was the mean between 
the two extremes of a completely empty bladder and a greatly 
distended one. We are not yet satisfied that sections, which 
show a completely flaccid bladder and an anteverted uterus, 
have any claim to be regarded as indicating the only normal 
disposition : one of the figures given in this work, that namely 
of a frozen section by Heitzmann (plate xxi, fig. 2) serves to 
confirm our doubts, for it shows an arrangement differing 
little from that usually figured in our anatomical works. 

Deserved prominence is herein given to the fact that the 
anterior segment of the pelvic floor is displaceable, and the 
posterior segment fixed, and the effect of this difference in the 
mechanism of parturition and in prolapsus uteri is lucidly 
described. The author's similes are sometimes funny, as for 
instance, where he speaks of the perineal body as "strengthen- 
ing, during parturition, the inferior margin of the sacral 
segment, where unprotected by bone, and is thus like the brass 
edge of a door step;" and when he says the "abdominal 
viscera and abdominal walls behave like a caoutchouc bag 
containing treacle." These similes have, however, one merit ; 
they indicate that Dr. Hart is not afraid to express any fact 
in what seems to him the most likely form for it to be under- 
stood by the reader. This explanation does not, we fear, hold 



Revieivs. 133 

good for some of the eccentricities in anatomical nomenclature, 
for therein he has evidently followed German models too 
servilely ; in this way we get the name ligamentum acuatum 
pubis for subpubic ligament, constrictor cumni for constrictor 
vaginae, and plexus uterine magnus for hypogastric plexus. 
We must also take exception to the use of the term cervical 
ganglion to describe the sympathetic ganglion placed beside the 
cervix uteri ; ganglion of the cervix is better, and does not 
lead the reader to speculations as to the connection of the 
sympathetic in the neck with the uterus. There are many 
eccentricities of diction throughout the work, some of them 
possibly the result of hurried correction of proofs, but many 
unexplainable on such a theory, and indicating rather the 
author's contempt for conventional English ; thus we note the 
expressions, "human foetal foetuses," "Polk gives the lie of 
the ureter," the " coecum muscle," and " the epithelium is in 
the form of irregular squames." The latter word was possibly 
suggested by Dr. Wendell Holmes's line — 

" The foles, languescent, pend from arid rames." 

A few lapses as to facts may be noted ; such are the state- 
ments that the great sciatic foramen is completed by the 
greater ligament, that the labia minora unite beneath the 
clitoris to form its suspjensory ligament, and that the pubic 
artery pierces the anterior layer of the triangular ligament 
before dividing into its terminal branches. 

Dr. Hart has an ingenious explanation of the mode in which 
the ovum gets into the Fallopian tube. He says (p. 11), "It 
is probable that the ovum shed at the menstrual period passes 
with the scrum current along the ovarian fimbria into the 
Fallopian tube," and he adds, "the statement that the 
fimbriated end of the Fallopian tube grasps the ovary during 
menstruation is imaginative." Seeing that his own view is 
so thoroughly the product of a fervid imagination, he might 
surely have spoken with less contempt of the most commonly 
accepted theory, especially as in Plate xxvi he copies His's 
figures, which show the ovary grasped by the Fallopian tube 
in the manner the author considers as improbable. We should 
require some evidence before accepting Dr. Hart's theory, 
which would lead us to think of the ovum as performing a 
slack-rope performance which a skilled acrobat might envy ; 
but no tittle of evidence is herein given. 

Tlif author's discussion of the genu-pectoral position is very 
important, and the figures given seem to support the definite 
conclusions at which he arrives. He says, "There is no 



134 Reviews. 

assertion more often made than that the retroverted unfixed 
uterus becomes replaced, i. e., anteverted, when the genu- 
pectoral posture is assumed and the vaginal orifice opened up. 
This is an undoubted error. The uterus really moves farther 
from the pelvic outlet, and becomes more retroverted. From 
the former fact the fundus of the retroverted uterus is not felt 
through the posterior fornix, but it has not become replaced, 
as the bimanual will show." " The genu-pectoral position is 
awkward and inconvenient, and only useful in ovarian con- 
gestion and replacement of the gravid retroverted uterus," 
but even in the latter he believes the genu-pectoral position 
alone does no good, the use of the volsella being necessary to 
draw down the cervix. 

Skene's tubes in the wall of the female urethra are figured, 
and are described as the representations of Gaertner's canals. 
This is the opinion held by Skene, Kocks, and Bohm, but Max 
Schliller considers them to be the ducts of a pair of glands he 
has found in the upper part of the urethra; recently Carl 
Reider has traced the remains of Gaertner's ducts in the 
uterine and vaginal walls, but he does not appear to have 
made out their continuity with Skene's tubules. It seems 
probable that the tubules are not parts of Gaertner's ducts, as, 
if they were, they should terminate in the vagina, and not in the 
urethra. 

The work throughout contains much that is speculative and 
even more that is theoretical, but it is well abreast of the 
science of the present day, and cannot fail to suggest even 
where it fails to convince. As an exposition of anatomical 
details in their relation to obstetrics and gynaecology, it has no 
rival in the English language, and we may predict that it will 
for years to come occupy the position of a standard work of 
reference on these subjects. 



TJie Surgical Treatment of Tumours and other Obscure 
Conditions of the Bladder. Bv Walter Whitehead, 
F.R.C.S., and Bilton Pollard, M.D., F.R.C.S. London: 
J. & A. Churchill. 

This most useful and interesting pamphlet was written with 
the view of corroborating Sir Hemy Thompson's observations 
on the digital exploration of the bladder through a perinatal 
section, as a means of diagnosis in obscure cases, and for the 
purpose of giving relief, especially in cases of tumour. After 
a careful description of the operation, the authors give minute 



Revieivs. 135 

details of 10 cases which have fallen under their observation 
and treatment, with the results. Of these, 8 were males and 
2 females. In 4 males and 2 females a tumour was found and 
removed ; in the others no tumour was found. All of these 
recovered from the operation, which is not therefore a very 
dangerous one ; but only 4 males can be said to have been 
permanently benefitted, as the others died within three 
months from uraemia or phthisis. Both females recovered 
completely. As these numbers are too few for statistical 
purposes, the authors have added in an appendix notes of all 
the cases of tumour of the bladder with which they were 
acquainted, a list which will be found most useful for refer- 
ence, and which shows that the results of median urethrotomy 
in these obscure and difficult cases will compare favourably 
with those of any other major operation. 



The Non-Bacillar Nature of Abrus-Poison, with observations 
on its Chemical and Physiological Properties. By L. A. 
Waddell, M.B., Surgeon I. M. S., Offg. Professor of 
Chemistry, Medical College, Calcutta. Calcutta, 1884. 

The observations recorded in this excellent monograph were 
made in Calcutta and under the immediate superintendence 
of Dr. Koch, who was then prosecuting his investigations on 
cholera at Calcutta. They may be received therefore with 
greater authority than the author can lay claim to, although 
in the style of work and its presentation, great scientific 
ability are shown, and a promise of eminence is given. 

The seeds of the abrus or Indian liquorice plant, are used 
hypodermically in India for poisoning cattle, and also occasion- 
ally for committing murder. The effects of the poison are 
somewhat different from those of ordinary chemical poisons, 
chiefly in respect that the symptoms do not show themselves 
for some hours after administration. Several observers have 
recently asserted that the symptoms are due to the action of 
bacteria, which are stated to be present in the seeds of the 
plant and to multiply in the wound after injection, afterwards 
penetrating to the blood and so producing the general symp- 
toms of poisoning. 

• The present author, after a very careful series of observa- 
tions and experiments, comes to the conclusion that there are 
no bacteria in the seeds, and that their action is not due in any 
sense to micro-organisms. Bacteria may be present in the 
wound, but they are secondary or innocuous. If large doses 



136 Revieivs. 

be given, no bacteria are to be found in the blood or internal 
organs, and besides, the rapidity with which death occurs 
negatives the idea of an invasion of bacteria, there being no 
time for their multiplication in sufficient numbers. The 
author absolutely contradicts the statement that a small dose, 
when its effects are recovered from, confers immunity against 
further inoculation. A preliminary dose, on the contrary, 
appears to precipitate the fatal result. We may regard these 
observations as completely disproving the bacterial theory, 
and we are only astonished that an observer of the eminence 
of Cornil should have given the weight of his authority to it. 

The author also goes into the question of the chemical 
nature of the abrus-poison, and concludes that it is a substance 
which he calls abrin, whose chemical relations are with the 
vegetable albumins. There are also Appendices on the 
botanical position of the plant ; the mode of using the seeds 
for poisoning cattle ; the harmlessness of the seeds when taken 
1 »y the mouth ; abric acid, its preparation and properties ; 
therapeutic use of abrus seeds in ophthalmia ; and distinctions 
between Indian and true liquorice root. 

Altogether we congratulate the author on having produced 
a monograph of sterling scientific value. 



The Student's Manual of Venereal Diseases. By Berkeley 
Hill and Arthur Cooper. Third edition. Smith, Elder 
& Co. 1883. 

This is a new edition of one of the best of our students' 
books. It is truly an " aid " to the study of venereal diseases, 
and one which we can heartily recommend to every student. 
It is short, pithy, and well arranged. Owing to its shortness 
many points are stated perhaps a little too dogmatically, 
though this may not lessen its popularity. A student likes to 
be told exactly what to see, and when and where to look for 
it. He prefers definitions and abstracts to clinical histories 
and long descriptions, and as these requirements have here 
been carefully attended to, we have no doubt that this revised 
edition will be as great a favourite with our young friends 
as its predecessors. 



On the Pathology and Treatment of Gonorrhoea, By J. L. 
Milton. Henry Renshaw. 1883. 

This being the fifth edition of Mr. Milton's book, but little 
remains now to be said by the critic but to give it a hearty 



Reviews. 137 

welcome. In many respects this edition is an improvement on 
former ones. It is smaller, and yet contains more matter of 
importance, space having been gained by the omission of many 
of the histories of cases. This space has been given to the 
sections on the treatment of gleet, orchitis, and gonorrhceal 
rheumatism, all of which have been revised, and to the 
description — now given for the first time — of gonorrhceal 
affections of the heart and pericardium, peritoneum, pleura, 
dura mater, and sheath of the spinal cord. The book still 
retains all its well known features, its easy style, its encyclo- 
paedic information as to the various modes of treatment in 
former and more recent times, and its statistical methods of 
testing the accuracy of results. We may add that the get up 
of the book is most excellent. The paper and type are good, 
the margins broad, the pages cut, and the index very complete, 
so that there is every ease and comfort in referring to its 
contents. 



Manual of Surgical Operations. By Joseph Bell, F.R.C.S. 
Edin. Fifth edition. M'Lachlan & Stewart. 1883. 

Surgical Applied Anatomy. By Frederick Treves, F.R.C.S. 
London : Cassell & Co. 1883. 

Mr. Bell's book still retains its character of being the handiest 
text-book for students practising operative surgery on the 
dead body. All the operations usually required by the 
examining boards are sufficiently described, and their details 
can be easily followed. We are glad to notice that the size 
of this fifth edition is not greater than that of its predecessors, 
while it is well up to date both in its historical notices and 
the statistics of the results of operations. The most impor- 
tant addition we have noticed is a series of tables showing the 
anastomotic circulation after ligature of the main arteries. 
These are short and accurate, and will no doubt prove useful. 

As regards Mr. Treves' surgical applied anatomy, we must 
confess that we opened it with some misgivings. A collection 
of dry anatomical facts, supposed to be interesting to a student 
preparing for his final examination, did not promise to be very 
pleasant reading. In this, however, we have been agreeably 
disappointed. The book is not only interesting, it is even 
amusing, and wherever it is opened, at once engages the 
attention by the liveliness of its st}de and the variety of its 
information. Perhaps something has been sacrificed to gain 
this end. We certainly looked in such a book for a tolerably 



138 Reviews. 

complete account of the surgical anatomy of the great vessels,, 
and of such an important subject as Hernia. But Mr. Treves 
thinks these and similar subjects are sufficiently treated of in 
the ordinary text-books, and he has rather written a com- 
mentary on the bearings of anatomy on the circumstances of 
practice, which presupposes a fair knowledge of ordinary 
descriptive anatomy, physiology, and surgery. This plan he 
has carried out with remarkable success, and there is hardly a 
nerve twig, branch of artery, or bit of fascia in the body 
about which he has not written something of interest. Per- 
haps he has even carried out his plan a little too far. Is it 
necessary for a student to know why Arnold's nerve is called 
the " Alderman's nerve ; " or the physiology of ear-coughing, 
ear-sneezing, or ear-yawning ; or the meaning of the terms, 
" Rider's bone," " Eider's sprains," and " Weaver's bottom ; " or 
why he always inserts a corkscrew by a movement of supina- 
tion ? Or is it a fact of the very slightest importance to any- 
body that the " dorsalis scapulse artery crosses the axillary 
border of the scapula at a point corresponding to the centre of 
the vertical axis of the deltoid muscle ? " (p. 166.) Fancy the 
state of mind of the student who has to get up a host of 
finical details of that kind before he can consider himself fit 
to appear before his examiners in descriptive or surgical 
anatomy. Surely there is a want of what we may call 
anatomical perspective here. If Mr. Treves had only borne 
more carefully in mind what he owns in the preface — " that 
all details in anatomy have not the same practical value," his 
interesting book would have been still better adapted to the 
wants of students. 



An Index of Surgery, being a concise Classification of the 
main Facts and Theories of Surgery, for the use of Senior 
Students and others. By C. B. Keetley. F.R.C.S. London : 
Smith, Elder, & Co. 1884. 

We had the pleasure only the year before last of reviewing 
the first edition of this useful little work of Mr. Keetley's. 
The rapid appearance of a second edition proves that the book 
has supplied a want, and either student or practitioner, or 
perhaps both, have found what is as much of service for an 
examination as for general practice. 

We must regret, however, that what we ventured to suggest 
(in reviewing the first edition) as likely to enhance the value 
of the work has remained unnoticed. We refer to the need of 



Reviews. 139 

more numerous " cross references," or in their place a full and 
complete appended index. 

The book is to all intents and purposes a reprint of the first 
edition. What little, however, surgery has added since the 
appearance of the former edition is included ; so that the 
present work may be accepted as being up to date. 



Fractures of the Neck of the Femur, with special reference to 
Bony Union after Intracapsular Fracture. By N. Senx, 
M.D., of Milwaukee, Wisconsin. Philadelphia : Collins, 
Printer. 1883. 

This consists of a lengthy communication to the American 
Surgical Association, from the Transactions of which it is 
extracted and published in a separate form. The whole 
subject is treated very fully and may be fairly deemed an 
exhaustive investigation of the subject. The author has 
spared neither time nor trouble in collecting material from far 
and near. The main object of the communication is to demon- 
strate the perfect possibility of bony union in intracapsular 
fractures, and in what manner it may be best effected. We can 
very warmly recommend the work to the perusal of all surgeons, 
believing that the author's arduous endeavours will be well 
rewarded by the far more hopeful views which surgeons will 
be induced to take of this class of injury, and by the far 
better results to be obtained by adopting the method of treat- 
ment suggested. 



On the Treatment of Spinal Curvatures by Extension and 
Jacket, with Remarks on some Affections of the Hip, Knee, 
and Ankle Joints. By H. Macnaughtox Jones, M.D. 
London : J. & A. Churchill. 1884. 

Admirers of Dr. Jones will no doubt find much in this small 
volume to interest them. As the author states, his object has 
been to place in their hands — or perhaps we should more 
strictly say, in the hands of medical friends whom he has met 
in consultation — some brief epitome of his individual experi- 
ence in the treatment of spinal curvatures. Dr. Jones is a 
warm advocate for the use of Sayre's jacket, and the most 
instructive part of the book is the first half of it, which deals 
with this particular method of spinal treatment. The latter 
half contains a heterogeneous collection of cases, many of 
which have previously appeared in the various medical 
journals. 



140 Meetings of Societies. 

Looked at from a purely surgical and scientific point of 
view there is little to commend the work; but the judgment of 
the author's contributions to literature is perhaps best left to 
those for whom it is specially written. 



Voice, Song and Speech: A Practiced Guide for Singers and 
Speakers; from the combined vieiv of Vocal Surgeon and 
Voice Trainer. By Lennox Browne, RR.C.S.Ed., and Emil 
Behnke. With numerous illustrations by wood engraving 
and photography. London : Sampson Low, Marston, Searle, 
& Rivington. 1883. 

This is a composite book, as the title indicates, and it bears 
evidence of its twofold origin in a certain disjointedness in 
its arrangement and presentation. The book is not intended 
for the medical profession, but rather for the use of singers 
and speakers ; we are not, therefore, to look for strictly 
scientific descriptions of the physiology and pathology of 
the vocal apparatus. At the same time there is much here 
that medical men would be the better to know, and which 
should be specially studied by those of them who are in the 
habit of treating diseases of these organs. We refer especially 
to the sections dealing with the "cultivation of the voice" 
and " the daily life of the voice-user." We wish every success 
to this meritorious attempt to put the study of the vocal 
apparatus more within the understanding of both professional 
and non-professional readers. 



MEETINGS OF SOCIETIES. 



MEDICO-CHIRURGICAL SOCIETY. 



Session 1884-85. 
Meeting VII— 4th April, 1884. 






Dr. Alexander Robertson in the Chair. 

Dr. Wolfe showed a patient who was totally blind from 
detachment of the retina, and had been cured by an 
operation. The following is a summary of his remarks on 
the subject : — 



Medico-Chirurgical Society. 141 

Detachment of the retina is caused by the effusion of serum 
between that membrane and the choroid coat. It may there- 
fore be called sub-retinal dropsy. Considering that the disease 
is situated around the posterior pole of the eye, behind the 
lens and the vitreous humour, it has been generally thought 
that that region is inaccessible, and beyond the reach of 
surgical interference. The present state of science in this 
department will be seen from the report of the meeting of the 
Ophthalmological Society of France, held on 28th January, 
1884. At that meeting M. de Wecker, who, by the bye, tried 
some operations of his own, stated that he failed in every 
operative attempt, and that he had lately found useful the 
application of strong revulsive measures by the repeated 
application of the cautery (pointes de feu) upon the surface 
of the sclerotic, and Gelezowski recommended putting the 
patient in horizontal position for several months without 
intermission for a single instant. In other words, it is a 
desperate affair, and something must be tried. 

My first case I showed to this Society in 1878 ; and I shall 
have the honour this evening to submit another operation for 
detachment of the retina which I have performed on the 21st 
of February — that is, fifteen days ago. Before submitting the 
patient to your inspection, permit me to say a few words with 
regard to the principles upon which that operation is founded, 
and how my attention had first been directed to its adoption. 
I have very frequently observed, in laceration of the sclerotic, 
with prolapse of the vitreous, how easily we can repair the 
injury by simply bringing the cut or lacerated edges together 
by a ligature. Here is a case in point : — Hugh G., a rivetter, 
who had his left eye knocked out seven years ago, had the 
misfortune to injure his other eye also, at the beginning of 
last month, with a rivet. The injury consisted of laceration of 
the cornea and sclerotic, and produced opacity of the lens. 
This you will see from the black mark extending a quarter of 
an inch into the sclerotic at its junction with the cornea. As 
you see, I have extracted the lens and brought the edges of 
the sclerotic wound together with a ligature applied to the 
corresponding portion of the conjunctiva, and you can satisfy 
yourselves as to the result obtained. The eye is useful, and as 
good as you can expect after the removal of the cataract ten 
days ago. The same accident frequently happens to other 
portions of the sclerotic. Now, it occurred to me, with regard 
to sub-retinal dropsy, that if we could dissect the soft struc- 
tures from the sclerotic, and rotate the posterior pole of the 
eye forward, there is no reason why we could not tap the 



142 Meet i ngs of Soc ieties. 

eyeball, remove the effused fluid from behind the retina in 
the same manner as we do to the thorax, abdomen, or any 
other cavity. Dr. Wolfe showed the instruments used for 
the operation, and described his method in the case of 
Sylvester H., aged 38, tailor, who applied for advice at the 
Glasgow Ophthalmic Institution on the 5th September, 1883. 
His right eye has been incurably blind for the last three 
years. The left eye began to be affected two years ago, and 
gradually became worse. On the date of admission he had 
to be led. The left eye has a nebulous cornea, but the pupil 
acts properly, and tension is normal. The ophthalmoscope 
revealed a detachment of the retina and the presence of 
large flocculi floating in the vitreous humour. The light of 
a lamp held before the eye could scarcely be perceived by 
the patient in any direction. On 3rd February the patient 
returned, most anxious that something should be done for 
that eye. The operation was performed on the 14th of 
February, under chloroform. The conjunctival and sub- 
conjunctival tissue having been opened, the sclerotic was 
punctured in the posterior hemisphere in a line of the vertical 
meridian. A ligature was applied to the wound. On the 
fifth day the ligature was removed ; vision then had so far 
recovered that the patient could see faces, count fingers at 
18 inches distance, but vision was limited to the outer part 
of the field, the inner being still a blank. The ophthalmo- 
scope showed the existence of a detachment at the lower and 
outer part of the fundus. Tension being normal I determined 
to repeat the operation in this region on the 21st March, with 
the result that four days after the operation the field of vision 
was found complete. The patient could read Snellen's type, 
No. 20, at 15 inches distance, and read No. 16 of Jaeger, 
and could tell the time to a minute on a watch, and follow 
with his finger accurately the movement of the small seconds 
pointer. This being the fifteenth day after the operation 
you will satisfy yourselves that his power of vision is very 
satisfactory. In this case there is no room for doubt, inas- 
much as I have just the other day learned that the patient, 
previous to admission, had attended another Eye Infirmary, 
and his card from that hospital, dated July 1883, is marked 
" Irido-choroiditis and detachment of the retina." Indeed, 
but for that circumstance, which furnishes me with corrobor- 
ative evidence from an independent source, I should not 
have shown the case to the Society. This case is also 
remarkable, being the first in which I ventured to repeat 
the operation in the same eye. 



Medico-Chirurgical Society. 143 

Dr. Robertson said that certainly Dr. Wolfe was to be 
congratulated on the success of his operation. He regretted 
very much the absence of those specialists under whose charge 
the case had formerly been, as they could have stated the 
condition of the patient while under their charge, and their 
prognosis. He had himself seen several cases of separation 
of the retina in the institution under his charge, and certainly 
he had always regarded it as a hopeless condition; and as 
such it appeared to be also regarded by the eminent French 
specialists whose words Dr. Wolfe had quoted. Dr. Wolfe's 
operation was beyond doubt a great advance on that of 
Professor Graefe, and met the case more completely. If they 
could so rotate the eye-ball as to allow puncture at the 
particular point where effusion had taken place, and so permit 
the fluid to escape, they certainly afforded a fair chance of the 
restoration of sight. 

Dr. Benton said that there could be no question that 
separation of the retina was generally regarded as a hopeless 
condition. In some instances, it was true, Graefe's operation 
was followed by a certain amount of benefit. Other pro- 
cedures had been suggested. One of these was the passage of 
a gold wire from one part of the sclerotic to another by way of 
& drain. In regard to Dr. Wolfe's case, he would have liked 
that a longer period than a fortnight had elapsed since the 
operation, so as to make sure that the ground gained would 
continue to be kept. But, looking to the case as it stood at 
present, Dr. Wolfe was to be congratulated on his success. 

Dr. Wolfe said that, in this case, the period which had 
elapsed was not long. But the results in the case which he 
had communicated to the Society in 1878 were not temporary, 
but permanent. He had never attempted the absurd operation 
of passing a gold wire from one part of the sclerotic to 
another, though he brought the instrument with him from 
Paris. On his next visit to Paris, he learned from Wecker 
that he had abandoned the use of' the wire. 

Dr. J. Crawford Renton showed three patients on 

WHOM HE HAD OPERATED FOR CLEFT HARD AND SOFT PALATE. 

He had used with benefit the late Dr. J. G. Lyon's needles 
with silver wire and horse hair stitches, allowing them to 
remain in position for a fortnight in two of the cases, and for 
four weeks in the third. Union was complete and speaking 
was decidedly improved in each case. 

Casts of the worst cleft, before and after operation, were 
•also shown. 



144 Meetings of Socit 

Dr. Robertson congratulated Dr. Renton on the success of 
the operation in these cases. In one of the cases it required a 
close inspection to detect that there had existed an ab- 
normality. 

Dr. Fleming said that the particular gag shown by Dr. 
Renton would be apt to slip from the want of roughening of 
the edges necessary to prevent sliding. A German inventor 
had gone a point beyond the sewing machine needles shown 
by Dr. Renton. His contrivance worked on the principle of 
the whole sewing machine. As soon as the needle passed 
through the palate, a slide automatically passed through the 
loop of thread, locking the stitch. 

Dr. Renton showed a glass case containing sections of 

EYES ENUCLEATED FOR VARIOUS INJURIES AND DISEASES, AND 
MOUNTED IN GELATINE ACCORDING TO THE METHOD RECOM- 
MENDED by dr. priestley smith. He also read notes of two 
cases of intra-ocular tumour, the one a melanotic sarcoma in 
an adult, which he removed along with the contents of the 
orbit ; the growth recurred and was again removed, but has 
since returned accompanied by marked constitutional symp- 
toms : the second, a spindle-celled sarcoma occurring in a 
child aged two years, and for which enucleation was per- 
formed — the child only lived three months after the operation. 

Dr. Frederick Pollock had made microscopic sections of the 
tumours, and these Dr. Renton showed to the members along 
with the tumours mounted in gelatine. 

Dr. Wolfe made a few remarks on the subject, in which he 
deprecated any interference with a staphyloma in the ciliary 
region. If they cut here, suppuration was sure to set in. 



GLASGOW SOUTHERN MEDICAL SOCIETY. 






Session 1883—84. 
Meeting XII.— 6th March, 1884. 



TJie President, Dr. Park, in the Chair. 

Mr. J. Stuart Xairne read a paper on abdominal section 
(see the June number of this Journal, p. 423), and showed the 
following specimens : — a dermoid ovarian cyst, two ovarian 



i 



Glasgoiv Southern Medical Society. 145 

cysts containing daughter cysts, and the parts in a hydro- 
salpinx. Mr. Lawson Tait sent two specimens of pyo-salpinx. 
There were also exhibited some of Mr. Tait's instruments and 
some new ones by the author. 

Mr. Stuart Nairne had not the advantage of being connected 
with any hospital, so that his surgical practice was entirely 
private, and he was quite sure that if general practitioners 
like himself would undertake their own surgical work, they 
would have quite as much and frequently more satisfaction in 
every respect than if they had sent the cases to hospital. He 
had done 39 abdominal sections, for various causes, with 7 
deaths. Seven of these operations were for ovarian cyst, 6 
recoveries and 1 death ; for cancer of ovary, 1 operation with 
1 death ; for hydro-salpinx (which included removal of both 
ovaries, for they were both cystic), 1 case and 1 death; disease 
of liver (hydatid, gall stone, abscess), 3 operations and 1 death ; 
abscess (intra-abdominal) and obstruction of bowels, 3 opera- 
tions, 1 death; uterine fibroid, 3 operations, 2 deaths; for pur- 
poses of diagnosis, 5 operations, no deaths ; for drainage, 5 
operations, no deaths; miscellaneous, 11 operations (sections), 
no deaths. Only one of these deaths occurred within 30 
hours, the others not till the fifth or sixth day. 

He enumerated a variety of cases in which he considered 
abdominal section admissible, instancing specially scirrhus of 
the rectum and exceptional cases of placenta prsevia. 

Dr. D. N. Knox complimented the author of the paper for 
the ingenuity displayed on the new wire clamps, and considered 
them a decided improvement on any of the existing instruments. 
He thought home surgery was certainly preferable to hospital 
surgery from many points of view, but it was not always 
possible. 

Dr. Alex. Napier, while not agreeing with all that Mr. 
Stuart Nairne said, had the greatest pleasure in corroborating 
a former observation of the author as to the site of the pla- 
centa being indicated by a pod-partiim painful spot, quite 
localised in the uterus ; and to that he would add that there is 
also an elevated spot in the very same situation. 

When, for any reason, the hand has to be introduced into 
the uterus after labour, the spot indicated may be easily felt. 
It is distinctly elevated, and probably about a couple of inches 
in length and breadth. On first detecting this elevation, Dr. 
Napier mistook it for an adherent portion of placenta and 
made several fruitless efforts to detach it, when it occurred to 
him that this must be the site of the placenta, contracted in 
dimensions from the general contraction of the womb, 

No. 2. L Vol. XXTT. 



146 Meetings of Societies. 

and elevated from thickening of the uterine wall at that 
part. 

Mr. T. F. Gilmour acknowledged the good and valuable 
work that had been done by the author of the paper, and 
expressed his satisfaction at having been present at one of the 
operations mentioned, since he was enabled to testify that Mr. 
Stuart Nairne was really not so rash as some might suppose. 
But while approving of his care and diligence, he could not 
homologate some of the sentiments expressed by the author. 
The Hippocratic maxim that the physician should at least do 
no harm was incumbent on all ; and he thought that to operate 
in hopeless cases was not true surgery. He agreed with Dr. 
Napier, too, in saying that he hoped it would never go out 
from this Society that they considered that lives were 
frequently sacrificed before the surgeon acquired sufficient 
dexterity in operating. He had been present at an operation 
performed by Mr. Stuart Nairne on a patient of his for 
double ovariotomy, and he was sure, from the care which was 
exercised and the preparation that had been made, that Mr. 
Nairne himself took every precaution to prevent any sacrifice 
of life. 



Meeting XLIL—QJih April, 188 J^. 
Dr. Park, President, in the Chair. 

Adjourned Debate on Mr. Stuart Nairne's Paper. 

Mr. Stuart Nairne said that since last meeting he had 
completed his fortieth abdominal section. The case would 
afterwards be detailed by Dr. Park. It was that of a woman 
about G6 years of age, who had been tapped some few months 
before, and relieved of a large quantity of bloody fluid. At 
the operation by abdominal section, it was found to be an 
ovarian sac full of bloody fluid, and quite stinking. It was 
completely covered by omentum, and adherent to the bowels. 
The patient was a fat old woman, and the operation was 
completed with a considerable degree of difficulty. Her 
temperature had never risen. The operation was done on 
the 12th of April. The wound was dressed only twice; and 
on the second occasion all the stitches were taken out. 

The cyst was shown. 

He also narrated the history of the case of dermoid tumour, 



Glasgow Soutfiem Medical Society. 147 

which had been exhibited last evening. It was done three 
months after the patient had been confined of a child. The 
operation did not interfere with her suckling, except on the 
day on which it was done : and the patient was quite well, 
and attending to her household duties within twenty -one 
days. 

Dr. Glaister congratulated Mr. Stuart Nairne highly on 
having the courage to carry through so much surgical work 
in private practice. He agreed with him heartily in recom- 
mending every general practitioner to do as much surgical 
work as he can manage. It is better for the patient. The 
patient's friends will never blame the doctor who has fairly 
stated the case to them before undertaking any serious 
operation. As to Mr. Nairne's opinions with regard to 
placenta praevia, he condemned them on a previous occasion, 
and he did so also on this. A case of placenta praevia ought 
never to be fatal to the mother ; and so long as this was 
the case, abdominal section was quite inadmissible, with all 
the risks of Caesarean section, for the purpose of saving a 
child. As to the instruments exhibited, he was sure they 
only required to be more widely known to be universally 
accepted. 

Dr. Polloh thought there was too much hurry in under- 
taking abdominal sections. Drs. Keith, Bantock, Knowsley 
Thornton, and Wells, councilled delay, and he thought that 
when a tumour had remained a long time in the abdominal 
cavity, the peritoneum got so changed, that when an operation 
was undertaken there was less likelihood of septicaemia from 
absorption. 

Mr. M'Millan congratulated the Society on having such a 
paper brought forward ; and he congratulated Mr. Stuart 
Nairne the more heartily on this occasion as on some former 
occasions he had not agreed with his opinions or practice. He 
thought the work displayed in this paper worthy of the 
greatest commendation, and he was sure, from the care and 
deliberation with which Mr. Nairne had gone about his cases, 
that he was not at all so rash as some might think from his 
words. 

The President, after reviewing the discussion and congratu- 
lating the Society upon having had such a paper read before 
them, and Mr. Stuart Nairne upon the ample and favourable 
criticism with which it had been received, proceeded to relate 
the following case, and to remark that he conceived the opera- 
tion had a much greater future and much wider application 
than probably most practitioners were ready to believe. He 



148 Meetings of Societies. 

alluded to certain cases of difficult}* in obstetric practice as, 
e. g., dystocia from too large a foetal head, or one too firmly 
ossified for moulding to take place ; to cases of placenta 
praevia complicated with projecting promontory, thus pre- 
cluding possibility of rapid delivery after detachment of 
placenta; to cases where great interests rested upon the 
birth of a living infant, as an alternative to craniotomy ; and 
to cases of obstruction of the bowels and diseases of abdominal 
viscera generally. 

The case narrated was as follows : — Mrs. H., set 66, multi- 
para, widow, one day in November 1883 was hurrying across 
the street, and had just escaped being run over by a tramway 
car, when she found herself in front of a van. She made a 
great effort to spring past this, but, missing her footing, fell 
amongst the horse's feet flat on her face. How she escaped 
with her life she didn't know ; but when she was lifted up 
and came to herself, she felt a severe pain in the right side, 
low down in the iliac region. She was not trampled upon 
by the horse. In the evening of the same day she had a 
severe rigor, but overcame this by application of such domestic 
remedies as are usually had recourse to, and was about her 
usual avocations next day. She had soon to return to bed, 
however, on account of the pain, and after a good deal of 
acute suffering, sent for me to see her. This was on 23rd 
November, exactly one week after the accident. I was not 
at this time informed of the latter, however. The leading 
symptoms present were constant pain low down and over 
right ovarian region. Superficial pressure did not make this 
pain worse, but deep pressure did; and a roundish tumour 
was felt, about the size of a man's fist closed. I concluded 
I had to deal with an ovarian cyst which had become inflamed. 
I prescribed blisters, and an anodyne mixture, and gave her a 
few hypodermic injections of morphia, and the inflammation 
subsided. After a few days I left her, and did not see her 
again till the 2nd January in this year, when her symptoms 
had again been acute for a few days. I now found the 
tumour had come more into the middle line, and was inter- 
fering with micturition. She had a high pulse, also, and 
considerable pyrexia. Moreover, about this time a very 
foetid vaginal discharge took place, and continued for over a 
fortnight. I now thought I had a pyo-salpinx to deal with, 
as vaginal examination revealed no opening, save the os uteri, 
from which the discharge could come ; and the uterus, though 
high in the pelvis, was otherwise normal in position and size. 
There was also considerable peritonitis. 



Glasgow Southern Medical Society. 149 

About the beginning of February the tumour had lessened 
in size considerably, and the flux per vaginam had ceased, 
there was no difficulty in micturition and the peritonitis had 
subsided to a great degree. About this time Mr. Stuart 
Nairne very kindly saw the case with me (and I take this 
opportunity of thanking him for all the gratuitous trouble he 
has taken with the case). He agreed with me that, whatever 
there might be besides, there was a pyo-salpinx, and that the 
case was one for operation. As we could not get her into 
either of the Infirmaries (they being full) nor into the Train- 
ing Home for Nurses, we agreed to perform an aspiration. 
On 20th February we did this, though not without regret, in 
view of the adhesions which would be set up. We drew off 
about a quart and a half of dark bloody material, in which 
there was neither pus nor any sign of decomposition. We 
were certainly at first surprised, but soon apprehended that 
we had simply a hematocele to deal with in addition to 
a pyo-salpinx. But where was the hematocele ? In the utero- 
vesical pouch or the ovary ? This was a matter for some 
thought, but we, I think, both agreed finally that it was 
ovarian, though there was the difficulty as to why a portion 
had suppurated and not the whole, and why the foetid flux 
had stopped when it did. On this point we thought the 
explanation was to be found in a choked state of the Fallopian 
tube involved. 

Well, the aspiration did no more than relieve the patient, 
and a considerable degree of localised peritonitis followed. 
On Saturday, 12th April, Mr. Nairne performed abdominal 
section, and, after separating a large number of adhesions (to 
do which safely he had to apply three ligatures) and evacu- 
ating through the trochar about half a pint of bloody fluid, he 
removed the cyst which you see before you, consisting of the 
right ovary. The operation, I conceive, was a more than 
ordinarily difficult one on account of the fatness of the 
abdominal wall, the smallness of the tumour, and the num- 
ber of adhesions ; nevertheless the patient has had no bad 
symptoms, her pulse to-day being 72 and her temperature 
OS'S , and she shows every prospect of making an excellent 
recovery. 

The operation was performed with very little loss of blood, 
not more than two ounces, if even that, Mr. Nairne's use of 
pressure forceps enabling him to control every vessel as it is 
cut and without loss of time. All the details of the operation 
and the care and management of the patient, both before 



150 Meetings of Soei* 

and after, seem to have been matter of close study, 
and impressed me with the idea of his being quite master of 
the subject ; and, should I have any case of this kind again, I 
would have pleasure in asking him to operate. 

Note. — Dismissed from home well on 5th May. 

Mr. Stuart Xo.irne, in reply, said that he felt all the more 
pleased that the reception his paper had met with had been so 
unexpectedly approving. For the last eight years he had 
shown cases of operation to this Society, many of them, he 
thought, of striking interest, and he had never, up till these 
last two nights, received a word of praise, or a recognition 
of his work. He spoke out the more strongly on this 
account that it was chiefly in the interests of the general 
practitioner he spoke ; and it was the general practitioner 
who should have been first to acknowledge the work done 
amongst themselves, and in the daily toil of general practice. 
He was sure, from what he knew of general practitioners, that 
there were many amongst them with good pairs of hands and 
clear heads who hung back from operating, greatly to the 
disadvantage of their patients. As to the operation of 
abdominal section itself, however, it was beyond all question 
a specially difficult and dangerous operation, and required 
the greatest preparation and care, and perhaps ought to be 
considered a field by itself. 

As to the criticisms on his paper, he had to thank Dr. Knox 
for his appreciative remarks ; it was something for a medical 
practitioner to merit the approval of an Hospital surgeon. 
He was pleased that Dr. Xapier had not only been able to 
corroborate his observations as to the postpartum painful 
spot, but was able to add an original observation of his own ; 
and he was sure that something definite would come out of 
such observations ere long. Mr. Gilmour had relieved the author 
of rashness in operating, but he was not sure that opera- 
tions were justified in hopeless cases ; nevertheless it was just 
in hopeless cases that the pride of surgical aid lay. To snatch 
one life that was totally miserable and hopeless from the 
grave was a great accomplishment ; and when Hippocrates 
said the physician should at least do no harm, he spoke not 
of distinct attempts to save life, but of experiment. An 
attempt is a thing very clearly definable from an experiment. 
As to the opinion which had shocked so many members of the 
Society, that a surgeon must almost needs sacrifice many lives 
before he could perfect himself in his art, his opinion would 
be rendered clear by quoting from Sir Spencer Wells — " But 
in this country such is the sacredness of human life, even when 



Glasgoiv Southern Medical Society. 151 

threatened by fatal disease ; so strong is the consciousness 
that the introduction of innovations like ovariotomy insures the 
destruction or shortening of a certain number of lives during 
the tentative stage of the practice, that men, even of the stamp 
of the Hunters and Bells naturally shrank from the responsi- 
bility imposed upon them by their position and reputation of 
adopting and inaugurating it as a part of legitimate surgery ; 
and elected rather, in the modesty of their greatness, stare 
decisis et non quietd mover e, to content themselves by tend- 
ing with careful pains the last flickerings of life in their 
confiding patients, and soothing as best they might their 
prolonged sufferings than, as it would seem to them, proceed 
to the choice and immolation of the sacrificial victims, 
demanded as the inevitable price of the safety of future 
generations, or the aggrandisement of their own fame." — 
Ovarian and Uterine Tumours, 1882, pp. 184-185. As to the 
expression of such a sentiment, every one was at liberty to 
form his own opinion ; as to this fact, there could be little 
doubt that a first operation could not by any possibility have 
the same chance of being as well performed as a second or a 
twentieth ; and it was also a well known fact that an 
operator's success somewhat travelled with his increased 
experience and dexterity in operating. Dr. Glaister's observa- 
tions he was pleased to hear, since they homologated his own 
opinion, always excepting that of placenta prsevia, a thing 
which doubtless Dr. Glaister had had a good deal of experience 
of. He hoped, however, on a future occasion, to take up this 
subject more fully. As to Dr. Pollok's opinions, he could assure 
him he was entirely in the wrong. It was only in cases of 
quiescent, non-bleeding, slowly growing fibroids that Dr. Keith 
advocated delay ; and, in fact, in many of these kinds of cases 
the condition of the patient was such as to bring them into 
Mr. Gilmour's forbidden list. In regard to other abdominal 
tumours, the universal opinion was to operate early before 
adhesion had taken place, and before the peritoneum had 
become a different kind of membrane from irritation. As a 
matter of fact, Bantock had published a book — Plea for Early 
Operation in Ovariotomy — in which he details several very 
interesting cases. In conclusion, he felt proud of having 
converted the much respected Treasurer of the Society, and 
thanked him for his words of commendation. 



152 Medical Items. 

MEDICAL ITEMS. 

UXDER THE DIRECTION OF 

ALEX. NAPIER, M.D. 

On Opening and Drainage of Abscess Cavities in the 
Brain. — The antiseptic method of operating and after treat- 
ment has not as yet been fully tested in operations upon the 
brain. This is natural, for not only have we inherited a just 
dread of dealing with an organ, the large majority of whose 
diseases are dangerous or fatal, but our knowledge of the 
physiological functions of the brain and of their pathological 
modifications being extremely limited, we are not in a position 
to form such an accurate diagnosis as calls for surgical inter- 
ference. Drs. Christian Fenger and E. W. Lee, of Chicago, 
in an extremely interesting paper on this subject in the July 
number of The American Journal of the Medical Sciences, 
consider the treatment of traumatic cerebral abscess, and 
report a case which was successfully treated by opening and 
drainage. 

Bergman, in discussing the treatment of cerebral abscess, 
unhesitatingly sets it down as an axiom that wherever there 
is an accumulation of pus, trephining is most clearly and 
indubitably indicated, for the opening of an abscess in the 
brain is as necessary as in any other part of the body, and 
we would add even more so. A correct diagnosis of abscess 
having been made, the further difficulty presents itself of 
locating it with sufficient accuracy, so as to be able to find 
it. A number of cases are on record, in which a correct 
diagnosis had been made, the trephine also put on more or 
less at the right place, but the knife or trochar being passed 
into the brain, nevertheless missed the abscess. Drs. Fenger 
and Lee show by their case that this difficulty can be obviated 
by multiple exploratory aspirations, performed at points 
sufficiently close to each other to prevent any abscess from 
escaping detection, even if the trephine opening should not 
have been made at the point of the skull nearest the abscess. 

There are on record a large number of cases of cerebral 
abscess, in which trephining was performed, pus evacuated, 
and temporary relief obtained; but later relapse followed, 
and a fatal termination ensued. It is possible, judging from 
the success the practice has met with in the treatment of 
abscesses in other situations, that drainage of the cerebral 
abscess cavity, with or without washing out, would have 



Medical Items. 153 

saved some of these cases by preventing the re-accumulation 
of pus and the continuous infection of the surrounding brain 
tissue, the acute oedema of which is well known to be, as 
a rule, the final cause of death. As far as Drs. Fenger and 
Lee are aware, draining and washing out of cerebral abscess 
cavities has heretofore not been tried ; that it can be effected 
and without any detriment to the patient is shown by their 
case, the treatment of which they hold strictly conforms to 
the rational methods of modern surgery in treating abscesses 
in general ; and because of this, and not because their patient 
recovered, they regard the case as answering affirmatively the 
question : Is it probable that abscesses in the brain can be 
treated advantageously on the same principles as abscesses 
in other parts of the body ? 

On the Pathology of Paget 's Disease of the Nipple. — 
Drs. Louis A. Duhring and Henry Wile, of the University 
of Pennsylvania, give in the July number of The American 
Journal of the Medical Sciences an instructive study of the 
pathology of Paget's disease, which has already evoked some 
discussion. The importance of the subject is apparent, and 
it ultimately resolves into the question of distinguishing 
between ordinary eczema of the nipple and another similar 
cutaneous pathological process which on good grounds is 
believed to lead to the formation of malignant disease of the 
mammary gland. 

The affection is regarded by Drs. Duhring and Wile as an 
abnormal proliferation and degeneration of the rete, with 
secondary destruction of the papillae of the corium, and 
subsequent development of scirrhous cancer of the atrophying 
variety. The cancerous change originates in the epithelium 
of the smaller ducts, and advances from below upwards and 
outwards as far as the skin is concerned; later it attacks 
the gland structure ; and the retraction of the nipple is an 
early sign of carcinomatous change. 

Improved Method of Applying Chrysophanic Acid in 
Psoriasis. — M. Besnier is at present engaged on a series of 
experiments regarding the best manner of using Auspitz's 
method of applying certain substances to the skin in a solution 
of gutta-percha in chloroform, named "traumaticine." He has 
used chrysophanic acid in the treatment of psoriasis by first 
brushing the patches energetically with a strong brush soaked in 
a 15 per cent solution of chiysophanic acid in chloroform. The 
duration and energy of the application should vary with the 



154 Medical Itemvs. 

thickness of the psoriatic patch. The application gives rise to 
a sensation of heat and pricking which is not severe, and soon 
passes off. In a few seconds the chloroform is evaporated, 
and the patch, being literally infiltrated with pure chiysophanic 
acid, is stained of a deep yellow. Then, with a large flat 
brush, " traumaticine " is applied over and be} r ond the edges 
of the patch. The result is said to be excellent. The arti- 
ficial cuticle referred to is made by dissolving one part of 
purified gutta-percha in ten parts of chloroform. This forms 
an excellent medium for fixing the application, as it adheres 
firmly and without alteration for two or three days, or even 
longer. On comparing it with gelatinous excipients, the latter 
are seen to possess the following disadvantages : — (1.) They 
are liable to be rubbed off by contact with the limbs or 
clothing, and hence usuallj- necessitate one or two renewals of 
the application. (2.) The gutta-percha compound, on the 
other hand, forms a thinner and more delicate cuticle than 
either collodion or gelatine, producing neither tension nor 
pain. (3.) Its neutral character adapts it as a protective 
investment to parts however sensitive. Prepared as above, it 
has never given rise to irritant symptoms, either in children 
or adults, even when painted over large surfaces. (4.) It 
exerts a more equable pressure than gelatine, the flexible 
elastic gutta-percha adapting itself better to uneven surfaces. 
Gelatine forms a brittle coating, so that an addition of 
glycerine is needed to render it sufficiently pliant, and 
prevent it from contracting when dried, especially when joints 
are to be covered. {Annates de Dermatologie et de SyphUio- 
graphie. No. 1, vol. v.) — The Practitioner. July, 1884. 

On the CEtiology of Tuberculosis. By Professor O. 
Bollinger, of Munich. 1883. — Dr. F. Schmidt, of Augsburg, 
has in the Pathological Institute of Munich instituted a series 
of experiments, which demonstrate that the tuberculous 
poison cannot enter the body by way of cutaneous injection 
— e. g., by vaccination. This result, taken along with that of 
Lothar Meyer, who excluded with certainty the presence of 
seven vaccinated phthisical patients, leads to the conclusion 
that an inoculation of tuberculosis in human vaccination is 
not to be dreaded ; also, the infectious nature of the air of 
rooms inhabited by phthisical patients is not so great as 
would be supposed, because injections of glycerine loaded with 
the dust of such sick chambers is always cmite unsuccessful. 

-Deutsche Medizinal Zeitimg. No. 9. 31st January, 1884. 
L. S. 



Medical Items. 155 

Cortical Lesions of the Brain. — While anatomical study, 
demonstrating a connection between various organs of the 
body and definite regions of the surface of the brain, may 
furnish grounds for a priori reasoning as to the function of 
those regions ; and while physiological experiments upon 
animals may afford valuable suggestions as to the probable 
effect of limited brain disease in man, an accurate determina- 
tion of the question of localisation can only be reached by a 
study of clinical cases. The appreciation of this fact has led 
Dr. M. Allen Starr to collect, in the April number of The 
American Journal of the Medical Sciences, the cases on 
record in American journals, in which a limited area of diseas 
of the cortex, whose position was determined by a careful 
autopsy, had given rise during life to definite symptoms. 
From the comparison and classification of these cases with 
the foreign cases collected by Charcot, Ferrier, Nothnagel, 
Exner, Wernicke, and others, certain general conclusions, 
which are of great practical importance, have been reached, 
and it is now possible to refer many symptoms occurring in 
the course of brain diseases to a destruction of a definite area 
of the surface. 

For instance, in reviewing the cases of lesion of the frontal 
region, it is noticeable that decided mental disturbance 
occurred in one-half. This did not conform to any one type 
of insanity. It is rather to be described as a loss of self- 
control, and a consequent change of character. The other 
symptoms are chiefly negative. 

The absence of disturbances of motion and sensation and of 
the special senses warrants the statement that the motor and 
sensory areas of the cortex do not lie in the frontal region, 
and that the diagnosis of lesions of the frontal convolutions 
must rest upon the presence of general symptoms of cerebral 
disease and of mental disturbance, and also upon the absence 
of motor and sensory disturbance. 

Lesions of the temporo-sphenoidal lobes may exist without 
giving rise to any local symptoms. Symptoms of disturbance 
of the special senses of hearing and smell, and loss of memory 
of perceptions acquired through these senses, may be caused 
by lesions of this region ; odours being probably perceived in 
the inner sphenoidal convolutions, and sounds in the first 
temporal convolutions. The areas connected with motion, 
with general sensation, and with vision, do not lie in the 
temporal lobes. 

The importance of a careful examination of all the special 
senses in any case of suspected brain disease is enforced by 



1 5 6 Met I ica I Items. 

the probability that some of the sensory areas lie in this 
region ; but that the symptoms produced by their destruction 
have been hitherto overlooked. 

The most prominent local symptom of lesion of the occipital 
lobes is a disturbance of vision — blindness. Absence of motor 
or sensory disturbance is also noted. A study of the cases 
warrants the conclusions that the visual area lies in the 
occipital lobes, and that the areas governing speech, motion, 
general sensation, and non-visual sensory impressions lie else- 
where. 



Corrosive Sublimate as an Antiseptic. — In the Progres 
Medical for the 12th April, 1884, an interesting review on this 
subject will be found. Professor Tarnier, who has been using 
corrosive sublimate in the wards of the Maternite de Paris 
since 1870, claims a reduction in the mortality, and the most 
successful results generally from his experiments. The writer 
holds that its importance in obstetrics was first recognised in 
France, and although in that country it has not yet been 
freely used in general surgery, the surgeons of other countries 
have employed it, especially Germany, where he says " there 
is scarcely a pathological institute in which at least one 
clinique, either surgical or obstetrical, will not be found to 
have adopted this antiseptic to the exclusion of all others." 

The review deals with laboratory as well as clinical experi- 
ments, and in this department Billroth, Kuhn, Petit, Koch, 
and others are quoted as giving their testimony in favour of 
its efficacy. 

So far as clinical work is concerned, it may be stated that 
since 1882 it has entirely replaced carbolic acid at the 
Maternite, and now Budin at the Charite', and Schroder in 
Berlin, have adopted it. 

In surgery, quite a number of writers in Germany, Italy, 
and America are said to have declared their results satisfactory; 
so far, no bad results having been noted. 

The only opponent is Stadfeldt, of Copenhagen, and his 
objections are seemingly founded for the most part on a death 
which, it is alleged by others, resulted from acute nephritis 
with uraemia. 

For surgical purposes, Weir, of New York, and Valerani, in 
Italy, use the drug in the proportion of 1 in 2,000. The latter 
states that, used in this strength, there are no toxic symptoms 
developed, and it has the advantages over carbolic acid of 
being inodorous and less expensive. — J. M. 



Medical Items. 157 

Glycerine in Acute Fevers. — Professor Semmola calls 
attention to the use of glycerine as an aliment in the treat- 
ment of grave acute febrile processes, and especially in typhoid 
fever. Alcoholic drinks, he says, have only a pretended 
antiseptic action, which has deceived many eminent prac- 
titioners. In his opinion, alcohol produces a toxic action very 
much as do other antipyretics — veratrine, digitalis, carbolic 
acid, and salicylic acid — disproving the dangerous Utopian 
ideas of some young physicians concerning the power of 
carbolic and salicylic acids, &c, to cure or abort typhoid 
fever. As to alcohol, on account of its exciting action on the 
heart and cerebrum, and its disturbing action on the digestive 
organs, Semmola has entirely discontinued its regular and 
constant use as an aliment in grave febrile processes, reserving 
this agent for combating threatening heart failure. Glycerine, 
on account of its chemical composition, long since appeared to 
Semmola a substance which might replace alcohol in these 
fevers, and which would give the patients a greater resistance 
to the action of the fevers. He uses the following formula : — 

R. — Glycerine, pure, . . . . 15J. 

Citric or tartaric acid, . . . 5j- 

Water, ad. f,5xvj. — M. 

S. — i5v-viij every hour. 

This solution is well borne by the patient ; but sometimes, 
on account of its acidity, Semmola gives it at the hours for 
taking milk or beef-tea. In the rare cases in which the 
solution is unpleasant to the patient, he replaces the acid by a 
few drops of oil of anise. The principal therapeutic effect, 
and the only one upon which Professor Semmola insists, 
consists in the quantity of urea eliminated. From an accurate 
observation of twenty cases of typhoid fever, he concludes 
that the diminution during twenty-four hours may amount 
to as much as 3vij, and, as a rule, it is from 90 to 100 grains. 
He has proved by experiment that the glycerine is an agent 
in this diminution. {Journal de M6d. de Paris, 22nd Dec. 
1883.)— The Practitioner. June, 1884. 

Metastatic irido-choroiditis. — Dr. Charles J. Kipp reports 
three cases of this kind in the April number of the Amt rican 
Journal of the Medical Sciences. They were all limited to one 
eye only. In the first case, the disease was caused by acute pur- 
ulent inflammation of the middle ear ; in the second, by chronic 
suppuration of both middle ears: in the third, by puerperal 
fever. In all three cases the affected eye was lost. The first 



158 Medical Items. 

and second of the cases, while not presenting unusual features, 
as far as either the eye or the ear diseases are concerned, are 
of value, since there are no cases on record in which this eye 
disease was caused by inflammation of the ear. The third 
case derives its interest from the fact that the patient recovered 
her health — a very uncommon event in cases in which suppura- 
tive irido-choroiditis follows puerperal fever. 

Opium Poisoning Associated with Albuminuria and 
Glycosuria. — M. Queyrat records the case of a lad of 16 
years of age who had taken an overdose of opium, and was 
admitted into hospital in a state of semi-coma. His urine 
contained a small quantity of albumen, and fully 9 grammes 
of sugar. The albumen disappeared in two days, and the 
sugar on the third. The case is of interest as confirming 
Claude Bernard's experiments in animals in which opium 
poisoning produced glycosuria. — La France Medicale. 4th 
January, 1884. — G. S. M. 

Lotion in Severe Contusions. — Dr. Hewson, who resides 
in a town of Texas, where accidents from saw-mills and 
lumber-works are frequent, communicates the formula of a 
lotion which he says he has found of great utility in treating 
the severest contusions : — 

R. Sodse hyposulphitis, . . . $iv. 

Acid, carbol. cryst., . . . 5ss. 

Glycerini, . . . . . |ij. 

Aquse, Oj. — M. 

A cloth well saturated in the solution to be kept constantly 
applied to the part. — Philadelphia Medical News. 23rd Feb. 

1884. 

Diphtheritic Paralysis. — In the July and September (1883) 
numbers of the Australian Medical Journal are recorded two 
interesting cases of diphtheritic paralysis. In the first case, a 
girl four years old, after a slight attack of throat affection, the 
child was observed to snore a great deal in her sleep, and her 
voice had a nasal intonation. The tonsils were much enlarged; 
the muscles of the palate did not show evidences of paralysis ; 
and there was no difficulty of swallowing. Six weeks after 
the throat affection, when she was apparently in vigorous 
health, she suddenly lost all power in the legs below the 
knees. Patellar tendon reflex was absent, the calf muscles 
obeyed the battery badly, and the limbs felt unnaturally cold. 



Medical Items. 159 

Four days later there was complete paralysis of the right arm 
and forearm, with slight ptosis of right eyelid. Next day the 
intercostal and pectoral muscles became affected, and the child 
died suffocated. The child could speak and swallow till within 
five minutes of death. There was no post-mortem examina- 
tion. 

The second case was that of a young man about 20, who had 
had a very mild attack of diphtheria. After he had been for 
some time quite convalescent he was seized with paralysis of 
the legs, with absence of patellar reflex. He became gradually 
worse, and the paralysis extended to the arms, but never to 
the eyes or throat. Under treatment by massage he gradually 
recovered. 

The recorder of the first case refers the lesion to the terminal 
ends of the nerves affected ; of the second, to the spinal cord. 
— G. S. M. 

The Transmissibility of Hydrophobia from Man to 
Man. — In December it was stated, in the Gazzetta degli 
Ospitcdi, that Dr. J. Huszar of Pesth, whilst dissecting the 
body of a man that died of hydrophobia, slightly cut his 
finger. Within a few days hydrophobia appeared and quickly 
proved fatal. In reference to this case, Professor Lussana 
of Padua, writes somewhat at length, remarking that if it 
be true it is of the gravest importance. It had, he says, been 
looked upon as a settled point that the disease was not by 
any means whatever transmissible from man to man, though 
it has occasionally been communicated from man to some 
species of the lower animals, especially dogs. The experience 
of various surgeons, from the time of Andy in 1780, is then 
brought forward to show that wounds received in dissecting 
bodies of persons dead of hydrophobia were never followed 
by the disease. Cases in which such infection is alleged to 
have taken place are examined and found to be equivocal. 
It may be mentioned that Drs. Brigidi and A. Bianchi, out 
of more than a dozen attempts (Lo Sperimcntale, August 
1883), to communicate hydrophobia from the human subject 
to the lower animals, succeeded only once. Though many of 
the other cases proved fatal, neither the symptoms nor the 
post-mortem appearance could properly be regarded as belong- 
ing to the disease in question, and septicemia was held to be 
the cause of death. — Birmingham Medical Revieiv — J. A. A. 



160 Books, &c, Received. 



Books, Pamphlets, &c, Received. 

Bader Almanach, Mittheilung der Bader, Luftcurorte und 
Heilanstalten in Deutschland, Oesterreich, Schweitz und den 
angrenzenden Gebiete. Zweite Ausgabe. Frankfort A. M. 
Berlin : Rudolf Mosse. 1884. 

Hints on the Health of the Senses. By H. Macnaughton Jones, 
M.D. London : Longmans, Green d- Co. 1884. 

Corpulence and its Treatment on Physiological Principles. By Dr. 
Wilhelm Ebstein. Translated from the Sixth German Edition 
by Prof. A. H. Keane, B.A., University College, London. 
Wiesbaden : J. F. Bergmann. London : H. Grevel. 1884. 

Clinical Demonstrations on Ophthalmic Subjects. . By J. Pv. Wolfe, 
M.D. With illustrations. London : J. & A. Churchill. 1884. 

Cremation, the Treatment of the Body after Death. By Sir Henry 
Thompson. Third Edition. With a paper entitled Cremation 
or Burial, by Sir T. Spencer Wells, Bart., and the Charge of Sir 
James Stephen, recently delivered at Cardiff. London : Smith, 
Elder & Co. 1884. 

Die Methode des Unterrichts an der chirurgischen Klinik der 
Univeritat Kiel, mit acht Beilagen. Von Prof. Dr. Esmarch. 
Kiel : Lipsius & Tischer. 1884. 

Vorschlage zur Beseitigung der Drainage bei alien frischen Wunden. 
Von Dr. G. Neuber. Kiel : Lipsius ib Tischer. 1884. 

Diseases of the Heart and Thoracic Aorta. By Byrom Bramwell, 
M.D. With 317 illustrations. Edinburgh : Young J. Pent- 
land. 1884. 

Syphilis and Pseudo-Syphilis. By Alfred Cooper, F.R.C.S.Eng. 
London : J. & A. Churchill. 1884. 

A Treatise on the Continued Fevers of Great Britain. By Charles 
Murchison, M.D., LL.D., F.R.S. Third Edition. Edited by 
W. Cayley, M.D. London : Longmans, Green &, Co. 1884. 

On Visceral Neuroses : being the Gulstonian Lectures on Neuralgia 
of the Stomach and Allied Disorders, March, 1884. By T. 
Clifford Allbutt, M.A., M.D., Cantab., F.R.S. London : J. & 
A. Churchill. 1884. 

Atlas of Porti'aits of Diseases of the Skin. Issued by the New 
Sydenham Society. Seventeenth Fasciculus. , 1884. 



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THE 



GLASGOW MEDICAL JOURNAL. 



No. III. September, 1884. 



ORIGINAL ARTICLES. 



THE PATHOLOGY OF SUPPURATIVE INFLAMMA- 
TIONS OF THE KIDNEY. 

By JOHN LINDSAY STEVEN, M.D. 

{Being his Thesis for the Degree of M.D. in the University of Glasgow.) 

In the following thesis it is my intention to discuss a group 
of affections of the kidney which, although well recognised, 
has not perhaps received the attention at the hands of 
pathologists and others which its importance demands. At 
various intervals during the past three years, in the course 
of my ordinary pathological labours, I have engaged in a 
minute investigation of the cases of Suppurative Diseases of 
the Kidney which came under my observation in the laboratory 
of the Glasgow Western Infirmary, the results of which will 
be given in due course ; but at the outset of my remarks I 
wish in the first place to draw attention briefly to certain 
points of distinction between these and the usual forms of 
Bright' s disease. 

In pathological terms we understand by Bright's disease 
(excluding altogether at present the amyloid variety) an 
inflammation, which may be acute or chronic, of the kidney 
tissue, attacking in the different forms of the affection different 
portions of the renal structure. Now it is a fact worthy of 
note that in the usual forms we do not meet with any change 
of a distinctly suppurative nature, although in the acute 
varieties we have an inflammation of a distinct and pronounced 
kind present. In these affections, too, we have generally a 
symmetrical disease, and one attacking every portion of the 
organ, the tubules in some, the interstitial tissue in others. 
There is generally, however, more or less merging of the one 
No. 3. M Vol. XXII. 



162 Dr. Steven — The Pathology of 

form into the other, constituting the so-called unity of Bright' s 
diseases. Here, too, we have a distinctly idiopathic affection, 
hut not even in the most acute interstitial nephritis, so far as 
my experience goes, can it be said that we have anything like 
suppuration. 

These points concerning Bright's disease being borne in 
mind, we have at once the key to the differences between it 
and the class of affections I am about to consider. In the 
first place, these diseases are characterised by the presence of 
suppuration, which does not involve the whole of the tissue of 
the kidney in which it is found. They may not be symmet- 
rical, and they are not idiopathic, at least in the same sense 
that an ordinary case of Bright's disease is. Of course, in a 
certain broad sense one might say that Bright's disease is not 
idiopathic either, i. e., all analogy points to the condition, viz., 
the inflammatory process, being the result of the action of 
some irritant, but from the fact of our ignorance of the nature 
of this irritant, and of its mode of action, we regard the 
disease as idiopathic. In this sense, however, the class of 
affections with which we are dealing is not idiopathic — the 
disease is essentially a secondary one, dependent upon a cause 
which can be demonstrated, and whose action can to a certain 
extent be watched. The distinction which I have thus 
attempted to draw between these two classes of renal affection 
is not without its analogue in other organs— thus, similar 
remarks might be made of the distinction between metastatic 
abscesses of the lung and croupous pneumonia. 

Having thus briefly indicated the main points of distinction 
between suppurative inflammations of the kidney and the 
affections usually classed as Bright's disease, I must now 
shortly formulate or define the characteristic points of sup- 
purative nephritis. 

Suppurative nephritis is an inflammation of the kidney 
tissue of a very violent nature, characterised by the rapid 
development of pus, and generally, perhaps always, secondary 
to the action of some intensely irritating exciting cause, e.g., 
micro-organisms, impacted calculi, suppurative disease of the 
lower urinary passages, &c. In many cases the production of 
pus is limited to minute areas scattered throughout the renal 
tissue, the intervening sul stance being often quite healthy : 
in other cases the production of pus is much more abundant, 
and, although at first limited to distinct areas, yet by gradual 
enlargement and coalescence of the, different centres it may 
gradually overtake and destroy the whole kidney tissue, 
converting the organ into a large uni- or multilocular abscess. 



Suppurative Inflammations of the Kidney. 163 

The former, though not always, is perhaps most frequently 
found in both kidneys, the latter in only one. 

Such may be taken as a definition of the class of diseases 
forming the subject matter of this essay ; and in these days, 
when operations on the kidney are ranking as part of the 
regular work of the surgeon, it will be readily admitted that 
an accurate knowledge of the pathology of such diseases is 
of great importance. I have already said that the subject 
of renal suppuration has not received the minute attention 
at the hands of pathologists and others which it deserves. 
In the case of scattered points of suppuration, the reason 
probably is that the affection constitutes a late and secondary 
phenomenon of some primary disease, that the diagnosis is 
difficult, and that even if diagnosed, it remains a question 
whether either surgery or medicine could afford much relief. 
But even in this class of affections a knowledge of the cause 
of the condition and of the mode in which it develops itself 
is of first rate importance, because, although we may be able 
to do but little once suppuration has become established, we 
will at least be in a better position to prevent its occurrence. 
That the minute pathology of renal abscess of the larger 
varieties has received comparatively little attention is probably 
due to the fact that until quite recently operations on the 
kidney were regarded as beyond the domain of surgery. I 
am aware that surgical kidney (one form of which is included 
under the head of suppurative nephritis) has long been under 
the consideration of surgeons, but for the most part only to 
be regarded as a condition beyond the power of art to alle- 
viate, and thus the minute morbid changes involved, and the 
mode in which the morbid poisons gain access to the organ, 
in this and allied affections, have to a large extent been 
overlooked. 

I shall, therefore, in what follows, endeavour to discuss the 
entire subject of renal suppuration, dwelling with special 
emphasis upon the cases which I have myself investigated, 
but also referring to others which I have not had the 
opportunity of examining in order to give completeness to 
the paper. It is necessary, therefore, in some way, before 
going into detail, to classify the various forms of suppurative 
inflammation of the kidney, and I beg to submit the follow- 
ing, which, based mainly on etiological considerations, I hope 
will be found to include most of the forms : — 

Class I includes those cases in which the suppurative 
inflammation owes its origin to septic and irritating material 



164 Dr. Steven — The Pathology of 

being carried into the kidney by means of the circulating 
blood, and of this class two sub-classes may perhaps be dis- 
tinguished, viz : — 

(1.) Where the abscesses are small, multiple, and sym- 
metrical, as in pyaemia. 
(2.) Where the abscess is large and may be confined to one 
side, as is sometimes met with in ulcerative endo- 
carditis. 

Class II includes those cases in which the suppurative 
inflammation owes its origin to disease or injury of the 
urinary passages beneath the kidneys themselves, and is 
caused by infective material spreading upwards, by impac- 
tion of calculi, &c. This class may also be divided into two 
sub-classes, viz : — 

(1.) Where the abscesses are miliary and multiple, and this 
may be further subdivided according as the virus 
has obtained access to the organ. 
(<7.) by the uriniferous tubules. 
(6.) by the lymphatic vessels. 
(2.) Where the abscesses are of large size ; and this may 
be further classified according to the cause operative 
in each case. 
(a.) impaction of calculi in pelvis. 
(6.) impaction of foreign bodies in the pelvis, and various 

injuries, 
(c.) suppurative disease of the lower urinary tract. 

Class III includes those cases in which the suppurative 
inflammation may be regarded as specific in origin, e. g., 
tubercular disease of the kidney (renal phthisis). 

Class IV includes those cases in which the infective 
material may be brought by the blood or carried from the 
lower passages, but in which the production of pus is mainly 
confined to parts immediately surrounding the kidney — 
perinephric abscess. 

Having thus classified the different forms of suppurative 
nephritis, I must, before going further, indicate the methods 
in which I have conducted my research, and point out the 
way in which I intend treating the subject. I have occupied 
myself mostly in investigating cases of multiple abscess of 
the kidney, because there can be no doubt that more informa- 
tion, both pathological and etiological, is to be obtained from 
such than from cases where the renal tissue has been veiy 



Suppurative Inflammations of the Kidney. 165 

largely destroyed by the suppurative process. Besides, 
excepting perhaps the cases of suppuration caused by calculus, 
injury, or impaction of foreign bodies in the pelvis of the 
kidney, it is likely that in a large number of the cases of 
extensive suppuration of the kidney due to disease of the 
lower urinary tract, the occurrence of scattered miliary 
abscesses is one of the preceding phenomena. I shall describe 
the various appearances in the order in which the different 
forms have been arranged in the table of classification, and 
shall, as an appendix, give the formal detailed account of the 
cases on which the facts and opinions recorded in this paper 
are based. 

The method of investigation was as follows : — The naked 
eye appearances and other general characters of the case were 
noted. Portions of the kidney containing abscesses were then 
hardened in spirit, and in some cases also portions of the 
lower urinary tract. Spirit was used in preference to any 
other hardening reagent, because sections of tissues so treated 
were found to stain better than those hardened by any other 
medium. After being thoroughly hardened, sections of the 
tissue were made. In my earlier cases, examined about three 
years ago, I cut the sections with the razor, because I found 
the freezing, necessary to employ either Rutherford's or 
William's microtome, seriously interfered with the proper 
staining of the specimens. During the past year, however, 
during which I have been engaged in investigating my later 
cases, I have made use of a microtome, which I first saw and 
used while working in the Pathological Institute of Leipzig, 
under Professor Cohnheim. The great advantage of this 
instrument is that by means of it very beautiful sections 
can be cut without the necessity of freezing the tissue, and thus 
it is peculiarly well fitted for the purpose I had in view — viz., 
to obtain sections which would stain well. Having cut the 
sections, they were first of all examined unstained, and, the 
general appearances having been noted, they were then 
subjected to staining in order that micro-organisms, if present, 
might be more easily demonstrated. In the course of my 
examinations I have made use of only two dyes — viz., 
Bismarck brown and gentian violet, especially the former, as 
it is only quite recently that I have been able to obtain a supply 
of srood gentian violet. The Bismarck brown was used dissolved 
in water, or in a mixture of water and alcohol, both forms 
of solution answering the purpose almost equally well. When 
water was used as the solvent, no definite quantity of the dye 
was employed, but simply enough to make a pretty strong 
solution, which was then filtered. When alcohol was em- 



166 Dr. Steven— The Pathology of 

ployed along with the water as a solvent, the following 
formula was found to give very good results : — 

Bismarck brown, . . . . . . ~ } ss. 

Alcohol, . . . . . . . ~) v. 

"Water, . . . . . . . 5 l. 

In using the gentian violet as a stain, a 2 per cent filtered 
solution in water was employed. Both dyes give very good 
results, but I prefer to use Bismarck brown, as it is that to 
which I have been most accustomed. The following quotation 
from Koch expresses very well the method of treating the 
sections, which is that of Weigert modified. " The objects for 
examination are first hardened in alcohol. The sections from 
these are allowed to lie for a considerable time in a pretty 
strong solution of methyl-violet. They are then treated with 
dilute acetic acid, the water removed by alcohol, cleared up in 
oil of cloves, and mounted in Canada balsam. Instead of 
methyl- violet, other aniline dyes (e. g., f uchsin, aniline-brown, 
&c.) may be used in the same manner." If the term Bismarck 
brown is used instead of methyl-violet in this quotation, 
it expresses exactly the method followed in the present case ; 
and with regard to the time necessary for staining the sections 
I found that from five to fifteen minutes was long enough, 
although no harm resulted from their bein£ left for much 
longer periods. 

When the sections were prepared in the way just described, 
they were subjected to a careful microscopic examination. The 
Bismarck brown stained the specimens of a rich reddish-brown 
colour, the nuclei of the epithelial cells and the inflammatory 
corpuscles being specially well brought out, and thus there was 
not the slightest difficulty in at once selecting the areas that 
were the seat of suppurative change. Organisms when pres- 
ent were also discovered with great ease, as they absorb the 
colouring matter so greedily that they stain of a very deep 
colour. When they occurred in colonies, so deep was the tint 
that the little groups could be picked out with the low power 
very easily. Where they were not grouped in colonies, but 
scattered, the}* were often more difficult to find, and in this 
case the use of Abbe's condenser greatly facilitated the search. 
By the use of this instrument we can get a "colour" as 
opposed to a " structure picture," the latter being that seen in 
or« Unary microscopic work. The effect of the " colour picture " 
is to get rid of the shadows, and bring prominently into view 
all parts of the section which are deeply stained. By such an 
arrangement minute organisms which are deeply stained, but 
hidden by the shadows of fibres and cells, are brought into 
view. The organisms discovered in the various sections were 



Suppurative Inflammations of the Kidney. 167 

mostly micrococci, but in a few of the specimens the appear- 
ance presented was that of minute ovals or rods. 

Having thus discussed the general aspects of the subject 
and the plan upon which the investigation has been conducted, 
I now pass on to consider the histology and etiology of the 
lesions included in Class I, which are known as 

Metastatic Abscesses of the Kidney. 

The occurrence of metastatic abscesses, not only in the kid- 
neys but in other organs of the body, in pyaemia has long- 
been very well known, and the dependence of this condition 
upon embolism is a fact that has been well recognised for a 
lengthened period. Latterly, also, the improved methods of 
research, which have enabled investigators to study the appear- 
ances and effects of micro-organisms in the tissues, have 
confirmed what was long surmised, that in pyaemia the emboli 
are irritating and septic in nature. These considerations 
render it, perhaps, less imperative that I should discuss this 
department of the subject in very great detail, but it is 
nevertheless necessary, both to confirm the observations of 
others and to give completeness to my paper, that I should 
record the conclusions to which I have come, after careful 
investigation of the cases, which I have myself had the oppor- 
tunity of examining. 

First of all, then, fall to be considered those cases included 
in my first subdivision of this general class, viz. : — where the 
abscesses are small, multiple, and symmetrical. The abscesses 
are not limited to the kidneys, but may be found in every 
part to which the poisoned blood has access, and from this 
circumstance, together with the fact that here the condition is 
but part of a very grave general disease, it arises that such 
cases constitute the most hopeless form of suppurative inflam- 
mation of the kidney. The remarks which I have now to 
make are based upon the study of the appearances presented 
in Case No. 7 of the appendix, and in a case of ulcerative 
endocarditis published by Drs. Renton and Coats, the kidneys 
of which I have frequently had the opportunity of examining. 

In pyaemia the abscesses are very numerous, and, from the 
peculiar arrangement of the renal blood-vessels, they are 
much more abundantly present in the cortical than in the 
pyramidal portion, it being a comparatively rare circumstance 
to meet with them in the latter site. But besides the 
peculiarities of situation, there are many others which 
strongly indicate that the abscesses owe their origin to 



168 Dr. Steven— The Pathology of 

some interference with the circulation. When near the 
surface they form little rounded elevations ; each little eleva- 
tion is generally surrounded by a very intense zone of 
hyperemia, or even by a minute haemorrhage, so that the 
fully formed abscess presents the appearance of a small 
yellow elevated spot, surrounded by a bright red ring. So 
deep is the red staining of the circumference of the abscess 
in many cases that prolonged immersion in spirit often fails 
to remove the red colour. Dr. Coats noted the same appear- 
ance in the kidneys of the case of ulcerative endocarditis 
already referred to, and says, "The kidneys were beset by 
innumerable hemorrhagic spots, each with a yellow spot 
(pus) in the middle. These were mostly present in the 
cortex, but were also present to some extent in the pyramids." 
The haemorrhagic condition of many of the abscesses is also 
indicative, as the microscopic examination shows, of the fact 
that a very rapid disintegration of structure has taken place, 
allowing of the escape of blood into the neighbouring tissues. 
The shape of the abscesses, too, is sometimes suggestive of 
their embolic origin, as they are generally observed to be 
of a somewhat pyramidal form. 

Having thus mentioned the more prominent naked eye 
characters, the microscopic appearances must now be described, 
in order to demonstrate the histological changes, and also, if 
possible, the nature and properties of the irritant producing 
them. If a section of the tissue containing a fully formed 
abscess be examined with the microscope, the following 
appearances are noted. The pus generally falls out from 
the central parts, leaving a ragged, torn aperture in the 
section. The ragged walls of this cavity are composed of 
round cells (leucocytes), frequently more or less mingled with 
red blood corpuscles, and external to this layer the tubular 
structure of the kidney is observed, with the inflammatory 
cells infiltrating it to a greater or less extent. The marginal 
parts of the abscess often show a homogeneous red colouration, 
due to staining with the blood pigment, which has been 
dissolved and carried to the periphery. In some of the 
sections a peculiar homogeneous and glassy appearance of 
the tubules is observed, which is somewhat suggestive, 
possibly, of the beginnings of the coagulation necrosis of 
Weigert. This appearance, however, cannot with certainty 
be insisted upon ; but still, the fact of its suggestion, together 
with the well known observation that in simple infarction 
of the kidney coagulation necrosis does occur, is another 
point more or less indicative of embolic origin. In the walls 



Suppurative Inflammations of the Kidney. 169 

of the abscess, and between the tubules immediately around 
it, numerous very dilated capillary blood-vessels may often 
be observed — in fact, a kind of hemorrhagic engorgement of 
these vessels. In saying this I may be thought to contradict 
my former statement in reference to coagulation necrosis ; 
but I wish it to be understood that I only mean to say that 
the appearance of the tubules is sometimes such as to suggest 
a change which is probably in the direction of coagulation 
necrosis. Whether in this I am right or wrong, there can 
be no doubt as to the engorged state of the capillaries. By 
a careful search, too, towards the proximal side of the abscess, 
the plugged vessel can often be discovered, a point at once 
placing the embolic origin beyond a doubt. In several of my 
specimens I was able to note this, both when the section was cut 
at right angles to, and parallel with, the long axis of the abscess. 
In what has gone before enough has been said to show that 
here the lesion in the kidney is primarily dependent upon 
the occurrence of embolism ; but the result is so different 
from what occurs in the case of simple renal infarction, that 
it at once renders it apparent that something more must be 
involved in it than a mere plugging of the vessels, such as we 
so commonly find in cases of endocarditis, &c. The explana- 
tion is briefly this, that in addition to plugging one of the 
renal vessels, the pyemic embolus also excites the most intense 
destructive suppuration in the immediate neighbourhood of 
the situation in which it becomes lodged, and this is dependent 
upon the presence in the plug of septic organisms. The 
connection existing between pyemia and the presence of 
micro-organisms has long been insisted upon by many writers, 
but it is only necessary that I should refer to the subject in 
so far as it bears upon suppuration of the kidney. In this 
regard the observations of Dr. James Israel, of Berlin, are of 
very great importance. In two papers which appeared in 
Yirchow's Archiv, he relates cases of pyemia in which, in 
the contents of the abscesses, various plant-like organisms 
were discovered — some like micrococci, others thread-shaped, 
and still another variety somewhat resembling spermatozoa. 
These were found in the pus from the superficial abscesses 
during life, and after death they were also discovered in the 
abscesses occurring in the internal organs. In the kidneys of 
the cases the same appearances were noted, the organisms 
being found in the contents of the abscesses and in the Mal- 
pighian tufts and capillaries ; he also states that the abscesses 
were entirely absent from the pyramidal portion of the organ. 
He also expresses his opinion that while the colonies of micro- 



170 Dr. Steven— The Pathology of 

cocci were often not surrounded by suppuration, the spores 
and threads were always associated with pus. Similar obser- 
vations have also been made with regard to ulcerative endo- 
carditis, and among others may be mentioned the communica- 
tions of Rudolf Maier, C. J. Eberth, K. Koester, and Coats. 
Without at all entering into the question as to whether these 
organisms are identical or non-identical with those occurrino- 

«... ^ 

in other diseases, diphtheria, &c., I have only to say, in 
bringing my remarks on multiple pyaemic abscess of the 
kidney to a close, that my own observations confirm the view 
that metastatic suppurations in the kidney are always asso- 
ciated with the presence of micro-organisms. In the case of 
pyaemia — appendix Xo. 7, — organisms, globular and rod-shaped, 
were discovered in the contents of the abscesses, but I could 
not discover colonies, or distinctl}* relate them to the blood- 
vessels. In Dr. Coats' case of ulcerative endocarditis I had 
not the slightest difficulty in making out large colonies of 
micrococci, both in the Malpighian tufts and capillaries, 
exactly as described by him in his paper. And lastly, in fatal 
cases of erysipelas, I have often seen large colonies of organ- 
isms in the kidney tissue. 

As regards the second subdivision of Class I, which includes 
those cases in which the renal suppuration is of large size, 
a //'/ may he limited to one side, I need not say more than 
that, while I have not had the opportunity of observing the 
occurrence myself, it can readily be supposed to take place. 
It can be easily understood that, in a case of ulcerative 
endocarditis, while the numerous small emboli causing mul- 
tiple symmetrical lesions of minute size are absent, one large 
plug of sufficient size to obstruct one of the larger renal 
arteries might be washed from the diseased valves, and set 
up a large abscess. In looking up cases of ulcerative endo- 
carditis, I have found one reported in Yirchow's Archiv, by 
Maier, in which this occurrence actually took place. Leaving 
out of account the condition of the other organs, with refer- 
ence to the state of the kidneys, it was noted that a large 
embolus had plugged the right renal artery, leading to the 
formation of a large abscess, in which numerous bacteria 
were discovered. 

Abscesses of the Kidney Secondary to Disease or 
Injury of the Lower Urinary Tract. 

Class II in my table of classification includes all those cases 
in which the suppurative inflammation owes its origin to 
disease or injury of the urinary passages beneath the kidneys 



Suppurative Inflammations of the Kidney. 171 

themselves, and is caused by infective material spreading- 
upwards, by impaction of calculi, &c. In this class, too, just 
as in the former, different forms of the suppurative process 
are met with. The abscesses may exist as scattered miliary 
points of suppuration in the renal tissue, or they may be 
present as large pus-filled cavities in the substance of the 
kidney ; and, as before, I shall first describe the etiology and 
pathology of the — 

Multiple Miliary Abscesses. — Abscesses of this kind occur- 
ring in the kidney form one of the varieties of surgical 
kidney, and I am inclined to think they constitute one of 
the most important varieties, not only because I believe it to 
be in many cases the antecedent phenomenon of much more 
grave and extensive destructive lesions, but also because Dr. 
Moxon of London has, with great justice, I think, shown that 
this condition may be recovered from. I cannot, it is true, 
corroborate him from my own observations, but the facts 
which he has communicated to the Pathological Society 
render it extremely probable that, under certain circum- 
stances, upon the amelioration of the exciting disease, such 
small abscesses may disappear, leaving simply small cicatrices 
in the renal tissue. That multiple miliary abscesses of the 
kidney in connection with abnormal states of the lower 
passages occur with considerable frequency is shown by the 
fact that of the 8 cases of multiple miliary suppuration given 
in the appendix, 7 are to be distinctly associated with the 
presence of lesions of some kind or other in the lower urinary 
tract. It must be remarked, too, in this connection, that the 
cases I give were not selected cases, but taken just as they 
occurred in the course of our ordinary pathological work. 
The primary causes of this affection of the kidney, as my 
cases show, may be very various ; e. g., a putrid abscess 
communicating with the ureter, a violent and putrid cystitis, 
stricture, enlarged prostate, &c. Any of these conditions may, 
under certain circumstances, be followed by the development 
of multiple small abscesses in the kidneys, and, just as in the 
cases of pyaemia and ulcerative endocarditis, there is reason 
to believe that a particulate organic virus is associated with 
the origination of the purulent points in the kidneys. But 
further, I believe, not only as the result of my own observa- 
tions, but also from the very nature of the case, that organisms 
of this kind are at the root of the formation of all multiple 
renal abscesses consequent upon disease of the lower urinary 
passages. When inflammatory processes extend from one 
part to a neighbouring part they do so either by direct 



172 Dr. Steven— The Pathology of 

continuity of tissue, and thus slowly overtake the more dis- 
tant parts, or they do so by portions of the exciting irritant 
circulating through the lymphatic and other spaces of the 
tissue, and setting up inflammatory foci in the areas where 
they happen to settle. These foci may occur in the second- 
arily affected part long before it has been overtaken by 
inflammatory change spreading by continuity, and so the 
secondarily affected areas may be separated by considerable 
tracts of unaffected tissue from the seat of the primary 
disease. It is in the latter of these methods — viz., by the 
transmission of the virus, that multiple small abscesses 
originate in the kidneys secondary to suppurative disease 
beneath them. As Mr. Marcus Beck points out, Klebs was 
the first to allude to the fact "that suppurative nephritis 
may occur without any continuity of the inflammation with 
that in the bladder. This was taken by Beckmann to be a 
proof that the inflammation of the kidney is due to blood- 
poisoning." Klebs, however, accounted for it by showing 
that organisms might spread up into the tubules of the 
kidney, and so excite the suppurative action. Mr. Beck, 
while admitting that organisms may be found in the pelvis 
and tubes of the pyramids, does not agree with the con- 
clusions of Klebs in all their details. My own observations, 
however, as will be shown in the sequel, lead me to the 
opinion that Klebs is in all probability correct. That the 
virus, too, in such cases is a particulate virus, and almost neces- 
sarily such, is proved by the fact that the affected areas are so 
scattered, and in many instances separated from one another 
by intervening strands of quite healthy tissue. A fluid virus 
circulating into the kidneys by way of the lymphatics or 
otherwise would be expected by its diffusion to produce not a 
localised, but a generalised and very extensive infection of the 
organs. This fact, however, may explain the occurrence of 
acute interstitial nephritis, which is often found associated 
with the presence of the small abscesses, although I am of 
opinion that we may not unfrequently meet with scattered 
points of suppuration in the kidney without any generalised 
interstitial nephritis whatever. 

Having thus in general terms discussed the etiology of this 
class of cases, I now proceed to consider in detail the pathology 
of that section of it in which the virus obtains access to the 
kidney by means of the uriniferous tubules. Case 1, in the 
appendix, is an exceedingly good example of this form of the 
affection, and will be taken as the text of the remarks which 
I have to make under this heading. 



Suppurative Inflammations of the Kidney. 173 

In the case of the metastatic formations of pyaemia it was 
pointed out that the abscesses were most abundant in the 
cortical region, but in the class of cases now under consider- 
ation the abscesses are found quite as abundantly in the 
pyramids as in the cortex, and sometimes no doubt they may 
be even more abundant in the former. Here, too, the 
abscesses are generally of no great size, and, though surrounded 
by a zone of hyperasmia, more or less intense, do not present 
this condition to such an extreme degree as do the pyaemic 
formations where, in addition to the action of a virulent 
irritant, there is also the necrosis set up by the embolic con- 
dition. The organ may or may not be enlarged, probably it 
will generally be so. In the case given in the appendix the 
affected organ weighed 10 ounces, a very great increase in 
weight, but it must be remembered that for a lengthened 
period the opposite kidney had been useless as a secreting 
organ, and that in the one under review there was probably a 
considerable degree of hypertrophy. Besides this, however, it 
can quite well be understood how a kidney, the seat of very 
numerous points of suppuration, should be somewhat enlarged, 
the presence of the abscesses themselves, apart from any 
primary generalised inflammatory change, which may some- 
times be present, being sufficient to cause it. 

Under the microscope, in such a kidney, areas of the most 
intense interstitial inflammation will be observed both in the 
cortex and pyramid, and very often it will be found that the 
intervening portions of kidney tissue are scarcely, if at all, 
different from the normal condition in appearance. These 
areas vary very much in size, and in the pyramidal portion 
are generally observed to be distinctly elongated in shape. 
In intensity, too, they vary from a mere infiltration of inflam- 
matory corpuscles between the tubules to a patch in which no 
trace of kidney tissue can be seen, and very often it will be 
found that, where pus has formed, the centre of the area is 
empty, the walls of the cavity being ragged and composed of 
masses of leucocytes. In the cortex the collections of leucocytes 
are generally more or less rounded in form. 

A careful microscopic search, if the sections are treated 
according to the method previously described, will generally 
reveal evidences of the exciting cause — viz., groups or colonies 
of micro-organisms, usually micrococci. The colonies are 
generally found to be closely associated with one of the 
inflammatory foci just described, or sometimes they may be 
discovered with no apparent relationship whatever to any 
neighbouring inflamed area, a point of some importance in 



174 



Dr. Steven — The Pathology of 



reference to the probable mode of action of the organisms, as 
shall presently be pointed out. In the class of cases under con- 
sideration the colonics are as abundantly present (and, in the 
case on the study of which these remarks are chiefly based, in 
considerably larger groups) in the pyramidal as in the cortical 
portion, a point, taken in connection with others to be 
mentioned, strongly in favour of their tubular situation. A 
striking feature of the colonies met with in the pyramids is 
their great length, and, as proving them to be situated within 
the tubules they may often be seen to be directly continuous 
with tubular epithelium. In addition, renal epithelial cells 
may frequently be noticed mixed up with the groups of 




Fir,. 1.— Longitudinal section of pyramidal portion from Case 1, showing 
a tubule blocked by micrococci, with renal epithelium between the two 
colonies. D Zeiss, No. 3 eye-piece. 

micrococci, and sometimes two colonies occupying the same 
tubule may be observed separated from one another by a mass 
of tubular epithelium. (See Fig. 1.) Again, if sections trans- 
verse to the direction of the pyramidal tubules be made, 
and a careful search instituted, groups of micrococci will 
frequently be seen surrounded by renal epithelium, in 
fact, occupying the interior of a tubule hi transverse 
section. Fig. 2 shows this state of matters very well, 
and is a very faithful representation of the appearances 



Suppurative Inflammations of the Kidney. 175 

presented in one of my sections. In the cortex the colonies 
are not elongated but generally somewhat circular in shape, 
a circumstance resulting from the character of the tubules ui 
which they are situated. Further, in cases of multiple abscess 
of the kidney due to virulent micro-organisms having obtained 
entrance to the uriniferous tubules, no micrococci will be 
found in the glomerular or other vessels of the organ, a point 
contrasting very strongly with the state of matters already 
noticed as & occurring in ulcerative endocarditis. The observa- 
tion of the points just described, in any case, can leave but 
little doubt as to the cause of the multiple abscesses— viz., the 
presence of a virus in the uriniferous tub ales exciting acute 
inflammatory action in their immediate surroundings. 




5^L 

II 

St);' 

Fir,. 2.— Transverse section of pyramidal portion from Case 1, showing one 
tubule completely, another partially, filled with micrococci, the latter illus- 
trating their tendency to adhere to the wall of the tubule. D Zeiss, No. 3 
eye-piece. 

A word or two must now be said with reference to the mode 
of action of the virus, and the manner in which it probably 
obtains access to the kidney. I have already said that it 
was important to note that in some situations the colony of 
organisms might be present without any relationship to an 
inflamed area. The most natural inference to be drawn from 
this is that the minute organisms must be present for some little 
time in a part before they produce their characteristic results, 
and the evidence is also in favour of the view that it is their 
products more than themselves which are the real exciting 



176 Dr. Steven— The Pathology of 

agencies. Similar conclusions have also been arrived at by 
other observers. Dr. Coats says, in his paper on Ulcerative 
Endocarditis already referred to, that " it is clear at any rate 
that the micrococci themselves are not a serious source of 
irritation. It is very possible, however, that their products 
may be so." And Israel, of Berlin, noted in his observations 
on pyaemia that around the micrococci there was no inflam- 
mation, whilst pus was always developed in connection with 
the threads and spores. With regard to the mode in which 
the virus travels to the kidney in this class of cases I think it 
likely that it extends along the surface and interstices of the 
mucous membrane of the ureter until it reaches the pelvis of 
the kidney, setting up a slight degree of catarrhal pyelitis. 
The virus then gains access to the uriniferous tubules, passes 
along them, settles and multiplies vigorously in various situa- 
tions, and gives rise to the formation of the multiple abscesses 
which have already been described. That this is the probable 
route of the virus in this class of cases is proved by the grey 
and injected appearance which the mucous membrane of the 
pelvis and ureter often presents. In so far as the remark 
bears upon the class of case at present under review, I agree 
with Mr. Marcus Beck when he says, " it is therefore probable 
that in all cases slight catarrhal pyelitis precedes the decom- 
position of the urine in the pelvis of the kidney ; but as soon 
as the decomposition occurs, the pyelitis becomes greatly 
intensified by the irritation of the ammoniacal urine." I 
cannot altogether coincide with him, however, in the opinion 
" that in consequence of the irritation to which the pelvis and 
ureters are exposed in common with the kidney, from the 
obstruction to the free passage of the urine, a slight degree of 
inflammation is set up," because I believe that in a large 
number of the cases there is no obstruction to the passage of 
urine, and even if there was, I do not think that it per se is 
able to give rise to inflammation, especially an inflammation 
which may lead to suppurative nephritis. It will generally 
be found that the starting point of such conditions takes 
place after organisms have had an opportunity of passing 
into the genito-urinary system from without, as the result of 
catheterism or other surgical interference with the bladder or 
urethra. 

Cases of multiple abscess of the kidney in which the virus 
obtains entrance by means of the lymphatic vessels: — As I 
consider the present class of cases to be of very considerable 
importance, not only with reference to etiology, but also 
because, so far as I know, exactly similar pathological con- 



Suppurative Inflammations of the Kidney. 177 

ditions have not hitherto been minutely described, I intend 
to refer in the remarks to be made under this heading, very 
specially to the cases in the appendix which illustrate them, 
thus differing somewhat from the more general method of 
description adopted in the earlier portion of the paper. I do 
so in order to render my descriptions as clear as possible. 
The cases in the appendix which chiefly bear on this aspect of 
the question are Nos. 2, 4, and 6, and I shall very specially 
refer to No. 2, the examination of which, conducted very 
nearly three years ago, first led me to the conclusions I am 
now about to record. I have also to mention that my friend 
Dr. David Newman has within the last few days favoured me 
with notes of a case of his own (see Appendix No. 8), which 
confirms in almost every detail my own observations and 
conclusions. 

Case 2 in the appendix was that of a man who died of a 
severe and long standing cystitis a few days after his admission 
to Dr. Hector C. Cameron's wards in the Glasgow Western 
Infirmary. A note of the post-mortem examination will be 
found in the appendix ; but with regard to the naked eye 
appearances of the urinary organs, it is necessary to observe 
the following particulars : — The urinary bladder was greatly 
distended with turbid urine, which deposited a thickish pus 
in the dependent parts. The viscus was exceedingly irregular, 
its internal surface presenting frequent rough projections, 
and there was no normal mucous membrane left. The right 
ureter was greatly distended, and showed near its upper 
extremity a sigmoid flexure : the pelvis was somewhat dilated. 
Small abscesses, sometimes isolated, and sometimes in groups, 
were discovered in the right kidnej'' in great numbers. They 
partially involved the capsule, so that on removing it many 
were laid open. The organ weighed twelve ounces. The 
left ureter was normal, but the kidney was much reduced in 
size, and converted into a number of cysts containing 
pultaceous matter : in the pelvis were one or two calculous 
masses. These appearances rendered it abundantly evident 
that the suppurative nephritis of the right kidney was due 
to the disease of the bladder, and the problem to be solved 
was to demonstrate the exact way by which the infection "had 
spread to the kidney. With this object in view, the micro- 
scopic appearances of the bladder, kidney, and ureter fall now 
to be described, and in doing so, I shall from time to time 
refer to the characters of the other cases of this affection, 
according as they illustrate points of similarity or difference. 
The bladder presented under the microscope the most 
No. 3. N Vol. XXII. 



178 Dr. Steven— The Pathology of 

typical evidences of inflammatory change. No trace of 
normal mucous membrane remained, what should have been 
mucous membrane having been converted into a thick layer 
of round-celled or granulation tissue. The surface of this 
la} T er was very irregular, its thickness varied considerably in 
different situations, and in some places the inflammatory 
change had invaded the muscular coat. These changes are 
exceedingly well illustrated in fig. 3, plate I. In the 
midst of the round-celled tissue, large numbers of micrococci 
were discovered, both in colonies and scattered individually 
among the leucocytes. In case No. 6 the appearances of the 
internal surface were on the whole similar, but presented 
these differences in detail. The inflamed layer was much 
thicker, and besides leucocytes showed numbers of large 
round cells suggesting proliferated epithelium — in fact, the 
whole appearance was that of a kind of diphtheritic 
exudation. 

The muscular layer of the bladder, with the exception of 
hypertrophy, was in both cases but little altered ; but in the 
spaces between the muscular bundles numerous localised 
patches of inflammation were discovered, showing the tend- 
ency which the infection had to spread by the bands of 
connective tissue. In these situations collections of round- 
cells were present, and amongst them numerous colonies of 
micrococci, many of which were seen to be scattering them- 
selves around the parent groups. The appearances presented 
by the patches of inflammation are well seen in fig. 3, 
plate I, and those of the colonies in fig. 5, plate II. Out- 
side the muscular layer, amongst the connective and adipose 
tissue surrounding the viscus, similar, but on the whole 
slighter, evidences of inflammatory action were discovered, 
and here the colonies of micro-organisms were even more 
abundant, and presented the dissemination to a greater extent 
than in the muscular coat. 

Turning now to the ureter, it is to be noted that veiy 
similar appearances revealed themselves. In the ureter of 
Case 2, the inflammatory action was found to be mainly 
confined to two situations — viz., to the internal or mucous 
layer, and to the external or connective tissue layer — the 
muscular coat being but little affected, except slightly in the 
way described with regard to the bladder. See fig. 4, plate I. 
Colonies of micrococci were also distinctly seen similar in 
appearance and situation to those described in the case of the 
bladder. With regard to the condition of the mucous mem- 
brane, it must further be noted that the inflammatory change 



Suppurative Inflammations of the Kidney. 179 

in it was by no means so intense as in the case of the bladder. 
In Case No. 6, the mucous membrane was comparatively 
slightly, if at all, affected, and it is a point well worthy of 
note that, in Dr. Newman's case, the mucous membrane was 
not at all involved. 

I have described the above appearances thus fully, because 
it is absolutely essential that they should be well understood 
in order that the changes in the kidney, now about to be 
described, may be appreciated. The small abscesses in the 
kidney were very numerous, sometimes collected together in 
groups and sometimes isolated. They were almost entirely 
confined to the cortex, in which region they were most 
advanced, although here and there the microscope revealed 
small areas of inflammation, as a rule not advanced to the 
stage of suppuration, in the medulla. The shape and exact 
situation of the cortical abscesses are points of great import- 
ance in connection with the present enquiry. In an article on 
Consecutive Nephritis, in Reynold's System of Medicine, Mr. 
Marcus Beck makes the following remarks with regard to the 
shape of the purulent points : — " The abscesses, and the pale 
streaks between them, naturally assume a wedge-like form, in 
consequence of the anatomical arrangement of the structures 
amongst which they are situated; but this is very different 
from the form of an embolic abscess. In embolic patches the 
width of the base is seldom less than half its length, but, in 
these abscesses of interstitial nephritis, the base showing on 
the surface may be only the width of a pin's head, while the 
length of the wedge may be one inch or more. Embolic 
patches, moreover, scarcely ever extend into the pyramids." 
With regard to the present class of cases (namely, where the 
virus enters by the lymphatics — but not that where it enters 
by the uriniferous tubules), my own observations confirm these 
remarks, but, in addition, they also convince me of something 
more. Thus, in Case No. 2, the abscesses were frequently 
found situated between the capsule and the renal substance, 
and involving the former quite as much as, sometimes even 
more than, the latter. When this was so, the abscess was 
oval or rounded in shape. See fig. 6, plate II. When, how- 
ever, the inflammatory process had spread in upon the kidney 
tissue, then the wedge-shape described by Mr. Beck was 
observed. This elongated shape of the suppurative areas was 
specially well seen in Case No. 6, in which the inflammatory 
process extended in a long and somewhat straggling manner 
from the capsule right through the cortex to the pyramid. 
In the stained specimens this appearance could be detected 



180 Dr. STEVEN— The Pathology of 

quite well by the naked eye, owing to the inflammatory 
corpuscles taking up the colouring matter so greedily. From 
what has just been said, it will readily be understood how so 
many of the abscesses should have been opened on removing 
the capsule. Upon microscopic examination, the inflammations 
in the kidney substance presented, with one or two exceptions, 
pretty similar appearances to those already described in 
connection with the other varieties. In their elongated and 
pyramidal shape and cortical situation, they differed from the 
suppurations occurring as the result of the entrance of the 
virus into the uriniferous tubules ; and they were easily 
distinguished from metastatic formations by the absence of 
evidence of embolism — namely, haemorrhage, necrosis, &c. In 
connection with the abscesses, micro-organisms were discovered 
in large numbers. In Case No. 2 they were present as small 
colonies in the neighbourhood, or interior, of the abscesses. 
In Case No. 4 the colonies were of very large size, and the 
individual organisms, though very minute, were distinctly 
rod-shaped, thus differing from the ordinary rounded shape of 
the micrococci. See tig. 7, plate III. It may be remarked in 
passing, that the inflammatory changes in this kidney seemed 
to be much more extensive and severe than in the others. In 
Case No. 6 the micrococci were scattered amongst the leucocytes, 
and were not grouped into distinct colonies. 

In Case No. 2 the capsule, which had been only partially 
removed at the post-mortem, presented microscopic appear- 
ances of very considerable importance as bearing upon the 
mode of infection. It showed well defined areas of leucocytes 
in its substance, which were strikingly similar to those which 
have already been described as existing in the external layers 
of the bladder and ureter. It also contained numerous capil- 
lary blood-vessels, outside many of which leucocytes were seen 
grouped in large numbers. In its substance, too, numerous 
colonies of micrococci were observed, and these were frequently 
seen lying in the lymphatic spaces surrounding the small 
capsular blood-vessels. As has been already noted, the 
small abscesses were often observed to involve the capsular 
as much as the renal tissue, the whole appearances being 
strongly indicative of the fact that they had primarily 
originated in the tissue of the capsule itself, and after- 
wards passed inwards to the substance of the kidney, 
as is well shown in fig. 6, plate II. 

Having thus at some length discussed the histological 
changes occurring in the bladder, ureter, and kidney, the 
next question for consideration is — How has the infective 



Suppurative Inflammations of the Kidney. 181 

virus obtained access to the kidney in this class of cases ? 
It is obvious, from what has just been said, that the route is 
different from that described in the previous subsection — 
that in fact we have two distinct modes of infection — viz. (1). 
by way of the tubules, already discussed ; and (2), (the mode 
at present under review) by the lymphatics. I do not find 
this distinction clearly insisted upon by any of the writers I 
have yet been able to consult. Thus, Klebs distinctly recognises 
the entrance of organisms by the tubules, and states that they 
may make their way into the interstitial tissue from them. 
Dickinson also holds that the virus enters by the uriniferous 
tubules, then passes into the veins, and is thus sown broadcast 
through the organ. And Marcus Beck, while he recognises 
that the lymphatics are involved in suppurative nephritis, 
also holds that the septic material first passes into the 
uriniferous tubules. Each of the opinions just stated might 
be applied to the first mode of infection — viz., by the tubules — 
but none of them to the second, and, in order that the state 
of matters involved under the second heading may be under- 
stood, it is necessary to say a word or two concerning the 
lymphatics of the kidney. 

The lymphatic vessels of the kidney and ureter were 
described as early as the year 1787 by Mascagni, in his work 
entitled Vasorum Lymphaticorum Corporis Humani. He 
showed that they were arranged in a superficial set, disposed 
in the capsule, and a deep set passing outwards from the 
hilus of the organ. He also describes a group of lymphatic 
vessels passing upwards along the course of the ureter. As 
the result of their researches on the histology of the kidneys, 
this description of the lymphatic vessels has been adopted by 
Ludwig and Zawarykin, although Sappey in his work on 
Anatomy, published in Paris in 1879, does not believe that 
there is a superficial set as described by these observers. 
Lud wig's conclusions, however, are accepted by the majority 
of histologists, and the results of the present investigation 
lead me very strongly to the opinion that they are right. 
Not only do I believe in the superficial and deep set of 
lymphatic vessels of Ludwig, but I also hold the view that 
the superficial or capsular lymphatics of the kidney are in 
communication with those ramifying in the wall of the 
ureter. Pathological evidence confirmatory of any point in 
normal anatomy or physiology is regarded by all as very 
valuable, and for this reason the testimony which this research 
bears to the correctness of Ludwig's views is all the more 
important. But the following observations are also of very 



182 Dr. Steven— The Pathology of 

great significance in the present connection : — At the recent 
Discussion on Albuminuria held by the Glasgow Pathological 
and Clinical Society, Dr. Newman's assistant, Mr. H. Lyon 
Smith, showed sections obtained from a kidney which had by 
accident been injected from the ureter instead of from the 
renal artery. Upon cutting up the organ, the injection mass 
(carmine and gelatine) was found to be distributed mainly in 
the cortex — it had, in fact, obtained access to the ljmiphatic 
channels of the ureter, had passed along the spaces of the 
connective tissue of the capsule of the kidney, had then 
penetrated its substance, and was seen, under the microscope, 
lying in spaces between the uriniferous tubules. Dr. Newman 
informs me that, some years ago, while working with the late 
Dr. Foulis, he noted similar appearances after injection of 
the kidney from the ureter. These observations are very 
strongly confirmatory of the opinion to which, as the 
result of purely pathological researches, I had long ago 
come, that the lymphatics of the ureter, and those of the 
cortex of the kidney, communicate directly with one ano- 
ther. I repeated these experiments, and injected three 
human kidneys from the ureter. Instead of carmine and 
gelatine, I used the cold Prussian-blue injecting fluid, as I 
thought it would more easily run through the very small 
vessels. The injection was made by means of a continuous 
injection apparatus, the pressure employed varying from 4 to 
8 cms. of mercury. The first effect was that the pelvis 
became greatly distended, then the blue fluid was seen to be 
making its way through the substance of the wall of the 
pelvis and the spaces of the renal capsule, and gradually 
filling up small star-shaped or tortuous vessels on the surface 
of the kidney. In one of the experiments a vessel in the 
pelvic wall of considerable size was seen to get slowly filled 
and stretch away over the surface of the kidney. On a little 
air getting by accident into the apparatus, minute air bubbles 
were seen to chase one another through this vessel, w T hich was 
about the diameter of a fine sewing needle. The time 
employed for injection varied from 15 minutes to 2 hours, 
then a ligature was put on the ureter, and the organ was 
placed in weak spirit and water for 24 hours. Upon examina- 
tion at the end of that period, the surface of the kidney 
presented a number of delicate star-shaped or tortuous vessels, 
which were filled with the blue fluid, and which were very- 
distinct from contrast with the general red colouration of the 
surface. A fair idea of the appearance is obtained from 
fig. 8, plate III. Upon section the cortex was seen to be 



Suppurative Inflammations of the Kidney. 183 

traversed by minute blue streaks, leading down from the 
injected vessels on the surface. Sometimes these streaks were 
long enough to reach the pyramid, but as a general rule they 
were not so long. In a few cases the lower half of the 
pyramidal uriniferous tubules had been injected, but the 
injection never went nearly so far up as the cortex, see figs. 9 
and 10, plate IV. Upon microscopic examination similar 
appearances to those observed by Mr. Smith were seen — - 
the blue colouration was found to be situated in the spaces 
between the uriniferous tubules, and to get gradually less the 
farther from the capsule it was. See fig 11, plate IV. These 
facts, then, taken along with the observations of Dr. Newman, 
render it almost certain that the lymphatics in the cortex of 
the kidney, and those in the wall of the ureter are intercom- 
municable, and, bearing them in mind, my theory as to the 
infection of the kidney by means of the lymphatics is readily 
understood. 

One of the primary factors in the process of infection is 
the greatly inflamed mucous membrane of the bladder, in 
which, as has been shown, septic organisms proliferate in 
great numbers. From this breeding ground the infective 
material passes outwards by means of the lymphatic spaces 
through the bladder wall, and the micro-organisms are then 
found abundantly in the external layers, often having ex- 
cited inflammatory changes in their progress. The organisms 
then obtain access to the lymphatic channels in the wall of 
the ureter, and gradually spread upwards ; here also, as has 
been seen, often exciting localised patches of inflammation 
as they go. The mucous membrane of the ureter may per- 
haps be somewhat inflamed, but, in order that the kidney 
should become infected, it is not at all necessary that the 
mucous surface should be involved. That this is so is abund- 
antly borne out by Cases 6 and 8 of the appendix, in which 
the mucous membrane was only very slightly or not at all 
affected. At length the organisms reach the pelvis of the 
kidney, and then pass into the lymphatic spaces of the 
capsule, in various parts of which, as the result of their 
virulent action, small abscesses form. These abscesses also 
involve the superficial parts of the renal cortex, and the 
morbid products are gradually disseminated through its 
substance, exciting the inflammatory formations in the way 
already seen. The fact of the abscesses being so frequently 
met with situated between the capsule and the kidney, and 
the elongated and pyramidal shape assumed by the inflam- 
matory processes when extending through the cortex are, as 



184 Dr. Steven— The Pathology of 

has been already pointed out, strongly suggestive of the 
virus being carried to and disseminated through the organ 
by the lymphatic vessels. 

I have thus, I think, rendered it clear that there are two 
quite distinct ways in which multiple miliary abscesses may 
originate in the kidney, as the result of primary disease 
of the lower urinary tract, and, although I have described 
them under two independent headings, there can be little 
doubt that, under certain circumstances, both methods may 
be more or less combined. Thus, in the same kidney we 
might have the virus entering both by the uriniferous 
tubules and the lymphatic vessels, and this I believe 
to have been more or less present in Case No. 4, in which 
the inflammatory change was very severe, and the colonies 
of organisms exceptionally large. In discussing miliary sup- 
puration of the kidney, I have not specially referred to the 
state of acute interstitial nephritis, because, although it may 
be present, I do not think that it is necessarily so. When 
it does occur, I believe that the explanation which is given 
by Mr. Marcus Beck is the true one, and which he expresses 
as follows : — " The pelvis of the kidney, and probably also 
the straight tubules for a greater or less distance, are filled 
with putrid urine at some degree of pressure. The contact 
of this irritating fluid damages the epithelium, and causes 
its rapid desquamation. The septic matter then passes 
readily through into the intertubular lymph spaces of the 
kidney, and excites a diffuse inflammation, which spreads 
rapidly towards the cortex between the tubules." This is 
just the explanation of diffuse interstitial inflammation that 
one would look for — viz., a fluid irritant which readily 
diffuses itself over the entire organ ; but this is very different 
from what goes on in the production of scattered abscesses. 
Here we have not a fluid, but a particulate and very destruc- 
tive virus which, from its very nature, cannot diffuse itself in 
the same rapid way, and so acts only on limited areas, but 
produces greater destruction. 

In concluding my remarks on this heading, I would only 
add that, while many writers have described the straight 
tubes as the portal of infection, this, so far at least as I am 
aware, is the first time it has been shown that the lymphatics, 
quite independently of any other mode of entrance, may form 
the pathway of the virus from the bladder to the kidney. 

Large Single or Multiple Abscesses of the Kidney. — Cases 
of this kind form the second division of Class II in my table 



Suppurative Inflammations of the Kidney. 185 

of classification; and as the general pathology of such con- 
ditions is much better understood than that of the cases, the 
consideration of which has just been completed, it is unneces- 
sary that I should dwell upon them so much in detail. The 
occurrence of one or more large abscesses in the kidney is a 
condition very frequently met with in the experience of 
pathologists, and sometimes also it may happen that the 
disease has attracted comparatively little attention during 
life. Numerous examples, too, will be found in all good 
pathological museums. Roughly speaking, renal abscesses of 
this kind may be classed under two headings — viz., (1) 
where the abscess cavity is formed partly by the pelvis and 
partly by the renal tissue ; and (2) where the abscess cavity 
is entirely in the substance of the organ. To the former of 
these the term pyo-nephrosis is often applied, and the general 
appearances may perhaps be said to be those of a hydro- 
nephrosis, in which the watery fluid is replaced by pus, that 
is to say, besides the obstruction to the free escape of urine 
necessary to set up a hydro-nephrosis, there is in addition the 
presence of an irritant capable of exciting purulent inflam- 
mation, e.g., a calculus. The interior of the cavity is lined 
with pus ; the renal tissue is generally more or less atrophied, 
and often distinctly loculated, from the suppurative process 
having encroached upon it more extensively at some points 
than at others. 

Abscesses of the second kind, namely, occurring in the 
substance of the kidney, may be either single or multiple ; 
and, with regard to their general appearance, nothing very 
special requires to be said. Their dimensions are very vari- 
able — often in the same kidney cavities varying in size from 
that of a pea to that of a walnut or larger being observed. 
The cavities often contain calculi, and frequently almost no 
renal tissue is left. The abscesses may or may not communi- 
cate with the ureter, and, when they do not, they frequently 
discharge by rupturing into it. In the later stages the organ 
generally becomes considerably diminished in size, consisting 
merely of a series of cavities, in which the original pus, from 
partial drying in, may have been converted into caseous or 
pultaceous material. 

Passing now to the subject of the causation of these con- 
ditions, a word or two must now be said under each of the 
headings mentioned in the table of classification. 

The presence of calculi is one of the most fruitful 
sources of this larger variety of renal abscess. The ques- 
tions relating to the intimate pathology and etiology of 



186 Dr. Steven— the P< > th ology of 

the occurrence of renal calculi I need not pause to consider, 
as I am simply dealing with one of the effects of their 
presence. In connection with the present subject, however, 
it is to be noted that a renal calculus may form in one 
of two situations, and, according to its site, may give rise 
to one or other of the two varieties of abscess just de- 
scribed. It may originate in the uriniferous tubules, when, 
if an abscess forms at all, it will occur in the substance 
of the kidney, and may or may not communicate with the 
ureter. If, on the contrary, the calculus forms in the calyces 
or pelvis of the kidney, then pyo-nephrosis may be one of the 
results of its presence. The rationale of the formation of 
abscess from this cause simply depends upon the well known 
pathological fact that suppuration is likely to ensue as one of 
several results of the impaction of a foreign body in the 
tissues. But it must be remembered that the presence of 
renal calculus is not always associated with the production of 
abscess. Calculi are frequently passed ; and, even if the stone 
remains in situ, there is no essential reason why abscess 
should result, for, as has been shown by several writers, a 
calculus, just like any other foi'eign body in the tissues, may 
become encapsuled by connective tissue and cease to give 
further trouble. 

It has also been pointed out that injury may be the starting 
point of large renal abscesses, and, on general principles, it is 
quite conceivable how this should be so. A much more impor- 
tant consideration, however, is as to the relationship which 
injury may bear to the starting point of some cases of renal 
calculus. In this regard a paper in one of the earlier volumes 
of the Medico-Chirv/rgical Transactions, by Mr. Henry Earle, 
is of much significance. In it he relates a number of cases of 
renal calculus accompanied by abscess, and shows that in some 
of them the beginnings of the symptoms could be distinctly 
traced to injury. In this way, then, injury, if not primarily, 
at least secondarily, may be the cause of a good many of the 
larger suppurations of the kidney. 

A very rare cause of renal suppuration is the impaction in 
the pelvis of foreign bodies other than calculi. It must only 
be very exceptionally that such a condition can occur, but that 
it is possible is proved by the following case, which occurred 
to myself, in which a bristle was found impacted in the 
pelvis. The specimen was obtained from the body of a man 
who had been admitted to the surgical wards of the Western 
Infirmary, suffering from fracture of the skull, and who died 
shortly after his admission, so that no history throwing any 



Suppurative Inflammations of the Kidney. 187 

light upon the condition at present under consideration was 
obtained. The organs generally presented healthy characters ; 
but upon proceeding to make a section through the right kid- 
ney, a large quantity of pure yellow pus made its escape. 
Upon laying open the organ, the pus was found to have been 
collected in a series of large cavities, chiefly in the upper part 
of the organ, and lying in the long diameter of the pelvis was 
observed a long black bristle, or wire-like looking body, about 
one inch and a half in length. That this had not accidentally 
(i. e., during the course of the examination) obtained its posi- 
tion in situ was at once proved by the fact that its lower 
extremity passed right through, and was immovably fixed in, 
a branched phosphatic calculus which had been deposited 
round about it. The branches of this calculus passed into the 
calyces in its neighbourhood. The foreign body lay exactly in 
the direction assumed by a probe when passed up the ureter 
into the pelvis. The bladder contained a little purulent urine, 
but was healthy, as was also the right ureter, which was dis- 
sected out in its whole length. A small portion snipped off 
the foreign body showed it was not metallic ; on placing the 
little bit in glycerine, and trying to tease it with needles, it 
split very readily into longitudinal pieces, which, upon micros- 
copic examination, were seen to be fibrous, and of a reddish 
colour. It was probably a bristle, and was about the thickness 
of a soda water wire. It must first have obtained entrance to 
the bladder, and then made its way up the ureter to the pelvis 
of the kidney. 

It should also be noted that abscesses of the kidney originat- 
ing in any of the ways just described may frequently attain 
very great dimensions, and numerous examples of this will 
be found in Dr. Bright's Clinical Memoirs on Abdominal 
Tumours. The fact, too, that such tumours sometimes burst 
externally and discharge calculi, indicates that these cases 
may often be benefited or cured by judicious surgical inter- 
ference. 

The last cause of this form of renal abscess which falls to 
be considered is old-standing disease of the lower urinary 
passages. In such cases the kidneys are generally found to 
be converted into a series of large ragged abscess cavities, and 
often this condition will lie limited to one kidney, whilst the 
opposite one presents the disseminated points of suppuration, 
which have already been described : in Cases 1, 2, and 6 of the 
appendix this limitation to one side was present. This cir- 
cumstance is very strongly suggestive of the fact that the 
formation of small disseminated points of suppuration precedes 



188 Dr. Steven — TJie Pathology of 

in many cases the development of the larger abscesses. Thus, 
it will easily be seen that there are two possible ways in 
which such abscesses may originate — viz., (1) by the virus 
spreading upwards and causing small disseminated abscesses, 
which, by enlarging and coalescing, give origin to the larger 
cavities ; and (2) by the suppurative process gradually ex- 
tending along the interior of the ureter, and so involving the 
kidney by continuity. 

It is quite unnecessary to say anything more than has been 
already said concerning the first of these methods, except 
again to draw attention to the great importance, from a 
therapeutic point of view, of Dr. Moxon's observation that 
disseminated abscesses of the kidney may undergo cure before 
leading to very extensive destruction of tissue. With regard 
to extensive suppuration of the kidney originating in the 
second way, it may be remarked that this is generally a slow 
process, and often accompanied by evidences of more or less 
obstruction to the free escape of urine. The ureter is, as a 
rule, very greatly dilated, and its internal surface is covered 
with ulcers. When the ulcerative process reaches the pelvis 
suppuration of the kidney begins — very often as a pyo- 
nephrosis — one essential feature in this, however, as in all 
suppurative affections of the kidney, being the presence of an 
infective virus or irritant. 

Specific Suppurations of the Kidney. 

Class III includes those cases in which the suppurative 
inflammation of the kidney may be regarded as specific in 
origin, e. g., renal phthisis. 

The anatomical and other characters of this group of 
affections are so well known, and have been so carefully 
described by many writers, that it is quite unnecessary for me 
to dwell upon them at any length. Briefly speaking, tuber- 
cular disease of the kidney may occur in two forms. It may 
exist as part of a general tuberculosis, or it may occur as 
a local affection limited to the organs themselves (renal 
phthisis). 

The former variety scarcely falls within the scope of the 
present essay, as it simply consists in the development of 
numerous miliary tubercles scattered through the organ, and 
presenting the same characters as those met with in other 
parts. It is never accompanied by suppuration. 

Local tuberculosis of the kidney consists in the development of 
a suppurative, or more strictly speaking a caseous inflammation, 



Suppurative Inflammations of the Kidney. 189 

leading to the more or less copious discharge of pus. It may 
originate in the organs themselves, or it may be propagated 
into them from the bladder and ureter, or from the generative 
organs. The morbid process generally begins in the apices 
of the pyramids, which present the usual appearances of 
tubercular ulceration, and the disease spreads in upon the 
organ and down the ureter by the continual breaking' down 
of successive crops of fresh tubercles at the margins of the 
ulcers. It may spread clown into the bladder, and up to the 
kidney of the opposite side, along the corresponding ureter. 
The whole organ may ultimately be converted into a large 
caseous mass, in which no renal tissue may be discoverable, 
and which is riddled by large irregular cavities with ragged, 
crumbling walls, which sufficiently distinguish it from a 
simple pyonephrosis. But the characters of the condition 
are so well known that it is unnecessary to particularise at 
greater length. 

The only circumstance, however, which does require further 
notice is that in some quarters there seems to be a doubt as 
to whether the morbid affection just alluded to is in reality a 
tubercular affection. Thus Ebstein, after pointing out that 
the majority of pathologists regard caseous inflammation of 
the kidney as a tubercular affection, says — " Without desiring 
to deny any positive observations, I must nevertheless insist 
that in a great number of instances neither of these assump- 
tions proves true." He then passes on to make the following 
somewhat astonishing statement — " The miliary tubercles that 
are met with in connection with them (caseous inflammations) 
are quite accidental." I think that few will now be inclined 
to agree with Ebstein in these remarks. The characters of 
the morbid change, and the presence of the tubercles, are of 
themselves sufficient to prove the real nature of the affection ; 
but if further evidence be wanted, it may be found by a 
careful search for the tubercular bacillus of Koch. Some 
time ago I had the opportunity of studying the appearances 
in a case of miliary tuberculosis of the kidney, and after a 
very careful search I succeeded in demonstrating the presence 
of bacilli in the miliary nodules. Quite recently, also, in a 
case of local renal tuberculosis which, along with Dr. Joseph 
Coats I had the opportunity of examining, huge colonies of 
tubercular bacilli were found in great abundance in the 
caseous matter forming the floors of the ulcers. These facts, 
then, I think, in the light of the most modern views on the 
etiology of tubercle, would prove beyond a doubt the true 
tubercular nature of renal phthisis. 



190 Dr. Steven— The Pathology of 

Perinephric Abscess. 

The consideration of the group of cases included in Class 
IV falls somewhat outside of the scope of the present com- 
munication, but I have included it along with the others 
mainly for the purpose of referring to a circumstance (ren- 
dered evident by the present investigation) of considerable 
etiological significance in connection with some at least of 
the different varieties of perinephric abscess. The formation 
of abscess in the tissues surrounding the kidney may be 
caused in a large number of ways, e.g., by injury to the loin, 
by wounds of the kidneys, by the spreading and bursting 
outwards of the different forms of renal suppuration, by sup- 
puration of the pelvic connective tissue spreading to the loin 
by continuity, &c. In addition, cases may be met with in 
which no very obvious cause can be made out, and which are 
attributed to such influences as exposure to cold, &c. From 
this it will be seen that there are cases which are distinctly 
secondary, and with regard to which there is but little 
difficulty in assigning a cause. In reference to the others, 
however, which may be looked upon as primary or idiopathic, 
there will often be great difficulty in finding out what has 
been the starting point. It is in such cases that I think my 
observations may sometimes be of service in determining the 
etiology. In such cases the abscess may often appear to be 
strictly limited to the region of the kidney, without any very- 
distinct relationship to disease in any neighbouring part, con- 
tinuous with it. In reference to some of these, the facts wdiich 
have already been described with regard to the lymphatics of 
the ureter and kidney may often offer a reasonable explana- 
tion. The virus may have originated in the bladder, and 
spread up by means of the lymphatics of the ureter to the 
capsule of the kidney and its surrounding connective tissue. 
It may then set up abscesses in this situation, which tend to 
limit themselves to the neighbourhood of the kidney rather 
than to extend in upon the organ itself. Thus, a perinephric 
abscess may originate which apparently has no relationship 
whatever to any other part. The condition of the capsule of 
the kidney, which has been described as being present in Case 
No. 2, is of importance in this regard ; and further, the re- 
markably loose connective tissue surrounding the kidney offers 
a very favourable breeding ground for the propagation of 
infective germs. I do not say that this explanation will suffice 
for all cases of apparently idiopathic perinephric abscess, but I 
believe that it will at least explain a certain number of them. 



Suppurative Inflammations of the Kidney. 191 

I have thus attempted to draw attention to some of the 
features connected with the pathology of suppuration in and 
around the kidney, dwelling at some length upon conditions 
which are still more or less obscure, and discussing more 
briefly those affections the pathology of which is better under- 
stood ; and I am hopeful that some of the observations now 
recorded may not be without value in clearing up points con- 
cerning which more or less difficulty and doubt have hitherto 
existed. 



APPENDIX. 



Case 1. M'S. was first admitted to Professor Gairdner's 

wards in the Glasgow Western Infirmary on the 29th January, 
1879, suffering from reputed nephric or perinephric abscess 
on the left side, with a nearly constant sediment of pus in 
the urine. The disease was possibly due to injury of the 
abdomen, and "commenced with rigors frequently repeated, 
frequent micturition, pain at the point of the penis, retraction 
of the testicle, nausea, &c, previous to . . admission." 
The tumour extended from the " hypochondrium to the iliac 
spine, and into the lumbar region, evidently surrounding the 
left kidney." A sudden subsidence of the tumour occurred, 
with every evidence of opening into the " intestinal canal per 
orem (?) et per anum." After seven months' treatment in 
hospital, he was dismissed much improved ; he commenced 
work in October 1879, and continued till November 1880. 
He was again admitted in January 1881, " when a large 
re-accumulation was discovered in the left lumbar region, 
which was opened antiseptically on January the 29th, with 
some relief and lowering of the temperature for the time." 
It is unnecessary for my present purpose to go more minutely 
into the clinical history of this deeply interesting case, and it 
will suffice to say that, after gradually sinking for a long 
time, he died on the 2nd May, 1881. 

The post-mortem examination was made by Dr. Coats, and 
I am indebted to him for the following notes, which contain 
the chief points of importance in the present inquiry. The 
heart, except that it was rather small, presented normal 
appearances. An open wound of elongated shape and about 
one inch in length, which communicated with an abscess 
having wide ramifications within the abdomen, and especially 



192 Dr. Steven— The Pathology of 

behind the kidney, was situated on the left posterior aspect 
of the body beneath the margin of the ribs. The left kidney 
was " found considerably reduced in size, and converted into 
a series of cavities containing pus. The ureter is in open 
communication with the abscess at a point slightly below the 
lower border of the kidney. Below this the ureter is nearly 
obstructed, apparently by a branch of the abscess, which 
nearly surrounds it. This branch of the abscess is found to 
communicate in a remarkable manner with the other ureter 
just above the bladder, so that pus was seen to issue from the 
right ureter into the bladder." The right kidney is very 
greatly enlarged. The mucous membrane of the pelvis has 
a grey injected appearance. The kidney tissue is the seat of 
innumerable miliary abscesses of very small size. These occur 
mostly in groups, and are present in the pyramids as well as 
in the cortex. This kidney weighs 10 ounces. 

The chief microscopic appearances in this case will be found 
in the text. 

Case 2. — The patient, a man, was admitted into Dr. Hector 
C. Cameron's wards on the 7th July, 1881, in a dying state, 
and on this account no very accurate clinical history has been 
preserved. It appears, however, that for a lengthened period 
he had suffered from scrofulous disease of the testicle, and 
had at some time undergone the operation of castration. At 
the time of his admission he was suffering from a severe and 
long standing cystitis, and in a few days died. 

The post-mortem examination, of which the following is a 
note, was made by Dr. Joseph Coats : — " External appearances 
present nothing remarkable. Chest. — The lungs are adherent 
at the apices. On section they present very scattered miliary 
nodules. Posteriorly there is engorgement. The heart is 
normal in size, weighing 11 ounces. The muscular wall of 
the right ventricle is very thin, and greatly invaded by fat, 
so that in some places the muscular tissue has almost or 
entirely disappeared. The muscular tissue of the left ventricle 
is of normal thickness and appearance. Abdomen. — The 
urinary bladder is greatly distended with turbid urine, which 
deposits a thickish pus in the dependent parts. The bladder 
is exceedingly irregular, its internal surface presenting 
frequent rough projections. There is no normal mucous 
membrane remaining. The right ureter is greatly distended, 
and shows near the kidney a sigmoid flexure. The pelvis is 
somewhat dilated. In every region of this kidney there are 
small abscesses in great abundance. These are sometimes in 
groups, but sometimes isolated. On removing the capsule, 



Suppurative Inflammatioyis of the Kidney. 193 

many of the abscesses are found partially to involve it, so as 
to be partially laid open in tearing it off. This kidney is 
considerably enlarged, weighing 12 ounces. The left ureter is 
normal. The left kidney is much reduced in size, and is con- 
verted into a set of cysts, filled with pultaceous material. 
Towards the pelvis one or two calculous masses are dis- 
covered." 

As the microscopic appearances have already been \ 3iy 
fully described, it is quite unnecessary that they should be 
further referred to. 

Case 3. — The kidneys in this case were sent for examina- 
tion by Dr. Yellowlees of Gartnavel, and were obtained from 
the body of a man who had suffered from enlarged prostate, 
with a prominent middle lobe. The bladder was much 
enlarged, evidently from habitual retention. 

The kidneys were smaller than usual, and weighed a little 
over three ounces, but the natural markings were well seen, 
and the capsule was slightly adherent. All through the renal 
substance were seen numerous minute abscesses, the largest 
being somewhat bigger than a pin's head. They are best seen 
on the surface, and only a very few are opened into on 
removing the capsule. 

In this case the microscope shows that the recent acute 
interstitial inflammation is much more generalised than in the 
preceding cases, though still distinctly patchy in character, 
leaving here and there areas of renal tissue but little affected. 
Here, too, the sections show that the most intense inflammatory 
action has been in the neighbourhood of the capsule, spreading 
inwards upon the tissue from it. Micro-organisms are not 
abundantly present, but here and there several small colonies 
are observed in the cortex. In addition to these signs of 
recent suppurative inflammation there is abundant evidence 
that, previous to its onset, the organs had long been in a state 
of cirrhosis. Many of the Malpighian tufts present the most 
marked sclerosis; those which do not, show considerable 
thickening of their capsules; and the interstitial tissue 
generally is much increased. 

Case 4. — In this case the post-mortem examination was 
performed on the 13th June, 1882. The patient died from 
the effects of extravasation of urine, but no accurate note of 
the clinical conditions has been preserved. The following arc 
the notes of the autopsy. 

There is considerable sloughing of the skin of the penis and 
No. 3. o" Vol. XXII. 



194 Dr. Steven— The Pathology of 

anterior wall of the abdomen. The heart is slightly enlarged, 
weighing 11| ounces, but otherwise is not abnormal. Both 
lungs present in their lower lobes distinct pneumonic consoli- 
dation, but in neither are there any localised metastatic 
abscesses. 

The liver is much enlarged, weighing 97 ounces ; it presents 
slight fatty infiltration, but no metastatic abscesses. The 
spleen is slightly enlarged, weighing 6 ounces. In it there are 
one or two small petechial spots, but no distinct abscess or 
infarction. 

Both kidneys present several groups of abscesses, as well as 
isolated small ones. The groups and single abscesses contain 
a creamy-yellow pus, and are surrounded by zones of hyper- 
emia, These abscesses are mostly visible on the surface, and 
on section are seen to extend through the cortex. In addition, 
elongated abscesses are occasionally visible in the pyramids. 
The urinary bladder presents a general thickening of the 
muscular coat. The mucous membrane is also thickened, and 
presents somewhat minute injection of the vessels, with here 
and there a slaty pigmentation. The prostate gland is pene- 
trated by sinuses of a ragged character, around which the 
tissue is distinctly slaty in colour. 

With regard to the inflammatory formations in this case, 
the microscope reveals very similar characters to those 
observed in the examples previously described. The inflam- 
mation in the kidney is patchy in character, less in some 
places, more extensive in others, and leaving areas of quite 
healthy tissue. In this specimen the micro-organisms were 
more abundantly observed and more beautifully demonstrated 
than in any of the others. With regard to their mode of 
access, it is very probable that they have obtained entrance 
both by the uriniferous tubules and the capsular lymphatics, 
but evidently much more abundantly by the latter. In all the 
inflamed areas large colonies of very minute distinctly rod- 
shaped organisms are observed. See fig. 7, plate III. In 
addition to the colonies organisms are often seen scattered 
individually, and this is frequently observed between quite 
healthy uriniferous tubules. The scattered organisms are 
micrococci. 

Case 5. — The specimens in this instance were obtained from 
a patient who died in Dr. Finlay son's Wards on loth October, 
1882. He was 39 years of age, and was admitted to hospital 
on account of pain over the liver, of 6h months' duration, 
followed in a fortnight by jaundice. During the residence in 



Suppurative Inf/im/niations of the Kidney. 195 

hospital the jaundice was very intense, and the liver was 
enlarged, but without pain. The appetite was bad ; there was 
no vomiting ; and the bowels acted regularly. After admission 
the temperatures were on several occasions high, with the for- 
mation of acute abscesses. A few days before death the thy- 
roid body enlarged and felt like an abscess. 

The post-mortem was made by Dr. Joseph Coats, and the 
following is a synopsis of the chief appearances observed : — 
The left lung was emphysematous ; the right lung presented 
grey or red hepatisation nearly throughout its whole sub- 
stance, and also oedema. The heart was normal. The liver 
was much enlarged, weighing 117 ounces, and was the seat of 
numerous pale tumours. The gall bladder and ducts were 
greatly distended, but it was still possible to press bile through 
the common duct into the duodenum, but the duct was sur- 
rounded by tumour tissue. The head of the pancreas was the 
seat of a hard tumour, which infiltrated its tissue, but did not 
involve the duodenum. Its duct was also distended. The 
spleen was somewhat enlarged, weighing 8J ounces. 

The kidneys, which were somewhat enlarged, weighing 6 
and 6 1 ounces, were the seat of multiple small abscesses, the 
pus in which was of a deeply yellow colour, while the renal 
tissue was unduly brown. The urinary bladder contained a 
large amount of bile-stained urine, and there was an abscess 
in the substance of the prostate. 

The intestine, though hypersemic in the jejunum, presented 
no trace of ulceration. The abscesses in the right sterno- 
clavicular articulation, thyroid body, and connective tissue of 
the neck below the thyroid contained a thick, creamy pus. 

The microscope revealed areas of inflammation in the 
pyramids and cortex, those in the cortex involving the 
capsule. Here and there colonies of micrococci were dis- 
covered. There was some difficulty in deciding whether 
the suppuration in this case was due to pyaemia or to 
disease of the lower urinary tract, but taking all the features 
of the case, macroscopic and microscopic, into consideration, 
I am of opinion that the abscesses owed their origin to the 
abscess in the prostate gland. 

Case 6. — R. W., a rivet maker, aat. 43, was admitted to 
Professor George Buchanan's Wards on the 18th December, 
1882, suffering from aggravated symptoms of stone in the 
bladder. He had been cut for stone when a boy, and had 
made a rapid recovery. About ten years before his death 
-vmptoms of vesical calculus again made their appearance, 



196 Dr. Steven — The Pathology of 

and continued with ever increasing severity until his death. 
He was so ill on his admission that only palliative measures 
could be adopted. 

An examination of the body was made on the 3rd January, 
1883, and the following are the chief points to be noted : — 

The heart was healthy, and the lungs presented nothing 
remarkable. Yellow semi-fluid pus was present in the peri- 
toneum, especially towards the fundus of the bladder. Imme- 
diately behind the bladder there was a large pus-filled cavity, 
which, by an aperture in its posterior wall, communicated 
with the interior of the bladder. The internal surface of the 
bladder was lined by shaggy, irregular projections, which 
could be in great measure removed from the mucous mem- 
brane, which was then seen to present a dark blue colour. 
The left ureter was greatly dilated, but its vesical aperture 
was not enlarged. The left kidney was converted into a 
series of cysts communicating with the pelvis, and containing 
a very large number of phosphatic calculi, large and small. 
The right kidney was somewhat enlarged. It contained 
numerous small abscesses, especially in the cortex, and also 
presented considerable areas of coalesced abscesses. The right 
ureter was not much dilated. 

The microscopic characters of this case have already been 
sufficiently considered in the text. 

CASE 7. — Summary of post-mortem, made 10th September, 
1883. Metastatic abscesses of lungs and kidneys. White 
nodules in the small intestine. No source of infection 
discovered. 

The heart was perfectly healthy. The lungs were slightlj' 
hyperaemic, and presented here and there small typical metas- 
tatic abscesses, with the usual sloughs, surrounded by pus, in 
their centres. 

The liver presented nothing remarkable. In both kidneys 
numerous small abscesses, each of which was surrounded by a 
zone of intense hyperemia, were discovered. On section they 
were seen to be mainly confined to the cortex, and were of an 
elongated and pyramidal shape. The urinary bladder was 
perfectly healthy. There was no ulceration of the intestine, 
but the entire mucous membrane of the ileum was beset by 
minute white nodules the size of millet seeds. Even in the 
absence of the discovery of any probable source of infection, 
there can be no doubt that this was a case of pyaemia. 

The microscopic appearances of the renal abscesses will be 
found described in the text. 



Suppurative Inflammations of the Kidney. 197 

Case 8. — This case, with the accompanying remarks, was 
communicated to me by my friend Dr. David Newman. 

"Summary of post - mortem. — Aortic valvular disease: 
hypertrophy and dilatation of left ventricle ; dilatation of 
mitral orifice, red induration of the lung ; nutmeg liver ; 
enlargement of the spleen ; stricture of the urethra ; ulceration 
of the bladder and pelvis of the left kidney ; multiple miliary 
abscesses of the left kidney. 

"With special reference to the condition of the urinary 
organs, the following remarks may be made. There is a firm 
stricture of the urethra in the membranous portion, through 
which a No. 4 catheter can be passed. The muscular walls of 
the bladder are hypertrophied, and the viscus contains about 
15 ounces of putrid urine. The mucous surface is covered by 
a greyish-yellow filament which, when removed, reveals the 
presence of extensive ulceration. The ulcers are very 
irregular in form with elevated edges, and their floors are 
coarsely granular. On laying open the ureters from the 
bladder to the pelvis of the kidneys, the right ureter is found 
to be practically normal, while the left is contracted, and its 
walls thickened and indurated, but there is no trace of either 
old or recent ulceration. The right kidney and its pelvis are 
normal. The pelvis of the left kidney is studded over with 
small ulcers, varying in size from a split-pea to a barley-corn. 
The edges are level with the surface, while the floors of the 
ulcers are only slightly depressed, and covered by what appear 
to be recent granulations. This ulcerative process is strictly 
limited to the pelvis, and does not extend into the calyces 
of the kidney, the larger ulcers being situated at its inferior 
extremity. The kidney is slightly enlarged, soft, pale in 
colour, the surface is smooth, and the capsule is easily 
separated. Immediately under the capsule, a number of small 
pale bodies are seen, the majority of which are not larger than 
a mustard seed. On section, the cortex and medulla are seen 
to retain their normal proportions, and the line of separation 
is tolerably distinct. 

" On microscopic examination, the muscular wall of the 
bladder is found to be increased in bulk, and the fasciculi are 
separated from one another by bands of fibrous tissue. The 
serous surface presents nothing worthy of note ; but on the 
mucous surface there are distinct areas of acute inflammation, 
the inflammatory products containing large numbers of 
micrococci. A section of the ureter about two inches from 
the pelvis of the kidney shows the mucous membrane to be 
practically normal in appearance, but the deeper structure 



198 Dr. Steven— The Pathology of 

are infiltrated with round cells containing micrococci. In the 
pelvis of the kidney are very similar appearances to those 
seen in the bladder. On examination of the kidney, the small 
pale bodies are found to be minute abscesses evidently of very 
recent origin. They are most abundant underneath the 
capsule, and although some of them are found in the cortex 
close to the medulla, in this region they are less abundant. 
None of these bodies is found in the pyramidal portion. The 
abscesses are also loaded with micrococci similar to those 
found in the lower urinary tracts. 

"The examination of this case leads Dr. Newman to the 
opinion that the progress of the infection was from the lower 
to the higher regions of the urinary tract. It seems to him 
abundantly evident that the lesions found in the bladder were 
of older standing than those in the wall of the ureter and 
pelvis of the kidney, and also that the line of transmission 
was not along the mucous surface, but in the deeper structures 
of the ureter, probably along the course of the lymphatics. 
The fact that the calyces of the kidney and the medullary 
portion were not involved in the inflammatory changes, seems 
also to indicate that the infective process did not extend 
through these regions, while, if we are to admit that the 
lymphatics extend from the pelvis of the kidney to the sub- 
capsular lymphatic spaces, it is only a natural inference to 
suppose that the substance of the kidney became infected 
through those channels. When it is borne in mind that the 
abscesses in the kidney are more abundant in the extreme 
cortex than in its deeper areas, this explanation becomes all 
the more acceptable." 

EXPLANATION OF PLATES. 

The drawing were made with the aid of the A and D lenses of Zeiss, and 
the No. 3 eye-piece, the former magnifying about 70, the latter about 
320 diameters. No camera lucida was used; but, although the sketches 
may not lie quite exactly to scale, they are very faithful and accurate 
reproductions of what was seen. 

Plate I. Fig. 3. — Section of wall of bladder from Case 2. a. Greatly 
inflamed internal surface of bladder, b. Muscular coat of bladder, c. 
Localised patches of inflammation in wall of bladder. Stained in Bismarck 
brown. A Zeiss, No. 3 eye-piece. 

Plate I. Fig. 4. — Section of wall of ureter in Case 2. a. Inflamed (but 
not greatly so) mucous layer, b. Muscular coat. c. Localised patches 
of inflammation in muscular coat. d. Adipose tissue and blood-vessels of 
external layer, in which numerous patches of inflammation were observed. 
Bismarck brown. A Zeiss, Xo. 3 eve-piece. 

Plate II. Fig. 5. — Section showing a localised patch of inflammation 
in wall of bladder of Case 2. Colonies of micrococci scattering themselves 



Suppurative Inflammations of the Kidney. 199 

are seen among the leucocytes. Bismarck brown. D Zeiss, No. 3 eye- 
piece. 

Plate II. Fig. 6. — Section of kidney from Case 2, showing small abscess 
situated between capsule and kidney tissue, a. Capsule, with leucocytes 
in its meshes, b. Abscess, c. Kidney tissue, but little affected. Bismarck 
brown. A Zeiss, No. 3 eye-piece. 

Plate III. Fig. 7. — Section of kidney in Case 4, showing inflamed prtch 
with large colony of rod-shaped organisms (a) in its midst. Bismarck 
brown. D Zeiss, No. 3 eye-piece. 

Plate III. Fig. 8. — Shows the appearance of the surface of a healthy 
kidney after injection from the ureter with Prussian blue, as described in 
the text. Natural size. 

Plate IV. Fig. 9. — Transverse section of kidney injected from ureter 
with Prussian blue, showing the appearance of the pale blue streaks 
extending from the capsule through the cortex, as described in text. 
Slightly enlarged. 

Plate IV. Fig. 10. — The same — longitudinal section — showing the iu- 
jected spaces partly in oblique and partly in transverse section. Slightly 
enlarged. 

Plate IV. Fig. 11. — Section of kidney injected from ureter, a. Capsule. 
b. Injected lymphatics, of blue colour, seen lying between uriniferous 
tubides. c. Uriniferous tubules. A Zeiss, No. 3 eye-piece. 



LITERATURE CONSULTED IN PREPARING THE 
FOREGOING PAPER. 

Investigations into the Etiology of Traumatic Infective Diseases. 

By Dr. Robert Koch (Wollstein). Translated by W. Watson 

Cheyne, F.R.C.S. London : New Syd. Soc. 1880. 
Notes of a Case of Ulcerative Endocarditis. By J. Crawford 

Renton, M.B., and Joseph Coats, M.D. Glasg. Med. Journ. 

Oct. 1880. 
Neue Beobachtungen auf dem Gebiete der Mykosen des Menschen. 

Von Dr. James Israel. Virch. Arch. Band lxxiv, p. 31 ; and 

lxxviii, p. 427. 
Ein Fall von Primarer Endocarditis diphtheritica. Von Rudolf 

Maier. Virch. Arch. Band lxii, p. 148. 
O. Beckmann. Virch. Arch. Band ix, p. 228. 
Zur Kenntniss der Mycosen. Von C. J. Eberth. Virch. Arch. 

Band lxv, p. 341 ; also lxxii, p. 103. 
On Recovery from Surgical Kidneys. By W. Moxon, M.D. Path. 

Trans. Vol. xxiii, p. 157. 
Surgical Kidneys. By James F. Goodhart, M.D. Path. Trans. 

Vol. xxiv, p. 144. 
Nephritis and Pyelitis consecutive to Affections of the Lower Urin- 
ary Tract. By Marcus Beck, M.S. A System of Medicine. 

J. Russell Reynolds, M.D. London: Macmillan & Co. 1879. 

Vol. v, p. 529. 
Handbuch der Pathologischen Anatomie. Von Dr. E. Klebs. Dritte 

Lieferung, p. 654. Berlin. 1870. 
On Disseminated Suppuration of the Kidney secondary to certain 



200 Dr. Pearson — Twenty-one Years of Vaccination. 

conditions of Urinary Disturbance. By Wm. Howship Dickin- 
son, M.D. Cantab., F.R.C.P. Medico-Chirur. Trans. Vol. lvi, 

p. 223. 1873. 
The Kidneys. By C. Ludwig. Manual of Histology. By S. 

Strieker. New Syd. Soc. 1872. Vol. ii, p. 105. 
Traite d' Anatomic Sappey. Paris. 1879. P. 547. 
Discussion on Albuminuria — Glasgow Pathological and Clinical 

Society. Glasg. Med. Journ. March, 1884. Vol. xxi, p. 219. 
On Penal Calculi. By Henry Earle. Medico-Chir. Trans. Vol. 

xi, p. 211. 
Clinical Memoirs on Abdominal Tumours. By Dr. Bright. New 

Syd. Soc. 1860. P. 198. 
Diseases of the Kidneys, together with the Affections of the Pelves 

of the Kidneys and the Ureters. By W. Ebstein. Cyclopaedia 

of Medicine. Ziemssen. London : Sampson Low & Co. Vol. 

xv, p. 543. 
Traite des Maladies des Peins et des Alterations de la Secretion 

Urinaire, avec un atlas in folio. Par P. Payer. Tome i, pp. 

620 et seq. 
Acute Suppurative Nephritis supervening on Chronic Disease of the 

entire Urinary Tract. By Sir Henry Thomson. Path. Trans. 

Vol. vi, p. 262. 
Perinephric Abscess. By A. B. Duffin, M.D. Path. Trans. Vol. 

xxiv, p. 138. Also Med. Times. 24th Sept., 1870. 
A Manual of Pathology. By Joseph Coats, M.D. London : 

Longmans, Green & Co. 1883. P. 710. 
Vorlesungen iiber allgemeine Pathologic Von Dr. Julius Cohnheim. 

Berlin : A. Hirschwald. 1880. Bd. II, p. 366. 



TWENTY-ONE YEAKS' EXPERIENCE OF 
VACCINATION. 

By ARCHIBALD PEARSON, M.D., Glasgow. 

I GOT from the Glasgow Royal Infirmary (May 1863) two 
tubes of vaccine lymph. The following month I was ap- 
pointed parochial doctor and public vaccinator to one of the 
largest parishes in the West Highlands. In those days it 
was not necessary to have a knowledge of vaccination before 
a degree or diploma could be got. When I was called 
upon to vaccinate I had to read up how this simple opera- 
tion was performed, as I had never seen a child or an 
adult vaccinated before. By following the rules given I set 



Dr. Pearson — Twentyone Years of Vaccination. 201 

to work. However, I found I was not always successful, 
although I took the greatest care, and that I frequently 
had to vaccinate the same child two or three times before 
I could give a certificate of successful vaccination. I laid 
aside the lancet for the time and got a four-pronged vaccin- 
ator, which was much extolled; this I continued for some 
months, with no greater success, but I should say with more pain 
to the child, than when using the lancet. I made it a point, if 
possible, to see the children I vaccinated on the eighth day ; it 
was only by such strenuous efforts that I could keep myself in a 
supply of lymph. The district was so very extensive, and the 
children had to be taken frequently from such great distances to 
the station assigned for vaccination, it never would do not 
to have a supply of lymph always on hand. I saw the style 
of vaccination I had was far from being perfect ; so, in place 
of using the lancet first, and putting the lymph on again as 
was recommended, I reversed it. I put the lymph first on 
the sound skin, and then pricked gently with the point of 
the lancet until I made about the eighth of an inch in 
diameter of a raw surface, drawing little or no blood. So 
gently can it be done that I frequently vaccinate the little ones 
asleep. Two such marks I always put on. I am fain to 
believe that two good typical Jennerian vesicles will suffice 
equally to half-a-dozen, and more than two is an infliction 
on the child. This method I found most successful ; and 
since I adopted it I seldom if ever had a failure. I am now 
upwards of fifteen years in Glasgow, and on no occasion 
have I been called to vaccinate the same child over again — 
each I vaccinate I am certain will be successful. By this 
method I always have a supply of lymph; nor had I need 
at any time, since the day I got the two vaccinating tubes 
from the Glasgow Royal Infirmary, to get it from any other 
source, from that matter vaccinating from arm to arm and 
from tubes. I have been able ever since to keep up a supply, 
always having plenty of filled tubes to meet my own demands, 
and to give to other medical gentlemen about here who might 
need such. Vaccination, although it is a subject that has become 
so trite, and is a matter too often looked upon as requiring little 
or no care, requires nevertheless the strict injunctions given 
by Jenner himself. It is an operation, simple as it is, which 
requires great care, especially in taking up the lymph. I 
seldom take more than three tubes from the same child, at the 
most four, sometimes only one or two, and that always on the 
eighth day. Of course I select. I do not take it up from all 
indiscriminately. It is wrong to use pressure on the arm 



202 Dr. Pearson — Twenty-one Years of Vaccmation. 

when filling the tubes; only the dew-like drop that oozes 
out without pressure should be taken up. By taking more 
than four tubes from the same child I consider the matter 
more apt to be deteriorated, being a mixture of vaccine lymph 
and lympha. 

It is known that vaccine matter mixed with equal, or 
even fifteen, parts of water, or glycerine, generally succeeds 
as frequently as lymph only in producing a tj-pical vesicle. 
"With the matter containing the lympha or liquor sanguinis 
you may probably have a good vesicle, providing the child 
from whom it was taken had a good constitution; but if 
otherwise, the results would be damaging to the little patient 
into whose system such vile matter had been introduced. 
The vaccine vesicle on the eighth day, in a child with consti- 
tutional syphilis, differs not from that of a healthy child ; 
and my opinion is, that with due care in only taking up 
one or two tubes, they would contain nothing but true vaccine 
virus, and vaccinating from such would probably produce a 
typical Jennerian vesicle. I have not tried the experiment 
of vaccinating from such. 

During my twenty-one years' experience I have never seen 
anything worse than vaccination with any of those I vaccin- 
ated myself. I have full confidence that nothing can be 
transmitted but the true vaccine virus to any I vaccinate, 
as I have no hesitation in telling the parents or guardians 
that nothing detrimental can happen to the child through 
my vaccination. I have heard medical gentlemen say that 
they never vaccinate but with fear and trembling. When 
such words do escape the lips of the doctor it is not surprising 
the public should be in dread of vaccination. Some medical 
men go so far as to use a needle, and a fresh one each time 
they vaccinate. I have been vaccinating with the same 
lancet ever since I began practice — all I do is to wipe it 
well before beginning and after I am done. The error lies 
with the lymph, and not with the lancet or needle. Let the 
vaccinator use the precautions I have mentioned ; he will 
find fewer complaints and be more pleased with his own results. 
I warn the patients against using dusting powders or oint- 
ments ; all that is necessary is to keep a loose sleeve over the 
arm, and the scab falls off generally in the third or fourth 
week. 

The subject of vaccination is one of the greatest importance 
at the present time, and to command a genuine, sound, and 
plentiful supply of vaccine lymph, is the grand desideratum 
we aim at. And it is held out, by using vaccine derived from 



Dr. Pearson — Twenty-one Years of Vaccination. 203 

the calf, one can get rid of the objection people have to 
vaccination as now performed ; but by such matter may we 
not inoculate the foot and mouth disease, a disease which is 
said to show itself in man with a vesicular eruption, or even 
some other more malignant disease to which the bovine tribe 
is liable ? I believe it has not yet been practically proved tnat 
a trustworthy, active vaccine can be procured from the cow 
upon a sufficiently large scale. However, there can be no 
doubt that a healthy human vaccine in large quantities is to 
be had — and all that is required is to preserve and carefully 
store it up in hermetically sealed tubes — using the precautions 
I have mentioned. I have found at the end of two years the 
matter perfectly vigorous, by guarding against its contamina- 
tion by introduction from a diseased individual. The matter 
I am using has passed through upwards of four thousand 
children since I got it twenty-one years ago, how long before 
then or through how many children I cannot say ; and to-day 
it is as vigorous as when I got it, if not more so. In bearing- 
out this point, I will give a recent case in my practice as 
illustration. In September of last year I was called upon to 
vaccinate three of a family that came from West America. 
Their history was that they had been vaccinated, all three, 
three different times unsuccessfully, each time by a different 
doctor there. Their mother considered them proof against 
vaccination, so she thought it useless to try it an} r more. 
However, she was advised by her friends here to give it a 
trial before she returned with her family to America. I 
was called and vaccinated the three ; on the eighth da}>- I saw 
them again — all three were successful with as fine Jennerian 
vesicles as could be wished for. And further bearing out 
this point, I take the liberty of quoting a part of a most 
interesting article by Dr. John Carter, in the Lancet of 25th 
February, 1871, page 266 — "Another child I attended with 
small-pox, a very severe case in which about two-thirds of its 
tongue sloughed off. The patient had a hard struggle in 
recovering. In the same house were two other children un- 
vaccinated. The mother objected, saying, if the children had 
the two together it would be sure to kill them, a foolish notion 
which I overruled. The ages of the children were about seven 
and nine. The youngest soon began to show signs of premon- 
itory fever and was confined to bed for three days ; then the 
small-pox eruption came out. The feverish condition passed 
off, the patient left her bed, and went about the house during 
the rest of her illness, the disease being very much modified. 
The vaccine vesicle, before the eruption came out, was looking 



204 Mr. Kirkwood — Complete Rupture of the Perineum. 

very pale, but after it began to appear there was a decided 
show of activity in it, giving the idea that it would keep the 
upper hand, as in fact it did. On the ninth day of the cow- 
pox the small-pox eruption had hurried on and arrived at (put 
on the appearance of) its ninth day. During this time I was 
anxiously watching the other child in whom the vaccine 
vesicle was going on actively, and continued doino; so through 
the eighth day. But on the ninth she also was confined to 
bed with the premonitory fever of variola, which lasted three 
days, but no eruption came out, and the patient felt compara- 
tively well. Now, the lymph that I used in vaccinating these 
two children was procured from the cow sixteen years before, 
and I -had been using it in weekly vaccinations during the 
whole of that period, so that it had passed through about 
eight hundred children when used on the above occasion ; 
therefore, I doubt the necessity of the frequent renewal of the 
lymph from the cow." I had not the like opportunity of 
putting my lymph to the test, but I have not the least doubt 
if I had, I would have somewhat equal results. Also, I am 
quite convinced there is no necessity for the frequent renewal 
of matter from the cow, as held out by many. If my success 
in human vaccination may encourage others less fortunate, or 
whose faith in it is weak, on reading this I hope they will 
take courage and throw prejudice and fear aside. 



COMPLETE RUPTURE OF THE PERINEUM. 

By T. KIRKWOOD, M.B., CM., Rutherglen. 

Though partial rupture of the perineum is of very frequent 
occurrence in labour, yet cases of complete rupture, involving 
the sphincter ani and the vaginal septum, are comparatively 
rare. The following may therefore be of interest : — 

After a severe and protracted case of instrumental labour, 
towards the termination of which I had the assistance of one 
of the neighbouring practitioners, it was discovered that the 
perineal tissues were ruptured right into the rectum, the 
lower part of the bowel for about a finger length being made 
continuous with the vagina. Two single stitches of silver wire 
were at once introduced deeply into the tissues, the one going 
through the sphincter and the other catching up the parts 



Mr. Kirkwood — Complete Rupture of the Perineum. 205 

nearer the fourchette. The patient's legs were then firmly 
tied together with a napkin, and orders given that she was 
neither to defecate nor micturate without assistance. 

On returning in a couple of hours I found the patient 
raving ; her tongue white and tremulous ; temperature 102° ; 
and pulse 105. I introduced a catheter, and found the urine 
to contain a very considerable quantity of blood. In the 
evening I was happy to find the toxic symptoms gone and the 
blood less in amount. From this time onwards her recovery 
was uninterrupted. As she objected to the use of the catheter 
she was instructed to micturate on her hands and knees. She 
always did so after the first day. On the fifth day I examined 
the parts, and as they looked well, I deferred taking out the 
stitches till two days later. Introducing the finger into the 
rectum, I felt a considerable amount of thickening over the seat 
of the wound, but no discharge of any moment ; and as there 
were no scybala, I refrained from administering the usually 
recommended enema. The diet was principally milk, with no 
stimulants. During the first two days Pil. Plumbi c. Opio 
was given with the double intention of soothing the patient 
and keeping the bowels at rest. On the tenth day a 
dose of castor oil and a soap suppository were administered 
with the desired effect. The wound was so completely solid- 
ified that not a drop of blood or pus was detected in the 
motion. 

The case is an interesting one, as showing what results, 
even in untoward circumstances, may be obtained in cases of 
this kind by prompt action, accurate apposition of the lacer- 
ated surfaces, and perfect rest of the parts. No antiseptics of 
any kind were used. Indeed, it is questionable if dressing* 
and injections are not productive of more evil than good, as 
implying disturbance of that perfect rest which all recent 
wounds so much require. The wound healed by first intention 
throughout. The patient, with four of a family and lodgers, 
had no one to nurse her except neighbours, who looked in to 
see how she progressed. On the eleventh day I found her up 
and sweeping out her house, steadying herself by a chair with 
one hand. It is now six weeks since her confinement; her 
retentive powers are complete, and she says she is quite as 
well as after any of her former confinements. 

Perhaps it is not customary to keep the bowels so long- 
confined as in the above instance. G. Bantock considers 
the practice of keeping the bowels confined for a week to 
be a mistake. As a practice it may be so, but in this 
particular case the patient's general condition throughout was 



206 Mr. Kirkwood — Complete Rupture of the Perineum. 

excellent, and the wound had full time to heal and consolidate 
before an action of the bowels occurred.* 

Dr. Thomas of New York recommends the washing out of 
the vagina twice daily with a tepid solution of permanganate 
of potash or chlorate of potash (3 to 5 grs. to §i) ; but in cases 
of partial rupture I have thought that syringing gave less 
satisfactory results than more simple treatment. 

Cazeaux, in speaking of complete rupture, asserts that 
though spontaneous recoveries do occur, yet it is far from 
being the general rule, and he instances M. Huguier, who had 
seen 15 or 20 (he is not very particular about the exact 
number) cases of spontaneous cures ! Dr. Thomas, on the other 
hand, is doubtful of spontaneous recoveries. Dividing lacera- 
tions of the perineum into the following heads : — 

1st. Superficial rupture of the fourchette and perineum not 
involving the sphincter. 

2nd. Rupture to the sphincter ani. 

3rd. Rupture through the sphincter ani. 

4th. Rupture through the sphincter ani, and involving the 
vaginal septum ; he states — " The first and second degrees of the 
accident are very generally trifling in their consequences, and 
frequently pass unnoticed by both patient and attendant. The 
third is an evil of much greater moment, and not at all likely 
to undergo spontaneous cure, while the fourth represents the 
most serious form of the condition. The greater the injury 
the less likely will be the spontaneous recovery. ... It 
may be affirmed, in a general way, that any laceration which 
does not entirely sever the sphincter ani, may heal without 
surgical treatment, and that none which converts the two 
passages into one will do so. Even when the rupture has 
been complete, it has been asserted that spontaneous cure has 
taken place, but such reports need confirmation. Peu once 
affirmed that he had seen a woman thus injured, and who 
passed her faeces involuntarily, entirely recover. De la Motte 
declares that 30 years afterwards he met and examined Peu's 
patient in Normandy, and found that no recovery had 
occurred." 

Authorities differ much as to ivhen the operation should be 
performed. Cazeaux, Roux, and Velpeau advise delaying the 
operation until after the first menstrual return, on account of 
the lochial discharge, &c, Nelaton, Verneuil, and Maisonneuve 
prefer to operate about a week after delivery, while Dieffen- 
bach, Thomas, Edis, and Bantock recommend the immediate 

* Bryant, speaking as a surgeon of the remote operation, says the 
bowels should be locked up for at least a fortnight after the operation. 



Current Topics. 207 

operation. I believe the recent operation finds most favour 
in this country, and there are many reasons why it is to be 
preferred. The wound is fresh, and the surface does not 
require to be raived ; the operation is almost painless owing 
to the numbness caused by the pressure of the head; the 
repair progresses during the ordinary confinement to bed ; 
there is little risk of septic absorption if the operation is 
successful ; if union do not occur, the remote operation is in 
no way interfered with ; and it sets the minds of the patient 
and all concerned at comparative rest when something has 
been done to remedy a condition which, if left to itself, would 
in all probability render the future life of the unfortunate 
sufferer calamitous in the extreme. 

That the satisfactory results in the above case will follow 
in the majority of cases where due care is taken I have not 
the least doubt. The principal difficulty in the after treat- 
ment is in keeping the parts at rest, but even that may be 
greatly obviated by an intelligent and willing patient. As 
many cases of partial rupture heal with no treatment at all, I 
fail to see that the lochia can be so irritating to wounds as 
is supposed in some quarters. 



CURRENT TOPICS. 



List of Candidates who were successful for appointments 
as Surgeons in Her Majesty's British Medical Service at the 
Competitive Examination in London, on 11th August, 1884. — 
1. J. R. Forrest, 2,475 ; 2. M. W. Russell, 2,395 ; 3. W. R. de 
Morinni, 2,370 ; 4. B. F. Zimmermann, 2,355 ; 5. A. F. Stace 
2,340; 6. A. Stables, 2,295; 7. J. F. E. M'Craith, 2,285; 8 
E. A. C. Smith, 2,265; 9. W. M. Hewson, 2,210; 10. G. E 
Moffat, 2,210; 11. H. A. Haines, 2,180; 12. J. D. Moir, 2,175 
13. R. Crofts, 2,150; 14. G. M. Dobson, 2,140; 15. G. E. Hale 
2,130; 16. C. W. Johnson, 2,110; 17. W. E. Berryman, 2,100 
18. A. T. J. Lilly, 2,080; 19. R. Caldwell, 2,075; 20. C. C 
Rcilly, 2,065 ; 21. S. E. Duncan, 2,060 ; 22. J. Maher, 2,030 
23. A. Perry, 2,030; 24. S. M. Cordozo, 2,010; 25. A. de C 
Scanlan, 2,000; 26. H. W. James, 1,990; 27. R. Trevor, 1,990; 
28. H. D. James, 1,970; 29. W. Turner, 1,970; 30. B. O. W. 
Norfon, 1,960. 



208 Reviews, 



REVIEWS. 



i 1 Jin leal Lectures on the Discuses of Women. By J. Matthews 
Dux< an, M.D., LL.D., F.R.S.E. ' 2nd edition. London : J. 
& A. Churchill. 1888. 

Ix the April, 1880, number of this Journal, we gave a some- 
what lengthy review of the first edition of these Lectures, and 
as there is no change in the book, except the addition of 
sixteen new lectures and seven appendices, we shall restrict 
our present notice to that which is new. 

We have first of all a short chapter on Abdominal Signs, Lb 
which the author urges his readers to lay more strain on 
signs than symptoms. " The history is derived from the 
patient, and cannot be relied upon; for while it rarely 
contains false statements, it frequently contains errors. Al- 
most every patient has a theory of her case, and she distorts 
historical details, and even symptoms, to suit her views. In 
helping to make your diagnosis, history has a limited place. 
and subsequently discovered errors in history form no excuse 
of error in a diagnosis which has been given without reserve, 
or with a high degree of assurance. 

"For diagnosis, signs are sought with eagerness, and their 
absence is deeply felt ; because without them all is insecure. 
So paramount is the importance of signs, that the physician 
entrusts the search for them and their description to no one, 
but does all himself. You should lose no opportunity of 
making physical examinations, educating your senses, and 
especially your hands, by constant repetition, to produce that 
eruditeness which we admire so much in artisans of many 
sorts. You have to look, to touch, to manipulate or press, to 
percuss, to measure, to listen, and even more than all that." 

Then follow chapters on Pelvic Signs, on Symptoms and 
Indirect Symptoms. In regard to the value of the latter, 
Dr. Duncan is greatly doubtful "It is familiarity with 
the phenomena of pregnancy that convinces one that then 
are remote or indirect symptoms of diseases of the uterus 
and its appendages beyond those I shall presently mention 
as sure and generally admitted. But the subject has been 
very imperfectly studied ; and I am sure you will, in any 
case, come much nearer the truth by doubting or repudiat- 
ing altogether so-called symptoms that are remote, than by 
adopting the present prevalent belief in their Protean 
character. 



Reviews. 209 

" Looking into popular gynaecological manuals you will lind 
this Protean group around split cervix, displacement, ulcer- 
ation, and other uterine diseases and disorders ; and I give 
you an example. A great author and practitioner describes 
retroflexion of the uterus as producing, or as having for 
symptoms, dysmenorrhea, menorrhagia, leucorrhcea, abortion, 
sterility, obstruction of rectum, ribbon stools, pain in defec- 
ation, intestinal paralysis, disturbance of digestion, flatulence, 
pyrosis, nausea, disorders of liver, disordered secretions, 
hysteria, intellectual disturbance, and many, many more. 
All of these may accompany retroflexion, no doubt, but 
they are in no sense symptoms. You will utterly reject all 
this kind of pathology as worse than useless, and examine 
the matter more narrowly. I have no hesitation in telling 
you that, compared with this, you will then find retroflexion 
to be a very innocent affair. The rules I gave you for testing- 
the reality or truth of direct symptoms apply to these indirect 
symptoms, and should be rigidly applied in order to your 
pursuing a right course for your patients." 

Three chapters are devoted to Retention of Mucus, Blood, and 
Fseces. Then follows a chapter on Hydroperitoneum, which is 
the name the author gives to a collection of serous fluid in 
the abdomen depending not on disease of remote organs, but 
on more or less decided inflammatory affections of the 
peritoneum itself. In the chapter on menorrhagia, there are 
some valuable remarks on treatment, the whole of which is 
summed up in two pages. " Then we come to medicines. Of 
all with which I am familiar — and I have tried a great 
number — ergot stands first. In obstetrics you are generally 
told that ergot produces its effect in about fifteen minutes. 
That is doubtful even in parturition ; but, in the unimpreg- 
nated woman, you must not expect it to act thoroughly till 
days of its use have elapsed, and in some cases I have observed 
its use has had no result, until it has been continued for 
weeks without intermission. After ergot, in popular estima- 
tion, come gallic and tannic acids. I am not quite sure that 
they have any effect at all. They may have an effect, and be 
as rationally used as other medicines. I have used them 
extensively, and the impression the}' have left on my mind I 
have just told you. The medicine which seems to me next 
best, after ergot of rye, is sulphuric acid, often combined with 
some saline; and no injury is done if the saline produces 
slight relaxation of the bowels. You have not long to wait 
for sulphuric acid to produce its effect. You may have to 
give it in large doses, and frequently; for instance, you may 

No. 3. 1' Vol. XXII. 



2\o ll' >■;, u)8. 

give one drachm, or even twice as much, in a day, dividing it 
into frequent doses. The beneficial influence of digitalis and 
cannabis indica is almost certain; yet, in point of trust- 
worthiness, these remedies come considerably after ergot and 
sulphuric acid. 

" One of the most powerful influences, and one with which I 
have been long familiar, is the use of heat. Heat is supposed 
by most people, professional and non-professional, to favour 
bleeding: but its influence in causing the contraction of 
involuntary muscles has long been known, and its use in 
cases of menorrhagia and metrorrhagia, whether simple or not, 
is very valuable. It is to be applied internally in the form of 
irrigation, by the passing through the vagina of a large 
quantity — pints — of water at 100° to 110° Fahr. This is not 
to be done loner at a time, beincr continued five to ten minutes, 
and repeated several times a day. It is almost universal to 
swear by cold as a haemostatic in our diseases, and I need not 
say that I have seen it used, and used it myself many times. 
In the form of ice applied to the external parts, it is, I think, 
quite as often injurious as not. It is best used by irrigating 
the vagina just as is done with hot water, or by placing small 
bits of ice in the vagina, Even used in this latter wa} T , my 
impression is that its value is inferior to that of heat." 

There is a chapter on Vaginitis. Of the non-specific forms 
the author believes that due to alcoholism is the most common 
and most important, and that there is no cure for it, except 
the removal of the cause. In the chapters on uterine growths, 
the author condemns the use of the term " intra-uterine 
polypi," and advances that of " intra-uterine tumours," as 
beinw more correct. His argument is as follows : — " An intra- 
uterine growth, not intra-cervical, is either sessile or has only 
a neck ; it has no distinct stalk to make it a polypus. You 
may easily perceive that, within the womb proper, there is 
no room for the development of a stalk to a polypus, which 
is of very considerable dimensions. You must understand, 
then, that intra-cervical polypi are generally called intra- 
uterine, and wrongly so ; moreover, they are easily diagnosed 
and managed, compared with truly intra-uterine growths, 
which are rarely, if ever, polypi, and have only sometimes 
a neck, never a stalk. You see I do not attempt to make 
a new nomenclature — that is an easy proceeding, which is 
rarely advantageous, and still more rarely successful ; — but I 
give a designation to growths which are truly within the 
cavities of the body of the uterus, calling them intra-uterine 
tumours, not intra-uterine polypi, from their origin and 



Reviews. 211 

situation combined ; and it is only of such truly intra-uterine 
tumours that I intend to speak to-day. You will under- 
stand the rationality of calling a tumour a polypus, accord- 
ing to its site of origin, and using other terms to denote the 
situation in which the body of the growth happens to lie, 
if you think of polypi of the nose. These sometimes hang 
down into the pharynx, and they are not called pharyngeal, 
but nasal polypi, and we are only carrying out the same 
rule of nomenclature." 

In speaking of displacements of the uterus the position 
is strongly taken up that in the majority of cases the 
symptoms are due, not to the displacement itself, but to the 
conditions which have caused it, or which accompany it. He 
accordingly thinks that the use of pessaries is only a very 
secondary, and indeed often undesirable, part of the treat- 
ment. Where pessaries are desirable he gives the following 
sensible directions for their use : — " One of the best examples 
of relief by a pessary is observed in the anteversion (by 
probe) of an engorged retroverted and descended uterus. 
Here a well fitted Hodge is comforting and curative. Main- 
taining the anteversion, elevating the uterus, or preventing 
descent on walking or standing, and preventing relapse into 
retroversion or retroflexion by keeping the posterior laquear 
of the vagina pressed against the sacrum. Another notable 
example of relief is seen in descent with tendency to cystocele, 
when the irritation of the cystocele pushing at the orifice 
of the vagina is most anno} r ing. In such, a suitable sized 
Hodge, or india-rubber ring, often, by its anterior limb, just 
catches the cystocele and obviates the tendency to protrusion 
through the os vaginae. For each case your pessary must 
be specially adapted — a ring — a boat shaped, or a double 
curved — and it must fit the patient in size and contour. 
Nothing can instruct you in this but bedside experience. 
Occasionally you have to try more pessaries than one to 
find the most suitable. Sometimes a woman, whose case you 
expected to relieve by a pessary, can bear none of whatever 
kind." 

We think the author's theor}', that considerable dis- 
placement of the uterus often exists without causing any, 
even functional, disturbance, sometimes carries him a little too 
far, as witness the following paragraphs : — " It is, I believe, 
universally admitted that versions, flexions, and descent are 
not necessarily the cause of any discomfort or disorder, 
and this is a cardinal fact in this question. Think of it. 
Thousands of blooming, happy, fertile women have displace- 



212 Reviews. 

ments. To treat a displacement simply because it exists, is a 
grave error, and yet not a rare one. Such simple uncomplicated 
displacement is not disease. It is the condition of equilibrium 
of that woman's pelvic viscera, and, therefore, the displacement 
is a constituent part of her comfort and health." " Thousands 
of blooming, happy, and fertile women," are, it is to be hoped, 
not presenting themselves for examination by gynecologists, 
and in the absence of such examination, how is he, or anybody 
else, to know that their uteri are displaced ? The volume 
concludes with five appendices, which are mainly interesting 
as dealing with out-of-the-way subjects and cases. These are 
" On Open Fallopian Tul le and Cervix Uteri," " On Spon- 
taneous Dilation of the Virgin Uterus with Haemorrhage," 
u On Intra-Uterine Menstrual Coagula," " On Intra-Uterine 
Puerperal Coagula," " On Foetid Parametric and Perimetric 
Abscess," " On two cases of Nerve Lesion in Gjoiaecology," 
" Notes on the Morbid Anatomy of Douglas' Pouch." 

To those who know Dr. Matthews Duncan's style we need 
not say that these Lectures are interesting. Those of our 
readers who have not seen any of his works will get a fair 
notion of their fashion and value from the extracts we have 
given in this notice. The first edition has been translated into 
Italian, German, and Russian, and we have little doubt 
but that the present one will also command an extensive 
circulation. 



A Study of the Bladder dv/ring Pa/rim rition. By J. Halliday 
Croom/M.D. Edinburgh : David Douglas. 1884. 

It seldom falls to the lot or wisdom of an investigator to 
choose his subject so happily as Dr. Croom has done. It has 
been too much the custom to regard the bladder as simply a 
convenient reservoir which, when empty, might be left out of 
consideration, and upon all obstetric occasions should be 
emptied. Such a policy of annihilation was certainly summary, 
but scarcely satisfactory. It deprived the bladder of any 
normal function during parturition, and if the urethra suffered, 
or even sloughed, the pressure of the foetal head sufficed to 
account for it whether a catheter had been passed or not. No 
one ever accused the catheter of producing mischief, yet a 
moment's consideration renders it evident that if the continued 
pressure of an impacted head upon the urethra may cause 
sloughing — the forcible increase of pressure caused by the 
passage of a catheter will not improve matters. 



Reviews. 213 

The essay consists of three parts. One concerns the normal 
relative anatomy of the bladder, one deals with the pressure 
to which it is liable during parturition, and its behaviour 
under it ; and one with the liabilities of the bladder during 
the early puerperium. 

We have no hesitation in saying that we are aware of no 
work in this language where so complete an account can be 
found. The relations of the bladder in the non- pregnant 
state, as well as in the various stages of pregnancy and labour 
— the effects of other surroundings, and of greater or less 
distension of the bladder itself, are demonstrated to possess a 
physiology of which too little account has been taken by 
English writers. 

Dr. Croom does not advance this part of his subject as an 
original revelation. He has collected widely, and his state- 
ments are clear and concise. Nothing that is of value seems 
to have been forgotten, and nothing is stated which would 
have been better omitted. Upon one point of diagnostic 
importance he modestly claims the merit of discovery. He 
has recognised that when the bladder is distended during 
parturition, the dragging up of the viscus causes a circular 
contraction of the upper part of the vaginal walls, and a 
constriction, most marked in front but extending all round 
the vagina, can be recognised by the finger. It is most 
marked in primiparse, and is seldom found in the non- 
pregnant state. This observation will certainly not be over- 
looked by practical accoucheurs. 

A study of " the extent and manner in which the bladder 
and its contents are influenced by the parturient efforts," is 
the professed object of the original study in the volume. We 
have noticed the preliminary groundwork, and before pro- 
ceeding to the ostensibly experimental part of the essay, we 
would record an observation of great practical importance, 
for which it is not easy to find a more suitable place. For 
reasons afterwards to be mentioned, it is concluded that the 
pressure upon the bladder during the second stage of labour 
is not due to the advancing foetal head, but merely to the 
action of the voluntary abdominal muscles (page 39). "In 
order to remove any possible doubt on this question, I made 
a few manometric observations during forceps delivery, and 
found that when marked traction was made on the head with 
the forceps, there was absolutely no rise on the mercurial 
column in the absence of a pain, and even during pains 
traction did not increase the pressure indicated." Again, 
page 29 — "Distension, even moderate distension" of the 



214 Revu "■■-■. 

bladder, " is a very rare thing in parturition. Although 
constantly referred to it must strike the practical accoucheur 
as a fact, that except as routine, and then with questionable 
benefit, the catheter is comparatively seldom required in 
labour." Surely as a preliminary to the forceps delivery of 
a firmly impacted head it is as a matter of routine a very 
questionable benefit. The other sources of pressure are the 
change in shape of the uterine ovoid, and the stretching of 
the cervix uteri. It is not unfair to deduce from the above 
remarks that Dr. Croom considers the usually received opinion 
as regards the pressure exerted upon the bladder by the foetal 
head to be erroneous. To have established this negation 
would have been a satisfactory result, but Dr. Croom has 
other aims which are not so easily expressed, nor so well 
fortified against criticism. 

Page 10. — ■" If it is possible to calculate the pressure which 
is to be subtracted from the entire uterine pressure lost on the 
bladder during parturition, further experiments may be made 
to ascertain approximately the amount of pressure lost upon 
other portions of the pelvis and its contents. It is only thus 
that a true estimate of uterine force can be obtained." These 
words occur in association with comments upon the calcula- 
tions of Haughton and of Matthews Duncan on the power of 
labour. 

That the pressure exerted upon the bladder during labour 
is due almost entirely to the action of the abdominal muscles 
is well substantiated by the following : — The enormously 
increased pressure measured during the second stage of 
labour, and the occurrence of similar rises in pressure coinci- 
dent^ with such voluntary efforts in coughing, vomiting, or 
bearing down during the first stage. Dr. Croom has ascer- 
tained that the limits of pressure exerted upon the bladder at 
varying stages to range between *1 and 3"2 on the square inch, 
but he wisely points out that the other terms of the calcula- 
tions are not ascertainable. We might estimate or measure 
the exact quantity of fluid contained in the viscus, but we 
could not estimate the displacement of the bladder walls, and 
would not have a satisfactory knowledge of the intra-vesical 
area. Further (page 38), " Were the bladder a rigid cylinder 
. . . it would be easy to estimate the precise sum of force 
expended on it, but its walls being more or less elastic, it 
would be necessary to determine both the degree and quality 
of that elasticity as a basis for any calculation in this direc- 
tion." At a later period, while considering the state of the 
bladder as regards contents, Dr. Croom refers to the condition 



Revieios. 215 

of over distension, a condition which practically disposes of 
the allowance to be made for the elasticity of the bladder 
walls. It somewhat detracts from the value of the present 
manometric observations to be told that in the case of an over 
distended bladder a very small pressure will cause a high 
reading ; yet the assertion is merely what might have been 
anticipated. Dr. Croom has not yet got observations with a 
distended bladder, and when he does get them we shall antici- 
pate much more useful results. There are, however, serious 
difficulties to be overcome, and prominently the risk of a 
distended bladder being burst by the force of labour, which it 
is not in our power to control. We do not notice that any 
observations are recorded concerning the bursting strain of 
the bladder wall. 

We congratulate Dr. Croom upon the mental attitude with 
which he leaves this subject uncompleted. It is the most sure 
guarantee of the value of the work which he has recorded, and 
the most hopeful of promise for greater results to follow. 

The last chapter of the volume refers to the bladder during 
the early puerperium, and is both interesting and instructive. 
Here, distension, moderate or in excess, is very liable to occur, 
and does really affect the position of the uterus, yet a routine of 
catheterism is not practised. The excellent description given 
in this chapter will surely fail in its purpose if it does not 
induce practical accoucheurs to secure their patients from 
conditions which are too often at present considered physiolo- 
gical. These notes do not at all comprise the whole contents 
of the essay, nor do we desire that they should. We hope 
sufficient has been said to excite interest, and we have every 
confidence in expressing our conviction that Dr. Croom's essay 
will sustain it. 



Text-Booh of the Principles of Physics. By Alfred Daxiell, 
M.A. Macmillan & Co. 

In the arrangement of tliis work the author has departed 
somewhat from the order which is usually followed in the 
older style of text-books. Instead of beginning with the 
consideration of the properties of matter he gives in his 
introduction information regarding matter and motion, which 
can only be understood after the text itself has been studied. 
He has also adopted the plan of making the reader familiar 
with the consideration of time, space, and ma--, and, follow- 
ing these in a natural order, velocity, acceleration, force, and 
momentum. This seems to us to be the more reasonable 



21 o' Revit ws. 

course to follow, as without an accurate knowledge of the 
units employed in measurements no student can grasp, much 
Less apply to physical phenomena, the principles of physical 
science, and without this his knowledge will consist merely 
of a compendium of physical facts, which have no apparent 
connection with one another. 

It is difficult for the unscientific thinker to dissociate the 
idea of mass from that of weight, and to see clearly that 
while the former is merely quantity of matter, the same all 
over the world, the latter is a force which varies as we 
change our latitude and distance from the earth's surface; 
and although this has been very clearly set forth in the 
hook before us, we believe the ordinary student will not 
become perfectly familiar with these distinctions until he has 
made some progress with his studies. 

Acceleration is here defined as the rate of change of velocity, 
whether that change be to increase or diminish the velocity; 
but this is scarcely a complete definition since acceleration 
sometimes only changes direction of velocity, as in the case 
of a body moving with uniform velocity in a circular orbit. 

The author of this book has evaded an expression which 
has been a stumbling block to many a student. He has 
defined the unit of acceleration as " the acceleration observed 
when a body alters its speed by one unit of velocity every 
second." This might be worded, if we adopt the usual 
phraseology — The acceleration observed when a body alters 
its speed by one foot per second per second, supposing Ave 
employ the foot as our unit of space. In lieu of the phrase 
per second per second, which has puzzled many a student, 
and not unfrequently printer also, we congratulate the author 
in having found one which answers the purpose, and is more 
suggestive. < >nce having grasped the idea of acceleration 
it is easy to lay hold on the idea of force, which is most 
conveniently measured by the acceleration produced in a 
given time. 

Under the paragraph on weight, considering its importance, 
there is some room for amplification and further illustration 
by worked out examples. 

The velocity acquired by a mass on which gravity has 
acted freely for one second is '.Y2± feet per second, this being 
the approximate observed value for Edinburgh and Glasgow. 
Now on working out the value of gravity at the Equator 
and at the Pole by the formula given by Rankin, we find 
that in the former case it becomes 32 - 08, and in the latter 
32*26 — an appreciable difference. Two or three examples 



Reviews. 217 

worked with these different values might assist the student 
to appreciate the advantage of an absolute unit of force 
— i. e., one which does not depend on our position on 
the earth's surface. For measurements of force, which do 
not require absolute accuracy, the weight of a lb. mass as 
a unit answers the purpose very well, and this is the one 
universally used by engineers. The same objection may be 
made to the chapter on work, the want of examples worked 
out to show the actual difference between the work done on 
a body by the force of gravity at different points of the 
earth's surface, and also the error introduced by adopting 
a unit which would be strictly accurate only in one latitude. 

In the chapter on Energy we have some statements which 
lean to the speculative side, and are apt to suggest farther 
speculations. We are pointed to a time in the future when 
we shall have none of these phenomena which are every day 
occurrences now ; and, looking back, we are asked to contem- 
plate a time before these phenomena began. But, suppose 
we look farther than that time, when the energy of the 
universe began to run down or become non-available, what 
do we expect to find ? We can hardly imagine this state of 
things always to have existed, and yet it is equally difficult 
to imagine anj- other. Our experience of physical phenomena 
up to this point has a certain continuity ; but here the con- 
tinuity is broken, and our experience fails us. We seem to 
be confronted with the same difficulty when we look forward 
to the time when the "whole physical universe will have 
run itself down like the weights of a clock." But these 
are speculations, and such should hardly find a place in a 
book which is professedly for a beginner. 

Notwithstanding the importance of the subject, especially 
when we come to consider the theory of light and sound, we 
think that more space has been devoted to the subject of 
harmonic motions than the scope of the work justifies. 

" Centrifugal force " is a term of very old standing, and one 
which will probably continue to hold its place; but the 
meaning attaching to it now is somewhat different from what 
it used to be. When a stone at the end of a string is whirled 
round, as in a boy's sling, there is a tension on the string 
which might lead us to believe that the string being cut the 
stone would fly straight out from the point about which it had 
been rotating, though the fact is that the stone liberated will 
move in a tangent to the curve which it was describing at the 
instant of its release, and in the same direction as it had in 
that curve at that instant. It appears, then, there is no 



218 Revieivs. 

tendency on the part of the stone to fly straight out when set 
free. When the governor of a steam engine begins to rotate, 
the balls rise until they are describing a certain circle. If the 
speed of the engine be gradually increased the balls will 
continue to rise, and in this case there seems to be some agent 
at work which corresponds to the old idea of centrifugal 
force, but the fact is, with the increased speed of balls, the 
momentum is increased and a greater force toward the centre 
is required to keep them in their orbit. But, as this force is 
supplied by the horizontal component of the gravity of the 
balls acting in a direction passing through the axis of rotation, 
the system of forces will seek equilibrium by the balls rising 
and increasing the size of their orbit, thus diminishing the 
force necessary to keep them in their orbit and at the same 
time increasing the horizontal component of the gravity of the 
balls. The ball of the governor, at any instant, might be 
maintained in its position by inserting a string between it and 
the axis round which it rotates, and then would be a force 
acting through the axis equal to the centrifugal force required 
to keep the balls at the same height. Mr. Daniell speaks of 
resolving the tangential velocity into two components, an 
expression which is not strictly correct, and is sure to puzzle 
the learner. It seems to us more convenient to speak of the 
velocity in the curve at any instant as being the resultant of 
a tangential velocity and an acceleration towards the centre, 
for we may consider the body describing the curve to move 
for an infinitely short time along the tangent, and then to 
receive a small pull toward the attracting centre, and this 
operation being repeated an infinite number of times, produces 
a curve. This last is a case in which acceleration does not 
alter velocity, but only alters its direction. 

It is, perhaps, more correct to consider what we understand 
by centrifugal force as a resistance to force. Newton's first 
law of motion tells us that a body set in motion will continue 
to move forward in a straight line unless it is acted upon by 
impressed force (ws im/presscb). Now, in the case of the 
moon revolving round the earth, the attraction of the earth 
continually draws the moon from the straight onward course 
which, neglecting the attraction of other bodies, it would 
follow, according to Newton's First Law, if it were not for 
the attraction of the earth, and it is to the resistance which 
the moon offers to being drawn from its straight onward 
course that we apply the term " centrifugal force." 

Perhaps this question of centrifugal force is one of the most 
interesting and most important that we come across in our 



lie views. 219 

study of physics, and on this account we have considered it at 
some length. When we consider that mechanics, pure and 
simple, has always formed a part of the medical student's 
curriculum, this subject seems to us to have got but scant 
justice, especially when we compare it with the voluminous 
treatment of properties of matter. 

Under "gravitation," we notice some facts about gravity 
which, we think, ought to have been treated of when the subject 
of weight was under consideration. 

The first law of thermodynamics is given thus : — " Heat, 
being a form of energy, can be measured in ergs," which the 
author admits to be rather different from the usual form. Of 
course, heat can be measured in foot pounds or foot poundals, 
and perhaps it would not be amiss to give this alternative 
expression of the law, as it sounds more familiar in our ears. 

Sound and Light are fully and well treated, and in the 
chapter on Electricity and Magnetism we have some valuable 
tables of the resistance and conductivity of different substances, 
and some equally valuable measures and units which, however 
uninteresting to the general reader, will doubtless be highly 
prized by those who make physics a study. 

In the preface Mr. Daniell tells us that this book was 
primarily designed as a contribution to medical education, as 
if that original intention had been departed from ; and we 
must confess, after looking over the work, that, in our opinion, 
it has been departed from. Although the author modestly 
speaks of the work as a stepping stone, we feel certain that 
the student who masters all the information in this volume 
will have a not inadequate idea of the whole range of physics. 
But we are equally certain that the average medical student, 
who would require to take up this subject as a small part of 
an extensive curriculum, would feel bewildered by the amount 
of information placed before him, and we would advise Mr. 
Daniell, if he wishes to see his book used largely as a medical 
student's manual, either to publish it in an abridged form or 
in a future edition to curtail it considerably. We question 
the advisability of using so much small type, and some of it 
might, we think, with advantage be omitted, especially s< inn- 
paragraphs in Chapter III. The author makes an apology for 
the sacrifice of literary elegance, which he says he has made 
in order to secure absolute lucidity of expression. But we 
must congratulate him upon having produced a work which 
is everything that could be desired as regards composition, 
and in which scientific accuracy has not been made subsidiary 
to mere arrangement of words. 



220 Reviews. 

Post-Nasal Catarrh, and Diseases of the Nose causing Deaf- 
ness. By Edward Woakes, M.D. London: H. K. Lewis. 
1884. 

This work on Post-Nasal Catarrh, by Dr. Woakes, is published 
as a supplementary volume to his already well known treatise 
on Deafness, Giddiness, and Noises in the Head. It has for 
its subject the catarrhal lesions of the naso-pharynx, of which 
ear disease and deafness are secondary and later issues. 

In considering the questions involved, he has been guided 
by the same physiological principles with which he essayed to 
elucidate the subjects of tinnitus and giddiness ; and in order 
that those principles be made fully intelligible to readers of 
this present volume, his theory is discussed in an introductory 
chapter. Shortly, his propositions, as summed up at the end 
of the first chapter, are " that we have in the human body a 
mechanism, that of the sympathetic system, which, when nor- 
mally constituted and healthily operative, is capable of main- 
taining the nutrition of the animal man, and that it is designed 
so to maintain it. That exaggerations or repressions of its 
normal activities produce those modifications of nutrition 
which initiate the morbid processes with which the subject 
treated of is concerned. And, lastly, that owing to the 
correlating function of the ganglia implicated, those processes 
are localised in the several organs which exhibit them." 

From this he proceeds to consider the etiology of catarrh 
under the headings of the " Prse-Catarrhal State " and " The 
Mechanism of taking Cold," the aim of which is to show " the 
existence and nature of a prse-catarrhal stage ; the mechanism 
of the chill, implying vessel dilatation in the parts of least 
resistance, in response to an afferent impression reflexly trans- 
ferred to this efferent area ; and the tendency of the chemical 
qualities of the consequent effusion to determine the issues of 
the inflammation thus brought about." 

The hygienic management of the catarrhally predisposed is 
carefully detailed, interesting alike to the general practitioner 
and the specialist. Then follows a sketch of the anatomy and 
physiology of the post-nasal space, in which he takes the 
opportunity of adding his testimony to the subsidiary position 
the mouth should occupy in the function of respiration ; and 
as a practical deduction from this, calls attention to the 
absurdity of advising the use of respirators, with the view of 
modifying the temperature of the inspired air, for the mouth 
only, leaving the nostrils exposed. 

In the closing chapter he protests, and that very properly, 



Reviews. ±'2\ 

against the prevalent custom of regarding every neoplasm 
met with in the nose as one of polypus, and insists upon the 
necessity for more accurate diagnosis as the first step to 
efficient treatment. 

Affections of the naso-pharynx are not easy of satisfactory 
examination, and many are difficult of remedy — troublesome 
alike to the patient and surgeon — and to have the subject 
investigated in a thorough and scientific manner, and treat- 
ment based on the results of such an enquiry, should be 
welcomed by all interested. 

Although in many points fuller practical information might 
be given with advantage, the treatise is very well worthy of 
careful perusal. 



Aids to Physiology. By Thompson Lowne, F.R.C.S. Eng. 
Bailliere, Tindall & Cox. London. 

In the Preface we are told this book is " intended to assist 
students to put together the knowledge they have already 
acquired by attending a course of lectures on the subject, or 
from the perusal of some of the well known text-books," and 
we agree with the author as to the proper function of " Aids." 
But he seems to have carried out his idea with considerably 
greater success in the parts on the Chemistry of the Body and 
the Histology of the Tissues than in the rest of the book. 
Indeed, this is a marked feature of the book — the great pre- 
dominance of the histology of tissues and organs over their 
physiology; and not only a marked feature of the book, 
but a strong objection to it. An example of this is seen in 
Part IV — The Circulation, where four pages are devoted to 
the structure of the blood-vessels and scarcely a page more to 
the consideration of blood pressure, the pulse, the rate of the 
circulation, the capillary and pulmonary circulations. No state- 
ment is made as to the forces that carry on the circulation of 
the blood, except this — "The movement or circulation of the 
blood is caused by the action of the heart." In this section 
also a strange confusion is made between blood pressure and 
arterial tension — "The clastic coat of the arteries is always 
more or less distended. The pressure which it exerts on the 
blood — blood pressure (!) — keeps it flowing continually throng] 1 
the capillaries." Now, students, as a rule, find a difficulty ai 
first in distinguishing between blood pressure and arterial 
tension, and if they turn to these "Aids," how will this help 
them ? In the sections on Digestion similar things are notice- 



•1-2-2 Reviews. 

able, the space devoted to structure — 1G pages — being not 
much less than what is given to the consideration of Food, 
Secretion, and the whole process of Digestion, although these 
are perhaps the most satisfactory sections of the book. In 
the paragraphs on The Senses we note the absence of any 
allusion to the physico-physiological theory of dissonance, to 
chromatic aberration, and to astigmatism. In short, the work 
confirms us in the view we have of the difficulty of writing 
a book of the "Aid" type that will satisfactorily fulfil its 
function. We are afraid that the student, who accepted the 
indications given in the Aids to Physiology as to what was 
necessary to work up for an ordinary pass examination, would 
find himself scarcely equipped when the day of trial came. 



Hay Fever: its Etiology and Treatment. A Lecture delivered 
at the London Hospital Medical College. By MoRELL 
Mackenzie, M.D., London. London: J. & A. Churchill. 1884. 

Those who are interested in the subject of hay fever will find 
in this little pamphlet a brief but comprehensive account of 
all that is known about it. After a few remarks on the 
history of the affection, the etiology is discussed in great 
detail, and it is shown that there can be no doubt that the 
disease is due to the action of pollen on the mucous membrane. 
After noticing the symptoms of the complaint, the writer con- 
cludes with some very excellent hints as to treatment. To 
the general practitioner, who must often be at a loss in 
dealing with cases of this kind, the present communication 
(coming, as it does, from one of the highest authorities) is 
likely to prove highly serviceable, and we have pleasure in 
recommending it. 



Clinical Chemistry. By Charles Henry Ralfe, M.A., M.D. 
London: Cassell & Co., Limited. 1883. 

We have pleasure in recommending this little book to the 
notice of students and others, especially in these days when 
in medical education the subjects of physiological and patho- 
logical chemistry are being brought so prominently forward. 
Accurate information as to the chemistry of the tissues and 
secretions in health and disease can only be obtained by 
reference to bulky volumes, especially German, and it must 
be exceedingly beneficial to the student to have in his posses- 
sion a manual like the present, where a short but general 



Medico-Chirurgical Society. 223 

review of the subject is given. The work consists of six 
chapters, of which the first two deal with the organic and 
inorganic constituents of the animal body, and their chemical 
reactions. In the third chapter is discussed the chemistry 
of the blood, chyle, lymph, and milk ; and in the fourth an 
account of the morbid conditions of the urine is given. 
Chapter five deals with the morbid conditions of the digestive 
secretions, and in the last the chemistry of various morbid 
products is discussed. 



MEETINGS OF SOCIETIES. 



MEDICO-CHIRURGICAL SOCIETY. 



Session 1884-85. 
Meeting VIII— 2nd May, 1SS4. 



Dr. Gairdner, President, in the Chair. 

The President exhibited some cases of pseudo-hyper- 
trophic PARALYSIS, and also one or two other cases with 
features somewhat resembling those of this affection. He 
also read a paper on the subject. 

Dr. Middleton read the report of a case in the Town's 
Hospital which died in an advanced stage of atrophy, and 
showed sections of various muscles and of the spinal cord. 
The lesions of the muscles were, in the main, such as had been 
already described. It seemed also that there was a lesion in 
the spinal cord, but the examination of the nervous system 
had not been completed. A detailed report of the micro- 
scopical examination will be published at a future date. 

Dr. Perry said that he had had several cases under his care 
in the Infirmary during the last four or five years, showing 
that the disease was not so rare as was commonly thought. 
Two brothers of the ages of eight and ten he sent out about a 
month ago. One of these was in an advanced stage, unable 
to rise from the floor; the other was less advanced. The 
treatment appeared to be thoroughly hopeless. 



224 Meetings of Societies. 

Dr. Steven said that two years ago he was requested to 
remove the spinal cord from a case of the disease which had 

died in the Town's Hospital. He was only permitted to open 
the back to remove the cord. He found the superficial 
muscles much altered, especially those opposite to the lower 
vertebra?, which resembled adipose tissue. On examining 
microscopically it was found that the higher muscles, about 
the region of the neck, were not much altered. On examin- 
ing the cord there appeared no naked eye alterations at all : 
and in putting sections under the microscope, there were 
found a number of these amylaceous bodies referred to by Dr. 
Middleton. Dr. Coats thought also that some of the nerve 
cells appeared to be defective. 

The President said, in closing the Session of the Society, hi ■ 
had no intention to inflict upon them any lengthened oration. 
On his election to the office of President it was mentioned to 
him that something in the shape of an address would be expected 
of him. But at that time he was in the unfortunate position 
of having been obliged to give five addresses within the period 
of 18 months, two of them University addresses to student- 
and graduates — one as President of the Medico-Psychological 
Association, and two on other similar occasions, none of them 
of his own seeking. In the matter of addresses accordingly he 
felt himself at that time pretty much worked out. But though 
very desirous of escaping without the usual formal oration, he 
had hoped that there would be found during the period of his 
tenure of office an opportunity of making up for this short- 
coming in some other way. But, as many members were 
aware, circumstances connected with his family had put it out 
of his power to carry out his intention of meeting the mem- 
bers of the Society in a Conversazione; and now, on this the 
last night of the session, he could only give them that 
apology for the want of a Presidential Address, though it was 
just possible that he might have something to say yet before 
being formally relieved from the duties of the chair. 

In casting a retrospective glance on the work of the two 
sessions during which he had had the honour of presiding, he 
thought that they had no reason to disparage themselves as a 
Society, as the w T ork done had been good and solid. At an 
early period of the former of the sessions they had an excellent 
paper by Dr. Cameron on some important surgical cases. At 
subsequent meetings of that session they had interesting con- 
tributions from Dr. A. Patterson on the Statistics of the Lock- 
Hospital ; surgical papers by Dr. Whitson; an account of the 



Medico-Ckirurgical Society. ~2'2o 

extraordinary case of catalepsy under the charge of Dr. Wood 
Smith ; observations on the radical cure of hernia by Dr. 
Renton ; and Dr. Baxter's case of ulceration of the duodenum 
consequent on a burn. In the present session they had a paper 
by Dr. Alex. Robertson on Alcohol in Cerebral and Mental Dis- 
orders ; one from Dr. Macleod of an exhaustive character on 
Intestinal Obstruction ; an extremely interesting discussion on 
Catheter Fever led off by Dr. Cameron ; and during the last 
two or three evenings important papers by Dr. Macewen and 
Dr. Wolfe on surgical and ophthalmic subjects ; and they had 
now finished the session by the contribution that evening on 
Pseudo-hypertrophic Paralysis. 

He had now little more to do than to thank the Society for 
their uniform kindness to him while discharging the duties of 
President. But before sitting down, he might mention that 
within the last few days his attention had been directed to an 
editorial article in the Medical Times, and Gazette of Saturday 
last, bearing on the management of an important public insti- 
tution in Glasgow, in which, as some of those present must be 
aware, there had been on more than one occasion differences 
between the lay directors and the medical directors ; the 
medical and surgical staff of the institution being presumed 
to be in sympathy with the latter, but having, on the most 
recent occasion, been entirely ignored by the management. 
In commenting upon this dispute, the Medical Times puts the 
following question — [Dr. Gairdner read the article in question 
from the Medical Times of 27th April.] 

Now, he had not the faintest idea who the writer of the 
article in question was, keeping aloof as he had himself done 
for many years from the anonymous in writing, and he did 
not want to know. But it was evidently written by some one 
having access to local sources of information, and disposed to 
read a lesson out of the facts to the profession in Glasgow — a 
lesson which, being well intended, ought to be taken in good 
part. Therefore, let them, as medical men in Glasgow, put it 
to themselves how far the facts are as the writer puts them. 
If he were disposed to answer the question put, it would be in 
some way like this: that, within his own knowledge, the 
public estimation of medical men in Glasgow, as indicated by 
the test of the remuneration given to them, had risen enor- 
mously during a considerable number of years. Coming, as 
he did, in contact with all classes of the profession in the city 
and neighbourhood, he had a fair amount of knowledge of the 
facts as regards especially the better class of practice. Within 
the last twenty-two years, during which he had lived in < ibis- 
No. 3. (,» Vol. XXII. 



22tj M< eting8 of Societu s. 

gow, the fees of Glasgow practitioners in good practice had 
risen enormously, and he sincerely hoped that this very great 
improvement had not been altogether confined to the better 
class of practice. To him it would appear a thing both 
improbable and unfortunate if, while by the willing consent of 
the community, the remuneration of the higher ranks of the 
profession had doubled or trebled during the period referred 
to, it should turn out to be true that the hard working practi- 
tioners doing duty mostly amongst the labouring classes had 
experienced no corresponding improvement. But as far as his 
information extended, the leverage applied to professional 
remuneration from above, and this, observe, without any kind 
of pressure, or trades-unionism, had, in fact, operated very 
generally all round, more or less, in Glasgow practice. This 
was the kind of answer which he would make to the remarks 
of the writer of the article as regards remuneration. As to 
whether the profession had risen in general estimation corres- 
pondingly during these years when their remuneration had 
been increasing, he would not positively say, as it was a 
difficult and complicated matter to speak about ; but most 
certainly, as gauged by education and general acquirement, it 
ought to have so risen. The state of preliminary education of 
the medical profession in Glasgow, as well as other parts of 
the West country, was formerly very far from satisfactory. 
This was largely the fault of the schools, which were miserably 
wanting in their provision for middle class education. In 
order that the profession should not fall short in point of 
numbers, the doors of the profession had to be opened to men 
who had not the education of a gentleman, and who conse- 
quently had not, and could not have, the social status nor the 
rank of gentlemen. In too many places the doctor in those 
days did not associate chiefly with the squire nor with the 
clergyman, but rather with the lower ranks of his patients; and 
for sheer want of mental resources he not unfrequently drifted 
into bad habits of living. The true way, therefore, to elevate 
the profession at large was to raise their education. This 
done the fees would probably, as a matter of course, adjust 
themselves to the higher social status of practitioners. 

Without venturing to say that the medical profession is, 
even now. in all respects what the writer of this article 
would desire or approve, it was at all events patent to every 
one that a large proportion of the medical profession in 
Glasgow are a vast deal better off, socially and otherwise, 
than they were only a few years ago. The moral of the 
article was a perfectly just one. Over and over again, he had 



Medical Items. 227 

told young men that, while eschewing anything in the 
shape of trades-unionism, they ought, from the very first, in 
their practice, to take up a good and firm position in the 
matter of remuneration. Let them, he told them, say to their 
employers frankly, such and such are the terms on which 
they were willing to give their own services, and this without 
any reflection on the scale of remuneration adopted or obtained 
by other practitioners. And the consequence was, that he 
had again and again known quite young men, when of good 
abilities and carefully trained, settling down i» a district 
demoralised, so to speak, by a low rate of remuneration, and 
at once obtaining, almost as a matter of course, much higher 
fees than any formerly paid in the district for medical ser- 
vices. Into the dispute on which this article in the Medical 
Times was founded he had no intention to enter, as it was by 
no means improbable that opportunities might yet occur of 
making a more effective stand than hitherto against a policy 
which, as the editor affirms, could have been adopted in no 
other hospital or infirmary in the kingdom. To manage an 
essentially medical institution without regard to medical 
opinion is not, on the face of it, a very judicious or promising 
venture ; and if the profession is only true to itself, it may be 
safely predicted that such an attempt must needs break down. 
He desired, however, on the present occasion to avoid, as far as 
possible, entering on controvertible matter, and would there- 
fore, with these remarks, bring the session to a close. 



MEDICAL ITEMS. 

UNDER THE DIRECTION" OF 

ALEX. NAPIER, M.D. 

Skin Affections connected with Diabetes. — Various 
forms of cutaneous disease are of frequent occurrence in diabetic 
subjects. These affections, which are partly functional and 
partly nutritive in their nature, and generally of an inflamma- 
tory character, may be enumerated as follows : 

1. Asteatosis and anidrosis of the skin. This is obviously 
only a relative condition, and consists of an abnormal dryness 
and exfoliative state of the general integument. It is not a 
uniform or pathognomonic indication of diabetes, but seems to 



22^ Medical Items. 

be merely a result of deficient nutrition, such as is met with 
in many other morbid processes involving a similar constitu- 
tional deterioration. Accordingly, it generally occurs in the 
more advanced stages of melituria. During the earlier period, 
while the patient is well nourished and preserves his adipose 
development, the secretory functions of the skin are usually 
well performed. Indeed, corpulent diabetics are, at this time, 
not unfrequently the subjects of excessive perspiration, leading 
to erythema and eczema intertrigo, affections which, under the 
influence of. the glycosuria, may assume a peculiar character, 
when localised on the genitals and surrounding regions. 

2. Prv/rvbus cutaneus, as a pure neuralgia, is not a rare con- 
comitant of diabetes, under the form either of pruritus univer- 
salis, or, in females, of pruritus vulvae. It is a most distressing- 
complaint, sometimes rendering the patient desperate, or even 
impelling him to suicide. The itching conies on in paroxy>ni- 
which occur several times a day, and sometimes last for hours, 
so that the patient is soon brought very low through want of 
sleep. It may accompany other diseases besides diabetes, but 
Hebra long ago assigned the latter as one of its causes, and 
his followers have made it a rale to examine the urine for 
sugar in every case of pruritus cutaneus. By applying this 
test I have often succeeded in ascertaining the existence of 
diabetes while the patient was still unsuspicious of his dis- 
ease. Like pruritus cutaneus in general, diabetic pruritus 
occasions no changes in the general integument other than 
those which are produced directly by the scratching. 

3. Urticaria chronica is another diabetic skin disease which 
I have repeatedly encountered. It consists of an eruption of 
small pimples which are subsequently lacerated by hard scratch- 
ing and end in suppurating excoriations and pustules. I have 
never observed it except in reduced and debilitated patients, 
whose low condition, however, was not caused by the diabetes, 
but had existed in the earliest stages of that complaint, and 
before its symptoms had become pronounced. In these cases, 
therefore, the emaciation, etc., must be regarded as resulting 
from the same obscure influences in which the diabetes chiefly 
originated. I have often observed this papulous eruption to 
become localized around the follicles, leading to their inflam- 
mation and the appearance of 

4. Acne cached icorum, occupying chiefly the extensor 
surface of the extremities and the nates. Thus all the varied 
manifestations appertaining respectively to pruritus cutaneus, 
urticaria papulosa, and acne cachecticorum may be found 
combined upon one and the same individual. 



Medical Items. 229 

5. As to the roseolous and erythematous eruptions reported 
to have occurred as concomitants of diabetes, and to have 
lasted for months before taking on a marked inflammatory 
character, they have never fallen under my observation, and, I 
believe, are but rarely met with. 

On the other hand, the truly inflammatory dermatoses 
constitute a very frequently occurring form in this connection. 

First among them are certain inflammations which have 
really nothing to do with the co-existing blood-dyscrasia, but 
arise from frequent moistening of the skin by the diabetic 
urine, with its tendency to fermentation favouring the produc- 
tion of fungoid elements, and its directly irritating effects. 
These are due to 

6. Eczema of various degrees, which must not be confounded 
with the effects of scratching in cases of pruritus cutaneus. 
Owing to its peculiar cause (the wetting of the skin by the 
diabetic urine), this kind of eczema is confined to the genitals 
and their neighbourhood. In men, it appears only on the 
prepuce, and is accompanied by balanitis. Hence, an attentive 
observer will be led to think of diabetes, when confronted by 
an obstinate balanitis associated with eczema of a relaxed 
foreskin, and diffusing a peculiar insipid, sweetish odour. 

This eczema occurs more frequently, more severely, and to 
a greater extent, on the female parts. The labia majora, 
genito-femoral sulci, and inner surfaces of the thighs then 
appeal- uniformly red, densely infiltrated, and generally 
moistened by sweat and urine, though rarely exuding of 
themselves. The affection is worse in corpulent persons. 
Polyuria and hyperidrosis of course favour the production of 
melituric eczema, or, as the French term it, " eczeme giycosu- 
rique." 

The external action of diabetic urine is likewise supposed 
by some authors to promote a more intense degree of inflam- 
mation ending in grangrene, as also the formation of abscesses 
and furuncles, on the genitals and their vicinity. But it is 
very doubtful whether these results can be attributed to the 
mere presence of sugar in the excoriated integument, since 
this substance is known to be without injurious effect on 
wounds in general. Here, as in cases of urinary infiltration 
from other causes, it is probably the products of the decom- 
position of the urine, especially its ammoniates, that really 
work the mischief. Certain forms, however, of diffuse 
phlegmonous inflammation — taking their rise from particular 
regions of the skin directly affected by the urine — do un- 
doubtedly occur, for which the diabetic blood-crasis must be 



230 Medical Items. 

held responsible. These comprehend the remaining diseases 
under our classification — viz. : — 

7. Paronychia diabetica. — This complaint, though it is seldom 
mentioned by authors, I have often met with, chiefly on the 
great and little toes, these being most exposed to pressure 
from the shoes. It also occurs occasionally on the middle 
tors. It is often quite indolent and tedious, and is then very 
apt to produce fungous excrescences ; in other cases it is 
exceedingly painful and obstinate. All my own cases have 
recovered, but I believe that gangrene has sometimes been 
seen as a result of paronychia diabetica. 

8. Furunculosis and "nth rax. — These are the cutaneous 
affections most familiarly associated with diabetes. They 
have generally been observed during the incipient period of 
the latter, constituting, according to Seegen, one of its earliest 
manifestations. Since furunculosis sometimes makes its 
appearance before the diabetes has been discovered, it was 
regarded, in such cases, as having preceded for years the 
actual development of the latter. This was accounted for by 
Pick, on the ground that the same influence which operates on 
the nervous centres for the production of diabetes, may, in 
particular instances, give rise to furunculosis (and subse- 
quently, perhaps, to other skin diseases, as pruritus), instead 
of to glycosuria ; and that, consequently, we may have a 
diabetic furunculosis without diabetes, or, if we adopt Koch- 
mann's view, during this furuncular period the diabetes is 
latent. The same theory was applied to carbuncle. While 
not denying the possible validity of this explanation, I may 
be permitted to remark that in no one of the cases reported as 
bearing upon the present question does it appear that the 
patient's urine was examined so as to determine whether the 
diabetes really existed before the appearance of the skin 
disease. Under such circumstances I think it would be more 
correct to assume that the diabetes was simply overlooked 
than that it was latent ; and hence it follows that the urine 
ought to be regularly tested in every case of furunculosis and 
of anthrax, both for albumen and for sugar. 

9. Gangrene. This is the least recognised and understood 
of the diabetic complications. According to most authorities, 
it bears a close resemblance to gangrama senilis. Some of the 
cases reported might be regarded as coming under the head of 
gangrsena e marasmo, or atheromatosi, but the larger number 
certainly present a peculiar character. Those recorded by 
Marchal De Calvi and Champouillon in particular, seem nearly 
allied to an unique case which recently fell under my own 



Medical Items. HSl 

observation, of what I have ventured to designate as gangrcena 
diabetica bullosa serpiginosa. 

It occurred in the person of a woman fifty-one years old, 
and terminated fatally after lasting about seven months. The 
special impress in this instance was imparted by the dissem- 
inated appearance of the complaint, its withdrawal from the 
outer limits of the affected surface, its restriction to the general 
integument, its serpiginous mode of progression, with subse- 
quent healing, and finally by the development of inflammatory 
patches and bullas upon the previously healthy skin. These 
characteristics were sufficient, in my opinion, to distinguish 
this highly typical case of gangrene as one clearly originating- 
in diabetes. 

It is well known that diabetic sugar has been discovered in 
all the organs, tissues, juices, and exudations of the body ; and 
it was unquestionably contained in the discharges from the 
gangrenous sores of the patient referred to. 

The sugar deposited in the skin (or one of its elementary 
products) may give rise : 

1. To an irritation of the secretory nerves, manifested under 
the form of pruritus cutaneus, although it does not follow 
that the latter affection in diabetes may not be sometimes due 
to influences emanating from the nervous centres. 

2. The sugar acts likewise on the secretory and vasomotor 
nerves, whence result anidrosis and hyperidrosis, asteatosis or 
xerosis of the skin, probably also erythema and urticaria. 

3. It affects the tissues and tissue elements traversed by 
these nerves, as well as those of the vascular walls, e. //., of the 
glands and corium. 

Speaking generally, the alterations thus produced result in 
irritative processes followed by inflammation leading to death 
of the tissues ; the skin being no less subject to these influences 
than are the internal organs, and we know that sphacelus of 
the lungs occurs nowhere more speedily than in diabetics. 

Such inflammations, with their necrotic sequelae, may be 
confined to circumscribed points, as in furuncle and carbuncle. 
Or, they may spread more widely, owing to a more extended 
saccharine impregnation, whence may result the diffuse forms 
phlegmon and gangrene. Or, finally, the deposition of diabetic 
sugar in the cutaneous tissues, like its secretion by the kidneys, 
may take place irregularly and intermittently, both as to 
quantity and locality, thus giving rise to bullous eruption and 
gangrene. 

In brief, the morbid processes brought about in this way 
are characterised by inflammation terminating in Hssva. 



232 Medical Items. 

necrosis, with but very slight tendency to the formation of 
inflammatory neoplasms. 

Nevertheless, it is conceivable that, when the irritating 
influence is slowly and moderately exerted, when sugar is 
secreted by the skin in small quantities and during only a 
short period of time, or when the tissues have become 
gradually inured to its deleterious effects, the inflammatory 7 
symptoms may terminate in tissue -degeneration instead of 
absolute grangrene, and inflammatory tissue-production may 
also take place. This being granted, I am able to conclude 
my list with a hitherto undescribed form of diabetic skin 
disease, which I will denominate: 

10. Papillomatosis diabetica. — It is derived from my 
observation of a single case, that of a Brazilian medical man 
who came under my treatment in September, 1882. He 
stated that he had suffered for twenty years from diabetes, 
polyuria, and polydipsia; but he was still well-nourished and 
vigorous. His disease was entirely confined to the left fore- 
arm and hand, which were tensely swollen. The backs of the 
fingers were covered partly by excrescences united to the 
agminate glands, and varying in size from that of a lentil to 
that of a kreuzer, partly by ulcers of like dimensions. The 
ulcers were rounded or kidney-shaped, and many of them 
were bordered by red, glandulous, easily bleeding vegetations, 
several mm. in height, and discharging a sero-sanious fluid. 
The forearm presented very similar appearances, but with 
interspaces of healthy skin, and in this situation there was no 
diffuse swelling. On the elbow was a growth as large as the 
palm of the hand, and over 2 cm. in height, deeply fissured, 
and having a slightly bleeding surface covered with warty 
protuberances. 

At first sight, this case might readily have been diagnosed 
as one of either syphilis ulcerosa et vegetans, or of lupus 
vegetans papillaris, but closer examination showed that the 
lending characteristics of these affections were wanting. I 
was then inclined to identify it with that form of disease 
which has been so much discussed by authors under the name of 
frambcesia of the Tropics, but, on grounds which it would take 
up too much room to detail, was forced to abandon this idea also. 

Under the treatment instituted — both internal and external 
— the affected parts, by the end of December, were nearly 
restored to their normal condition ; the fingers were flexible, 
and the hands quite useful. On the first of January, however, 
symptoms of diabetic coma made their appearance, to which. 
within ten days, the patient succumbed. 



Medical Items. 233 

Many questions connected with our general subject must 
lie re be left unanswered. What is the modus operandi of the 
sugar in the tissues ? Why does this agent excite sometimes a 
general and sometimes only a local inflammation ? And why 
does this inflammation, which usually terminates in necrosis, 
occasionally result in outgrowths of connective tissue and of 
vascular substance ? 

If the foregoing contribution to the study of the diabetic 
dermatoses, however unimportant in itself, shall succeed in 
arousing the attention and directing the efforts of my fellow- 
specialists and the profession at large, there can be little doubt 
that this missing chapter in pathology will ere long be fully 
supplied. — [M. Kaposi, Wien. Med. Wochenschrift, Jan. 5, 12, 
19, and 25, 1884.] Journal of Cutaneous and Venereal 
Diseases. June, 1884. 

Precipitates in Mixtures of Different Tinctures. — M. 
Pierre Vigier (Gaz. Hebdom. de Med. et de Cltir., 13th July, 
1883) calls attention to the precipitates that are sometimes 
formed in mixing tinctures. Physicians often prescribe 
mixtures of different tinctures to be taken by drops. Such 
mixtures are very often turbid, perhaps because the tinctures 
which compose them are made of alcohol of different strengths ; 
perhaps because there is some chemical incompatibility in the 
substances mixed together. Sixty per cent alcohol, which is 
nearly half water, dissolves the gummy matters of plants, which 
are precipitated by stronger alcohol. On the other hand, 80 or 
90 per cent alcohol dissolves the resinous matters, which are 
precipitated by weaker alcohol. In case a precipitate forms 
in any given case, the liquid can, of course, be filtered, but it 
is often not known what remains upon the filter. It is well, 
therefore, in mixing tinctures, to put together such only as are 
made with alcohol of the same strength. However, even this 
precaution will not always prevent the formation of precipi- 
tates. For instance, if equal quantities of the tinctures of 
calumba, of gentian, of cinchona, and of the bitter tincture of 
Baume" (which contains weak alcohol, soot, carbonate of potash, 
and the beans of the Ignatia arnara) be mixed together, the 
resulting compound is turbid. It is found, by combining 
these tinctures in various ways, that the precipitate results 
from the reaction of the tinctures of calumba and of cinchona 
upon each other. The vjscous material contained in the 
tincture of calumba is thrown down by the soluble principles 
of the cinchona. This precipitation may not destroy the 
value of the filtered mixture; nevertheless, it is better not 



2."U Medical Items. 

to prescribe the two tinctures together. (Dublin Journ. Med. 
Science, November, 1883.) The Practitioner. April, 1884. 

Pulsatilla in Acute Epididymitis. — L. E. Borcheim, 
M.D., in the Journal of Cutaneous and Venereal Diseases for 

April, 1884, says: — Numerous disappointments in the treatment 
of this disagreeable and painful affection by the usual methods, 
and the perusal of a few brief articles published in the journals 
at various times by Piffard, Sturgis, and Fox, of New York, 
have led me to employ experimentally the tincture of pulsatilla, 
and I am pleased to state, to my complete satisfaction, as in 
using this drug I found that not only was the relief its 
administration afforded more prompt than by the former 
methods employed by me (cathartics, poultices, rest, etc.), but 
that it completely did away with one of the most objectionable 
features of that treatment, namely, rest in bed. 

The cases upon which I base these few remarks are twenty- 
four in number, all of which have been treated within the 
past eighteen months, and they were all in the acute stage of 
the disease; hence I think I can safely draw correct conclusions. 

During my hospital service in New York, I had ample 
opportunities for practically testing the value of the treatment 
of acute epididymitis as advised by Prof. Bumstead (Bumstead 
and Taylor, Yen. Dis., 4th Edit., p. 145 el seq.) } and arrived at 
the conclusion that the only source of benefit was the fact that 
rest in the recumbent posture was strictly enjoined. Now, 
the class of men who are liable to this disease are principally 
young men who prefer to suffer almost anything rather than 
have their troubles known, and it is with the greatest difficulty 
that they can be induced to go to bed. Now, here I think 
we have a remedy which does not require so exacting a 
discipline, as I never found in all my cases any necessity for 
complete rest in bed, the only requirement being the wearing 
of a suspensory bandage, and taking of the medicine. The 
relief from pain usually takes place within three days. The 
preparation employed by me is the tincture of pulsatilla 
manufactured by Boericke and Tafel, of New York, the dose 
being two drops every two hours. No benefit is derived from 
the use of larger doses at longer intervals. 

Treatment of Varicocele. — G. P. Clark, M.D., in '-'Notes 
of Practice" {New York Med. Journal), says books and 
teachers of surgery constantly, or customarily, warn us not 
to mistake a varicocele for a hernia, and aggravate it by the 
employment of a truss. Now the fact is, that the best of 



Medical Items. 235 

all treatment for this wearing and wearying affection is a 
weakish truss. It has never failed in my hands ; and I have 
used it scores of times, not only entirely or greatly to relieve 
the sufferer, but by continued application, to effect a perma- 
nent cure, save in very aggravated cases. The theory of its 
operation is, that pressing upon the spermatic veins the pad 
takes the place of the deficient valves, supporting the super- 
incumbent column of blood which their defection has let 
weigh down upon the sensitive parts below. This particular 
of practice is the more important, because the ailment is one 
that makes a man " feel bad all over," and arsrues to the 
mind of the patient, and not seldom of his surgeon, a variet}* 
of diseases that have no existence. When the bars of honour 
in our profession are still farther let down, and the "go as 
you please " principle becomes our law, I propose to advertise 
a list of the cases of Bright's disease, heart disease, dyspepsia, 
hypochondriasis — in fact almost everything but retroflexion 
of the womb and fissure of its os — that I have cured by the 
gentle pressure of a truss on the spermatic veins where they 
pass over the pubic bone. I was my own first case. — J. A. A. 

Propositions Concerning Vaccination. — James F. Hib- 
bard, M.D., presents the following propositions in a paper read 
before the American Public Health Association at the annual 
meeting, 1882. 

1. Perfect vaccination is a positive protection against 
small-pox, i. e., vaccinia of a typical development is as much a 
safeguard against variola as is a primary attack of variola 
against a secondary attack of the same. 

2. Taking vaccination as ordinarily accomplished, an un- 
known but large percentage of the vaccinees will be liable to 
an attack of true or modified small -pox at some future time. 

3. The number of persons who have had vaccinia that will 
be liable to small-pox increases with the lapse of time after 
the date of vaccination. 

4. Neither our observation of the progress and termination 
of vaccinia in an individual, nor our subsequent examination 
of his cicatrix, will enable us to say whether or not such 
individual is liable to small-pox. 

5. The only practical and reliable evidence we can have 
that an individual who lias had vaccinia is not liable to small- 
pox, is the failure of re vaccination. 

6. When vaccinia cannot be induced by vaccination, variola 
cannot be induced by inoculation. 

7. A failure of primary or military vaccination is evidence 



236 Medical Items. 

that .such person is not impressible by small-pox contagium at 
that moment, but is not trustworthy testimony that such person 
will not contract either vaccinia or variola at some future time. 

8. In order to obtain and maintain the completest protec- 
tion that vaccinia can afford, revaccination should be 
repeated, say every five years. 

9. Revaccination may induce vaccinia, or it may induce 
vaccinoid ; and whenever vaccination, primary or multary, is 
followed by vaccinia, the vacinee was liable to variola, and 
whenever such vaccination is followed by vaccinoid, the 
vaccinee was liable to varioloid. 

10. Active, unadulterated vaccine virus, bovine or human- 
ised, will induce nothing but vaccinia in healthy individuals. 

1 1 . The nature and extent of pathological changes that may 
ensue from the insertion of true vaccine virus is always be- 
cause of a morbid condition of the vaccinee. 

12. When disorders not belonfdno- to vaccinia are induced 
by the insertion of true vaccine virus, it is always because of 
a morbid condition of the vaccinee. 

13. Vaccine virus, originally pure, may undergo such 
change in time as to be either, first, inert; or, second, poisonous. 

14. Some latitude in the length of the period of incubation 
of vaccinia, and some irregularity in the development of its 
symptoms, are not incompatible with, and should not be held 
to invalidate, its protective virtue. 

15. It is not certain that typical vaccinia, the product of 
bovine virus, is a better preventive of small-pox than typical 
vaccinia, the product of humanised virus. 

16. All things considered, bovine virus is less likely to be 
contaminated than humanised virus. 

17. A physician's confidence of the purity of bovine virus 
must rest on his faith in the knowledge, the skill, and the 
integrity of the party who cultivates it. 

18. While fully recognising the desirability of universal 
vaccination, it is obvious that it can be accomplished at this 
time among the people of the United States, neither by 
persuasion nor by compulsion. 

19. An attempt at compulsory vaccination will not only fail 
of success, in the existing state of public opinion, but will 
seriously retard the growth of faith among the populace that 
universal vaccination is a reasonable service. — Reports and 
Papers of American Pub. H. Assoc. Vol. viii, p. 123. 

Mercurials in Diphtheria. — Dr. A. Jacobi, in a paper read 
before the New York Academy of Medicine, after giving a 



Medical Items. 237 

thorough historical review of the use of mercury in diphtheria, 
states the result of his own observations, which have led him 
to a higher estimate of its value than he held a few years 
ago. He concludes the paper as follows : — 

First. — The mercurial treatment of pseudo-membranous 
affections of the respiratory organs is one which promises 
great results. 

Second. — The corrosive sublimate is the preparation best 
adapted for internal medication. 

Third. — The system must be brought under its influence 
speedily by frequent doses. 

Fourth. — It must be given in dilutions of 1 to at least 
3,000 to 4,000. 

Fifth. — Babies of tender age bear one-half grain and more 
a day, and many days in succession. 

Sixth. — Salivation and stomatitis are rarely observed, and 
appear to heal kindly. Gastro-intestinal disturbances are 
not frequent ; they are moderate, can be avoided by the 
administration of mucilaginous and farinaceous food, or of 
mild doses of opium. 

Seventh. — If not well tolerated, the inunction of sufficient 
and frequent doses of hydragyrum oleate takes the place of 
the corrosive chloride, either together, or alternately with the 
internal administration. 

Eighth. — The treatment of croup may be preventive to a 
great extent. Most of the cases are complicated with, or 
descend from, diphtheria of the fauces. Here the preventive 
treatment of croup must begin. Without desiring to encourage 
mere local treatment, which, in unwilling patients involves a 
resort to force or violence, and thereby does great harm, 1 
point to the peculiar local effect of mercury on the pharynx. 
both in the healthy and sick, as a means to influence the 
threatened invasion of the larynx. — X. Y. Med. Record. 24th 
May, 1884. 



Calomel in Diphtheria. — Dr. I. P. Klingensmith reports 
the successful treatment of three cases of diphtheria with 
large doses of calomel. He gave first 20 grains and then 10 
grains every hour until the symptoms were relieved. In one 
case, (hiring three days, 720 grains were administered : in the 
second case 160 grains were given in fifteen hours; in the 
third case 130 grains were given in twelve hours. He recom- 
mends this treatment to further trial. — N. V. Mai Record. 
12th July, 1884. 



238 Medical Items. 

Caffein Citrate. — Dr. H. G. Leffman, in a recent paper 
read before the Philadelphia College of Physicians, says : — 

There is no caffein citrate in the market, and it is doubtful 
whether any such a salt can be prepared. The commercial 
preparations are either pure caffein or variable mixtures of it 
with citric acid. 

Of the manufacturers in this city each furnishes a different 
article, except in cases in which they buy from a common 
source ; and a house in a neighbouring city furnishes an 
article which contains no citric acid. Some of the samples 
are purely bitter in taste, while others are distinctly sour. 
Analyses of some of the commercial salts are recorded in a 
paper read before the last meeting of the American Pharma- 
ceutical Association by Dr. G. C Wheeler. He found the 
quantities of caffein varied from 96*5 per cent to G3'5 per cent; 
of citric acid from 3G"5 per cent to 3"5 per cent; none of these 
figures corresponds with the proportion of a true citrate. 

It seems to me that accurate clinical observation cannot be 
made with a preparation of so uncertain a character ; for, as 
seen by these figures, the proportion of active ingredient may 
vary 33 per cent, and the lesson that these analyses teach us 
is that when the effects of caffeine are wanted they are best 
obtained by the use of the pure alkaloid, and not by a pre- 
tended and uncertain compound of it. [See this Journal, 
vol. xvii, p. 301]. 

Tenotomy for Pianists. — The limited power of extension 
possessed by the ring-finger is sometimes of great incon- 
venience, especially to pianists. In the case of men in whom 
this condition was very marked, Dr. Forbes recently divided 
the cross fibres connecting the tendon of the extensor com- 
munis for the ring-finger with those passing to the middle and 
little fingers. The operation was almost painless and the 
wound healed quickly, leaving an almost imperceptible scar. 
Before the operation the finger could be raised scarcely one- 
fourth of an inch, but after the tenotomy it could be extended 
one and one-fourth inch, and lost nothing of its strength in 
consequence. — (Wiener Med. Wochenschrift, Sept. 22, 1883.J 
The Practitioner. May 1884. 

The Prevention of Blindness in Infancy. — The follow- 
ing instructions, based upon the directions of the Society for 
the Prevention of Blindness, have been issued by a committee 
of the Manchester and Salford Sanitary Association, for the 
information of mothers and nurses. 



Medical Items. 239 

" One of the most frequent causes of blindness is the 
inflammation of the eyes of new-born babies. Yet this is a 
disease which can be entirely prevented by cleanliness, and 
always cured if taken in time. 

" The essential precautions against the disease are : — 

" 1. Immediately after the birth of the baby, and before 
anything else is done, wipe the eyelids and all parts surround- 
ing the eyes with a soft dry linen rag; soon afterwards wash 
these parts with tepid water before any other part is touched. 

" 2. Avoid exposing the baby to cold air; do not take it into 
the open air in cold weather ; dress the infant warmly, and 
cover its head, because cold is also one of the causes of this 
eye-disease. 

" When the disease appears it is easily and at once recognised 
by the redness, swelling, and heat of the eyelids, and by the 
discharge of yellowish white matter from the eye. Immediately 
on the appearance of these signs seek the advice of a medical 
'man ; but in the meantime proceed at once to keep the eyes 
as clean as possible by very frequently cleansing away the 
discharge. It is the discharge which does the mischief. 

" The cleansing of the eye is best done in this way : — 

" 1 . Separate the eyelids with the finger and thumb, and 
wash out the matter by allowing a gentle stream of lukewarm 
water to run between them from a piece of rag or cotton-wool 
held two or three inches above the eyes. 

" 2. Then move the eyelids up and down and from side to 
side in a gentle, rubbing way, to bring out the matter from 
below them ; then wipe it or wash it off in the same manner. 
This cleansing will take three or four minutes, and it is to be 
repeated regularly every la df hour at first, and later, if there 
is less discharge, every hour. 

" 3. The saving of the sight depends entirely on the 
greatest care and attention to cleanliness. Small pieces of 
clean rag are better than a sponge, as each rag is to be used 
once only and then burnt immediately; sponges should never 
be used, except they are burnt after each washing. 

"4. A little washed lard should be smeared along the 
edges of the eyelids occasionally to prevent them from sticking. 

Special Warning. — " Of all the mistaken practices which 
ignorance is apt to resort to, none is more ruinous than the use 
of poultices. Let them be dreaded and shunned as the 
destroyers of a new-born baby's sight. Tea leaves and sugar 
of lead lotion are equally conducive to terrible mischief, 
stopping the way as they do to the only right and proper 
course to be taken." 



240 Medical Ttems. 

Hypodermic Injection of Iodide of Potassium. — Bt 
Gilles de la Tourette confirms a statement previously published 
by M. Besnier to the effect that in the rare cases in which the 
administration of iodide of potassium by the mouth cannot be 
tolerated the medicine may be safely injected subcutaneously. 
A cubic centimetre of distilled water containing half a centi- 
gramme of the iodide may be injected, provided the solution is 
neutral. The injections should be made into a part rich in 
areolar tissue, and at points not too close to one another. — 
(Annales de Dermatologie et de Syphiligrapkie. Vol. 4, No. 
TO.) The Practitioner. ' May, 1884. 

A Test for the Purity of Iodoform. — Dr. Bouma, of 
Ley den, is of opinion that the symptoms of iodoform poisoning- 
are due to the presence of impurities in the drug used, and in 
the Centralbl. f. Chir. for Dec. 1, 1883, brings forward striking 
facts from the practice of several surgeons in proof of this. 
He holds that no iodoform should be used which has not been 
tested for impurities, and states that he has not yet seen 
unfavourable symptoms arise in a case where this rule has 
been adhered to. The most reliable test is a modification by 
H. Agema, apothecary to the Leyden Hospital, of one given by 
most authorities, and consists in shaking up the iodoform witl i 
distilled water, filtering, adding to the filtrate an alcoholic 
solution of nitrate of silver, and allowing this to stand for 
twenty-four hours. At the end of this time a slight grey 
deposit will usually be found at the bottom of the test tube : 
but anything approaching to a black precipitate (reduced 
silver) indicates that the iodoform is not pure enough to be 
safely used. 

Dr. Bouma believes, however, that iodoform which has been 
kept for some time exposed to light and air may cause evil 
effects, even though this test fails to detect impurities. — D. M'P. 

Successful Inoculation of Actinomycosis from man 
to an animal. — This experiment has, for the first time, been 
successfully performed by J. Israel (Centralbl. f. </. Med. 
W Lssensch., 1883. No. 27) upon a rabbit. The seat of inocula- 
tion was the peritoneal cavity, and the interval between 
inoculation and the death of the animal was 2£ months. 
During this time the minute piece of tissue had increased 
to the size of a cheriy, with numerous processes extending 
from it through the retro-peritoneal connective tissue. At 
one point the disease had invaded muscular tissue. Centralbl. 
f. Chir. 1883. No. 46.— D. M'P. 



THE 



GLASGOW MEDICAL JOURNAL. 



No. IV. October, 1884. 



ORIGINAL ARTICLES. 



THE THEORY AND PRACTICE OF THE CURE OF 
PHTHISIS BY HARD MOUNTAINEERING, AS 
EMBRACED IN WHAT I KNOW ABOUT CON- 
SUMPTION. A MEMOIR. 

By RICHARD GERNER, M.E. 

What I know about consumption, I know entirely from ex- 
perience, and there will be nothing in the following essay on 
the subject gleaned from any alien source, even on the best 
authority. My purpose in giving my views and knowledge 
into print is twofold : first, that the medical fraternity may 
profit by my experience in its practice ; secondly, that the 
patient may have a vade mecum to guide him in the general 
principles of his treatment of himself. Both physicians and 
patients may, I trust, read what I have to say to advantage, 
even though I am not a qualified medical practitioner. I know 
that the word Consumption is in a popular sense an ugly one, 
and many who are still physically interested may pass this 
essay by as not intended for them ; I will, therefore, say that 
all who have anything at all the matter with their lungs, 
might well give me their attention. If the word is unfor- 
tunate, and not in every case quite correct, it is, however. .•>- 
comprehensive as any other. Many patients do not realise 
that they are possessed by the dread disease until it has done 
them irreparable pulmonary harm, and many others, who are 
merely afflicted with capillary bronchitis, imagine that they 
are consumptive. I faithfully promise at the outset that I 
have no commercial cause to expound, and that the bulk of 
this essay is not an introduction to any thing or subject to be 
No. 4. R Vol. XXII. 



24:2, Mr. Gejrner — The Theory and Practice of the 

thus cleverly advertised to the medical fraternity and the 
public. This is not a quack doctor's or a dogmatic pedant's 
ruse to catch patients or to court notoriety, but the honest and 
conscientious story of a sufferer, to which is appended a com- 
plete specification of the conditions and practices necessary to 
a cure ; or, if it is too late for that, the greatest possible 
amelioration of the effects of the disease. These conditions 
and practices, which I have fully tested in my own and in 
numerous other cases, and confirmed by repeated experience, 
are not the result of the cogitations of one mind, but the care- 
fully matured results of nearly fifteen years of daily obser- 
vation and experiment, upon over ten thousand patients, by a 
number of some of the first physicians in Europe, who have 
devoted their lives to the study and treatment of consumption. 
I may add that these results have been accepted, and these 
views adopted, by some of the most eminent practitioners in 
England and in the United States. I propose to include the 
narrative of my experience in my present writing, and as such 
it must a priori take the form of a species of memoir. I shall 
not stop to classify the heads of my discourse, either with refer- 
ence to importance or to scientific interest. I presuppose that 
one sufferer will always take an interest in the sufferings of 
another, the character of the ailment being the same. 

What is consumption? Phthisis? Tuberculosis pulmonalis? 
A disease of the lungs well known to the public at large by its 
manifestations, since more than a tenth of our mortality is due 
to it. These manifestations, or symptoms, are pains in the 
chest, distressing coughs, nauseous breath, filthy expectorations, 
enervation, night-sweats, fevers, cold extremities, laboured res- 
piration, loss of flesh, rapid exhaustion, hemorrhages, collapse 
of the physique, and premature death. Physiologically, it is 
still an open question whether the disease is mechanical or 
organic, while on the subject of its origin our first authorities 
are entirely at loggerheads. I do not propose to join in the 
argument. It may sound ridiculous to attempt to cure a dis- 
ease of the very nature of which we are in doubt, but the 
discussion of the matter does not cure the disease, and I see 
my way clear to an effectual treatment of the disease, even 
though I must waive the most elementary points. 

I never saw any permanently good results grow out of send- 
ing the patient to the sunny south, or merely into the country, 
or to the seashore, or to sea. I believe in fresh air and in 
plenty of exercise, but that is not all ; I must beg to be per- 
mitted to qualify both the nature of the air and the character 
of the exercise. I must, moreover, introduce a number of 



Cure of Phthisis by Hard Mountaineering. 243 

medicamental elements. Since heat is productive of lassitude, 
and lassitude is inimical to action and exercise, it stands to 
reason that the patient should be sent north and not south, or 
its equivalent, to the highlands and not to the lowlands. 
Again, going into the country merely is but a slight modifica- 
tion of the evils with which the lung patient is beset at home, 
to which must be added an exchange of home comfort for all 
manner of discomfort, that is, for dust, bad food, ennui, want 
of proper medical attendance, and all sorts of annoyances. 
Dust is the lung patient's greatest foe, and bad food comes 
next. And again, the air to which the patient should be 
treated, as will appear hereafter, must neither be moist nor 
windy nor condensed, and hence sea air is out of the question 
for him. To broil him at sea under the equator is as vicious 
for him as to expose him to the fierce gales of higher latitudes ; 
he cannot endure either. If I had to choose between two evils, 
though, I should prefer the latter for him. The lungs should 
be treated harshly up to a certain point. They will become 
distressed to intoleration in a tempest, but will accommodate 
themselves gracefully, even after the disease has already made 
sad havoc, to the ascent of ambitious mountain heights. There- 
fore, if the patient is to be exiled from home, let him be sent 
into the mountains. The altitude at which he should live 
must exceed 5,000 feet, to enable him to breathe an air of a 
proper degree of rarefaction, not to mention any more argu- 
ments in favour of going to such a height. 

On the subject of exile, let me say here that it is the patient's 
duty toward himself to shun and to flee from all atmospheres 
that are either warm or moist. What I have at times suffered 
from the want of cold and dryness, beggars description. I 
regard heat as the foster-mother of the disease, and for that 
reason I say that there are worse climates in the world for 
consumptive patients than England's. But on the whole, its 
conditions are not such as I should wish to recommend to any 
of my fellow-sufferers, while a sojourn in London I regard as 
simply suicidal. It is true that a tolerably comfortable sojourn 
in England, and even in London, may be maintained by great 
care and a diligent practice of the treatments hereinafter pre- 
scribed, but the relapses are many, and the disease makes giant 
strides. Therefore, if the patient has the means and the leisure, 
let him emigrate. Let him go into the mountains. There are 
many more or less reputable resorts for him the world over, 
but I object to all that are not situated in the high mountains. 
Let him choose between the Alps, the Pyrenees, the Alleg- 
hanies, the White and the Rocky Mountains. For reasons 



244 Mij. Gerneb — The Theory and Practice ofihe 

that appear from the spirit of my essay, I object to all the 
resorts along the Mediterranean. I object also to Goerbers- 
dorf in Silesia, because of numerous faults in its administra- 
tion which have come to my notice. Taking one consideration 
with another, I think I can safely recommend Davos-Platz, in 
the Grisons of Switzerland; there are a number of English 
works on the place published in London and abroad. But 
there are many resorts that will do as well, or at which even 
1 setter results may be achieved, especially in cases where there 
is a predisposition to congestion; most results as direct issues 
of a cure depend upon the individuality of the patient. 

It does seem a little strange that almost every diseased 
organ should require gentle care and rest, and the lungs when 
diseased, alone sturdy unrest, but this proceeds from the very 
nature of the trouble — viz., that the disease is primarily born 
of inaction and decay, like rust on a neglected ploughshare 
which, taken back into the field and pressed into active duty, 
is, as it were, cured and restored to health. I consider, in 
general, the so-called practice of moderation to be not alone 
useless, but in particular cases harmful, since the time thrown 
away in the treatment is time not alone lost but in most cases 
means an augmentation of the disease. There are some mild 
forms of pulmonary troubles that it may remedy, but such are 
curable by almost any treatment as long as fresh air is the 
chief agent. But let me hear no more of so-called moderation 
for serious cases of capillary bronchitis and for tuberculosis ; 
as well scrape the rust oft' a ploughshare with a kid glove. I 
will not deny that there may be other ways and means of a 
medicaments! nature ; and where there is no opportunity for 
rugged exercise, the latter should of course be tried. But 
when a patient has nothing else to do than to attend to his 
cure, and has the worldly means for this purpose, let him go 
into the mountains and give himself into the hands of Mother 
Nature, where she is at her bluffest. If he cannot effect a 
cure, tli" disease having already advanced too far, he can at 
least effectually check its progress, and prolong his life many 
years, and ameliorate his condition to such an extent that he 
may bring himself to entirely forget the curse that is upon 
him, or at least live and breathe in and with physical comfort. 

And now to my memoir. What is above and beyond the 
considerations I have thrown out, I leave to the learned to 
investigate, to discuss, and to expound. 

If consumption is not always the result of unwitting impru- 
dence, I think it was so in my case. Eating at irregular hours, 
now too much, then too little ; eating too hastily, especially dur- 



Cure of Phthisis by Hard Mountaineering. 245 

ing business hours ; eating too often what was most indiges- 
tible : all this brought on a gastric trouble over which live years 
passed before I was well rid of it. I have read that consump- 
tion is " a special morbid condition of the digestive system." 
Bathing at improper seasons, bathing too long at a time, and 
drying myself in wind and sun, weakened my chest. Devot- 
ing my nights to literary labour, undermined my constitution 
in general. Smoking to excess, and numberless excitements, 
mental and physical, destroyed my nervous system. I always 
shunned cold water. In fact, as the saying goes, I burned the 
candle at both ends, and never stopped to think that this could 
not go on for ever. 

It did not. The punishment came, and in a pulmonary form. 
At the end of my teens I found that my breath soon gave out 
when attempting to indulge in a prolonged physical exertion. 
That was the first symptom. In the course of a few years I 
grew lazy, apathetic and listless, physically, not mentally. I 
paid no attention to this. If I did, I thought it would pass 
over. I did not practise the most common precautions in 
issuing from heated into cold air. I went on donning summer 
clothes early in spring, and going out without an overcoat in 
midwinter. I caught one cold after another, and acquired 
rheumatic pains and cramps. I was too busy to consider my 
health. Whenever I stole an hour from the night, I thought 
it was an hour gained. Into my everyday philosophy never 
entered the idea that it might be an hour lost. 

My apathy and listlessness increased, and I began to expec- 
torate slime, watery and colourless at first, then more milky, 
finally with a lemon <>r rather with a lime-fruit tinge. It 
came spontaneously, without coughing, so I paid no attention 
to it. Unfortunately I lived between a long stretch of marshy 
meadows and a broad river, in a climate latterly cold in winter, 
and unmercifully hot in summer. I had my office in a crowded 
metropolis wherein the drainage was defective and the sanitary 
systematisation bad. I refer to New York, otherwise the lung 
patient's paradise from November to April. The atmosphere 
in the dog days, to use a vulgar but comprehensive term, was 
overpoweringly heavy and poisonous. From year to year I 
grew thinner and lazier. My cheeks fell in, and my chest 
ceased to expand. Soon it began to collapse. I abandoned 
walking where I could ride, could not be persuaded to go pro- 
menading, thought skating in winter and tramping in summer 
too laborious, gave up all exercise, and with difficulty ascended 
stairs. I used to lie on my lounge to read and study, and Later 
on I lay there for hours doing neither. A walk of half-a-mile 



246 Me. Gerner — The Theory and Practice of the 

was too inuch for me. I became fretful and peevish, disagree- 
able and pessimistic, and made myself and my surroundings 
unhappy. The doctor said it all came from my nerves, and I 
believed him. I was treated accordingly. I swallowed almond 
milk, bromide of lime, and other sedatives. Cold water was 
prescribed too, but I shunned that. I was to take a vacation, 
but I could not think of neglecting my business. I was 
lectured on the necessity of living principally on oatmeal, 
gruel, milk, rice, hominy and such, but these my soul abhorred. 
Nor could I bring myself to give up smoking. 

So matters stood when, I remember, I caught a bad cold 
and I began to cough. The expectorations grew in quantity 
and in density. Still, the idea of my trouble being pulmonary 
entered neither my head nor my doctor's. It was a cold, 
nothing more, I was told. I took to drinking hot milk and 
soda water (not, I think, to be recommended in any case), and 
to carbolic acid (95 per cent strength) in water (5 drops in a 
tumblerful of water), horehound and tar, pectorals, liquorice, 
and all that sort of thing. I swallowed nauseous quantities of 
syrups, troches, pastilles, and drops that were to help me. Of 
course they did not. My cough grew worse, and my lassitude 
increased. I began to get frightened. My doctor told me I 
must go into the country, or the consequences would be serious. 
A- if they were not serious enough already' But just then 
there was no possibility of my leaving my business. At last I 
broke down altogether. I lay on my sofa one afternoon in a 
complete state of enervation. The next day I was off to the 
country. 

My destination was an inland lake surrounded by forest 
scenery. There, I felt like a fish out of water. I was too 
lazy, and it was indeed too hot, to ramble about. I tried to 
read, but my thoughts were far away. I spent the days lying- 
in a hammock, drinking cold claret cup and other iced bever- 
3. I was not alone there, and to kill time, we played at 
cards and billiards. Or I wrote letters, and filled a few literary 
engagements. I was as wretched and unhappy as the day was 
long, and at last, I could stand it no longer, and went home. 
The pressure of business carried me over a few more months, 
and then an enervation, which it was vain to battle against, 
came upon me once more, and I at last realised that my case 
was desperate. 

I did not know what to do then. I did nothing. My doctor 
shrugged his shoulders. One morning I awoke bathed in per- 
spiration. This new symptom surprised me. It came again, 
and it perplexed me. I returned to the country. I grew 



Cure of Phthisis by Hard Mountaineering. 247 

worse every day. Fevers set in. I knew that quinine was 
good for fever, and took heroic doses of it, up to twenty grains 
and more at a time. I lost my sleep and my appetite, and was 
so fretful that it was impossible to associate with me. My 
only medicine then was carbolic acid water. I stayed at the 
lake-side a week or so, and then went home ao-ain, more dead 
than alive, to see my doctor. It was arranged that I should 
go to the seaside. I went. The doctor told me that I must 
bathe ; that is, plunge into the water, stay there a minute, 
come out again, and be rubbed dry. It nearly took my breath 
away, and I lay in my hammock for hours after it. On the 
second day, being a cold day, it more than took my breath 
away. I was carried into bed, got a burning fever, and that 
night I had bad pains in the chest. An examination of me 
showed that I had an inflammation of the lungs. I ought to 
say here that I had had one before, when I was fourteen years 
old, and that I then recovered with difficulty. I was now 
treated with benzoe, and began to scorch my chest with iodine. 
Fever and night-sweats continued. My cough grew yet worse. 
I used to lie in my hammock, or on the deck of a yacht, or on 
the grass, from morning till night, very weak indeed. I ate 
little or nothing, and was glad to be let alone. Everybody 
thought it was all up with me, and I thought so myself. 
Evidently, the seaside was not the place for me. After a few 
weeks' stay, I was taken home once more. 

Having lost all faith in the man who had been my doctor 
during seven years, I called for one in whom I had reason to 
repose every faith. He examined me, and then the truth came 
out : my lungs were affected. The lower part of my right lung- 
was paralysed, and the action there was extinct. The upper 
part of the same lung was diseased, and the rest was saturated 
with mucus. But this was mildly put to me, and the word 
consumption was not breathed. I was ordered to give up 
smoking at once, on the peril of my life. I was to go into the 
mountains, on to a farm, drink milk, sleep with my window 
open, and move in the fresh air constantly. I was to eat as 
much meat as possible, learn to take kindly to porridge, and 
to drink all the wine, beer, brand};, and whisky I wanted to. 
This was an unexpected and welcome part of the programme. 
I imagine that the order was given on the principle that a 
lung preserved in alcohol lasts longer than one that is not. I 
was also ordered to inhale tannin by means of a steam in- 
halator, to my mind now the best proof that my physician had 
made anything but a specialty of pulmonary diseases. Fur- 
thermore, I was to apply cold water to my chest at nights, 



Mb. Gerxer — The Theory and Practice of the 

carefully covered with India-rubber sheeting. Which meant 
that I had a lung catarrh too. I have had four more of them 
since. 

With these instructions I set out to go into the mountains, 
and I ensconced myself in a wee chamber in a farmhouse, 
situated at the foot of tolerably high mountains, at an alti- 
tude of about 1,500 feet above the level of the sea. It was 
very warm there ; but a cool breeze, to which the house was 
exposed, made matters more comfortable in this respect. My 
hosts were plain people, and my spoiled palate but slowly 
accustomed itself to the homely fare there dispensed. How- 
ever, I got used to it, that being the least of my troubles. 
Accustomed to milk of questionable purity, I drank the 
iily molken milk here with delight. Unaccustomed to 
the picturesque grandeur of rugged mountain scenery, I 
roamed about from morning till night. I regained my appe- 
tite, and ate with avidity at what I would before have 
turned up my nose. I began to feel better. My spirits 
rose, my enervation subsided. I coughed less, and even gained 
a few pounds in weight. Improvement brought new hope 
and fresh life, and my blood chased quicker through my 
sluggish veins. I was accustomed to tramp at least four 
miles every day after a while, which I had to do to get my 
mail, and soon walked as much a^ain. I ventured to climb a 
little, in spite of the consequent distress ; and everything 
would have gone well if the climatological and meteorological 
influences of the district had been favourable. I met a native 
one day who opined, to my horror, that this was not at all the 
region to come to for a lung trouble, and a year later I learned 
from a priest, who knew the country and people there well, 
that at least one quarter of the natives ailed hi that respect. 
I remember that the son of my host, a sturdy yeoman, com- 
plained of pains in the chest. 

In spite of a life which was a model one in every respect 
for a person in my condition, I felt that I was soon after 
again losing ground. I wrote to my new physician about it, 
and received by way of reply several dozen bottles of artificial 
a mineral water, which I was to drink — a pint 
every morning. The water male me vomit. I did not feel 
well after the inhalations, and abandoned them. I had a 
return of my fevers, and awoke mornings to find my pillow 
and bedclothes soaking wet. I had frightful coughing fits 
nights, and my hostess doctored me with honey to assuage 
m, which it did not. My expectoration was now heavier, 
denser, more plentiful, and assumed shades of dark yellow, 



Care of Phthisis by Hard Mountaineering. 249 

grey and light green. My coughing brought up great quanti- 
ties of white slime. I lost flesh from day to day, my lassitude 
returned, and I was fast verging toward complete enervation 
once more. To make matters worse, I grew homesick. This 
time I struggled against my ills, and made extended excur- 
sions. One day I ascended one of the high peaks in the 
neighbourhood, the exertion lasting nearly six hours. It had 
been far beyond my strength. When the summit was attained, 
I sank down almost lifeless on the rock, and it required a 
considerable quantity of whisky to revive me. I trembled in 
every limb, and my brain seemed afire. After an hour's rest, 
I began the descent, and reached the farmhouse in four hours, 
footsore, feverish, and utterly worn out. I did not sleep a 
wink during two nights. My feet had swollen so that I had 
difficulty to divest myself of my boots, and for many days 
afterwards every bone in my body ached me, to say nothing 
of a nettle-rash the adventure brought with it. 

Still, on the whole, the exertion did me good, but the benefit 
was transitory. I soon began to collapse again, and at the end 
of my ten weeks' sojourn there, I was as ill as when I set out. 
I returned home to consult my doctor, and to hear what the 
trouble was. The verdict was against me. Matters had grown 
worse. I had the tuberculosis. The winter was setting in, and 
I was to continue to live as he had first prescribed. I consoled 
myself with the thought that the conditions in the mountain 
district I had visited had been against me, and that all would 
be well where I was, at least during the winter. Fallacious 
hope ! My cough grew so bad that I was on the point of 
bursting a blood-vessel every time it came on, and I soon 
noticed to my terror that my expectoration was tinged with 
blood. There is nothing that frightens a lung patient so much 
as blood. I had a high fever regularly every afternoon, which 
I met with great quantities of quinine and rye whisky. The 
rest of the time I lounge^ about, feeling enervated and miser- 
able. I ate but little, and had an unconquerable craving for a 
cigar, so that I indulged in one occasionally, against my doctor's 
orders. I was punished by exhausting coughing fits. But 
that was because I did not know Low to smoke then without 
swallowing some of the smoke. There is smoking and smok- 
ing. Believing that the mucus was better outside of me than 
inside, I heightened the tendency to cough with bitter water, 
salt water, and the like. The doctor prescribed morphine, 
opium, and prussic acid. Throughout my illness I have never 
attempted to suppress a cough, or to take a remedy to soothe 
it, A cough is as delightful a tiling to a lung patient, especi- 



250 Mr. Gerner— 2%e Theory and Practice of the 

ally when it ends in the expectoration of oppressive mucus, as 
a sneeze to the snuff-taker. 

At last, matters grew so bad that my case was once more 
desperate, and my physician went to consult a noted authority 
on lung diseases, who appointed a day for -me to come and be 
examined. About this time, too, an ambitious practitioner, 
who was recommended to me, offered to completely cure me 
with nitrate of lime inhalations. I declined to be nitrated, and 
was examined by the noted authority. I remember that he 
measured my temperature at a time of day when it was gene- 
rally lowest, and found it to be upwards of 103° F., or about 
39"5° C, to a pulse normal at 120. That was the first time I 
saw a maxima thermometer, which no pulmonary sufferer 
should be without, as being the only reliable means of ascer- 
taining the degree of fever. 37° C. is normal. A degree more 
is already too high. To measure one's temperature with it, it 
should be placed under the tongue during seven minutes. My 
examiner told me I was very ill, and that I must be very care- 
ful. He prescribed home gymnastics and cold water ablutions, 
and approved of my physician's treatment of me. I was in- 
clined to smile at the gymnastics — a great mistake — and did 
indeed not practise them. The cold water ablutions I soon 
abandoned also — another great mistake. I sulked, and pre- 
ferred to grow worse. The fear of death is a sensation I have 
never experienced ; again and again, when in the height of my 
distress, have I prayed for its sting to put an end to my 
miseries. The end of the thing was that my doctors, between 
them, agreed to send me away, as I thought, to die. A globe 
was shown me, and I was told that I must go there and there, 
an outpost of civilisation, 2,200 miles away from my then 
home, lying over 7,000 feet above the level of the sea, in a 
wild, barren country, infected with every impediment to civil- 
isation. But the air there was to cure me. I did not believe 
a word of it. I was to stay there several years. Monstrous ! 
I protested, but soon I grew too weak to protest. I was so ill 
that I did not care what was going to be done with me, and I 
wished I was dead. 

One cold November night I started out for my new exile, 
and after a journey of a week, I arrived within thirty miles of 
the place. I halted in a town that I thought would do as well 
as my fixed destination, and put up at a hotel where the rain 
penetrated through the roof and the canvas ceiling of my room. 
Over this canvas the rats used to chase at nights. The popula- 
tion of the place was of the pioneer class, and there was but 
one thing that they and I agreed on, and that was the merits 



Cure of Phthisis by Hard Mountaineering. 251 

of good whisky. The fare at my hotel attracted the epicures 
of the district, and included tripe salad, untoothable beef and 
mutton tissue, and sauerkraut. Although not far from a 
luxuriant wine-growing country, the price of the wine went 
beyond my means, and a judicious mixture of whisky and 
water served to satify the cravings of my thirst. I stayed at 
this place for two whole months, the most miserable and home- 
sick man in it. To ameliorate my situation, I allowed myself 
three cigars a day, and obeyed my doctor that far that I drank 
unlimited quantities of whisky. Near the place was a hot 
sulphur spring, and I one day persuaded myself that a bath 
would do me good. The experiment resulted in my being- 
carried out in a stupor. The physician at the springs poured 
a glass of whisky down my throat, and in the course of the 
day I was able to go home. So much for sulphur and con- 
sumption. The wind storms in that district were something- 
frightful. To venture out of doors was to incur distress at 
every ten paces. The dust would penetrate the houses every- 
where, and lie literally fingerthick on the furniture. I braced 
up wonderfully in a few weeks, not to say days, and but for 
the fevers now and then, the coughing fits nights and morn- 
ings, and the foul expectoration, I should soon have forgotten 
that I was ill. I now gained flesh rapidly. I was out almost 
every evening, and sometimes far into the night, and lived like 
a man who had nine healths to lose. Strange to say, I gained 
in vigour from day to day, and I ascribe it all to the continu- 
ally azure and cloudless sky, and the pure, dry, thin, cold, 
crystalline air. But one day I had a relapse, experienced ex- 
quisite pains in the chest, and became very weak. I brought 
up a lot of bloody tissue. I consulted a physician who knew 
as much about the lungs as swine do of pearls, and he told me 
I had a lung fever, whatever he meant by that. I threw his 
physic to the dogs, and sipped whisky. Within two days I 
was well enough to climb on to a train and to travel the 
remaining thirty miles to reach my pre-ultimate destination, 
and where I should have arrived ten weeks ago. This I will 
fix geographically, as being of interest to my readers as a 
pulmonary health resort. 

La Villa Reale de la Santa Fe, on the Atchison, Topeka, and 
Santa Fe Railroad, the capital of the territory of New Mexico, 
was the town that received me. It is situated 7,100 feet above 
the level of the sea, on a dreary plateau in the Rocky Moun- 
tains, the surroundings being mostly sandy and rocky, and the 
vegetation stunted. But against that sky, the Italian was as 
nothing, and the sun blazed down on the plateau, but for the 



252 Mb. Gerner — The Theory and Practice of the 

intervals of the nights, uninterruptedly for months. The 
winter was bitterly cold, the summer burning hot — too hot 
altogether, but in the latter season the nights were nearly 
always comfortable. When in the winter it did snow, which 
was seldom, the snow came down in little flaky shells, and 
rarely endured up to noon. In that region the drinking water 
was nectar. I lived in an adobe (the reverse of a decent 
abode), being a house, or rather cabin, built of sun-dried mud 
bricks, with only a door and no windows. The eating in a 
hotel of the town was wretched, but a restaurant there fur- 
nished juicy beefsteaks, which I often indulged in. Guiness' 
stout was shockingly dear and rare, but I gladly paid its price 
for the good it did me. Santa Fe offers much vivid interest 
and varied pleasure to the sojourner for his health, but is very 
expensive. I spent my time roving over the mineral hills in 
search of specimens, in horseback exercise, and in hewing 
wood. The door of my cabin stood open day and night, season 
in, season out. On cold winter nights I would get up a roar- 
ing fire in my cabin, and then run out, half undressed, into the 
cold or snow, tumble about for a minute or more, turn in again, 
rub down, and go to bed. My fevers were now few and far 
between, my cough was much improved, and the character of 
my expectoration more satisfactory. I found that my chest 
had expanded two inches in circumference within six months. 
My frame became sturdier, and my spirits rose, but I could 
not shake ofl" the home-sickness that has ever retarded my cure 
in exile. It was this that was also here fatal to me, and at 
last it wrought upon me so that my situation became unen- 
durable to me. 

It was here that I first tried the merits of cod liver oil in 
the form of an emulsion, together with the hypophosphites of 
lime and soda, to which I had added later on malt extract, egg 
and brandy. I could appreciate the benefit I reaped from its 
use, although it invariably upset my stomach. It is on this 
account that I have altogether discarded its employ. I gained 
slowly, but surely, in weight. My doctor there brought to my 
knowledge that in addition to the tuberculosis, I had capillary 
bronchitis ; that the former was the source of my foul expec- 
toration, and that the latter caused the violent coughing fits 
to which I have ever been there. I should have shaken off 
the latter ill there, but melancholy came upon me, and one 
bright spring day I packed up and ran away home. 

The spring of that year was lovely the world over, and I 
felt well in the crowded metropolis, but not for long. The 
fevers returned, and there came another night-sweat. It 



Cure of Phthisis by Hard Mountaineering. 253 

frightened rue, and I determined on a sea-voyage. That did 
me good ; at any rate, no harm. For months after I felt com- 
fortable in the " dear old smoke " of London. I found that my 
fevers did not return, but my cough augmented in violence and 
duration at every fit, while my expectoration became heavier 
and fouler, and was often tinged with blood. When I lay 
down, and when I arose, I had to cough. I had pains in the 
chest, and often breathed with difficulty. I railroaded to 
another climate where good wine was plentiful, and felt better. 
Business called me back to London, and I collapsed again. 
Ever since I left my first mountain resort, I smoked as much 
as I wanted to, and do now. 

Thus matters stood when I determined to go to Davos-Platz, 
the health resort already referred to. My sojourn there I shall 
detail at length, and the reader will, I expect, find it a remark- 
able recital. My experience thus far is as I related it to my 
physician in Davos-Platz when I arrived there, a plain, brief, 
unvarnished tale. It does not, I suppose, materially differ 
from those that thousands of others in my position might 
have to tell, and may be accepted as typical. 

Before I came to Davos-Platz, I had read any quantity of 
books on the subject of Consumption, and the more I read, the 
more I was convinced that medical science had much to exploit 
in that direction. Much progress had been made, to be sure, 
but the science of the cure of Consumption to-day is anything 
but an exact science. There was one book that had made a 
deep impression upon me, written by an American physician 
who was possessed of more natural common sense than of 
medical knowledge, for his book contained many medical bulls. 
His theory was in common with that of the present greatest 
living authorities on lung diseases, that consumptive patients, 
so far from having to be carefully guarded from every breath 
and slightest alteration of temperature, and so far from having 
to be carefully dieted, and their lives cut out for them just so, 
should be exposed to every weather, eat and drink plentifully, 
exercise freely, and do many other things which the old school 
viewed with horror. He even went farther. He advocated 
positive hardships, a wild life, physical and nervous excesses, 
and heroic practices of every description. I accepted his then 
more than now novel dictum as the incontrovertible truth, 
moved thereto by the testimony of many who, brought to 
death's door by their own physicians, tried the method in 
despair, and were cured, or at least spared through many more 
years than they ever expected to be. However much or little 
charlatanry there was in the work, it still impressed me as 



254 Mr. Gerxer — The Theory and Practice of the 

being not very far from the correct notion. I jumped to the 
last and, you will say, absurd conclusion : I told myself that 
the same causes which bring on consumption must, by re- 
exposure to them, cure the ill again. In a word, similia 
82 niilibus curantur. I must be permitted to say that this 
statement is to be accepted with a number -of qualifications. 
But it characterises what was then my notion. However 
much the reader may be inclined to smile at the extravagance 
of the notion, let him reserve his ridicule until he has read this 
to the end. I did not, of course, include social excesses in this 
category, but I had in mind such exposures to nature as the 
healthiest man would carefully guard against. With this 
notion I came to Davos-Platz, and I preached it there as a 
doctrine. 

The diligence journey from the last railway station to Davos- 
Platz I made in accordance with the notion. I sat beside the 
driver of the sleigh all the way, facing a bitterly cold January 
north-east wind and occasionally sweeping snow, during seven 
and a half hours. As I said, I always did all I could to super- 
induce a cough, not to soothe it. Another principle with me 
was that as long as then is something t<> cough cj> or to pro- 
duce a cough, there can he no cure. This appears to me to be 
almost an axiom. I arrived at Davos-Platz feeling better that 
evening than I had felt for many a day. 

If you want to know all the geographical, meteorological, 
sanitary, social, industrial, and commercial particulars apper- 
taining to Davos-Platz, a whole library of books, in all lan- 
guages, to be procured through the one bookseller in the place, 
will initiate you fully, and I shall say nothing further than that 
it is a town of about 3,000 inhabitants, situated in a singularly 
well sheltered valley, about a quarter of a mile broad and 
seven miles long, 5,120 feet above the level of the sea, pro- 
vided with about twenty hotels and hostelries of all classes, 
capable of accommodating over 1,200 guests, for the weal and 
amusement of whom there is every possible provision. Davos- 
Platz pleased me in one respect especially — the life at the 
hotels. For it was a third principle with me that melancholy 
and consumption are good friends, and do much for each other. 
I thought more of a jolly good laugh than of a bottle of medi- 
cine (and I now think that in the advanced stages of the 
disease a chuckle is the best expectorant, though dangerous 
as to inciting a haemorrhage), and believed ever that good 
spirits, both literally and metaphorically, were worth more 
than all the doctor's visits. In an exile such as a health resort, 
pleasant company helps one over home-sickness and pining for 



Cure of Phthisis by Hard Mountaineering. 255 

absent dear ones. Variety is the spice of life, and new faces 
call up a new turn of things and of thoughts. Relatives are 
apt to keep the patient in the old groove. They effeminate 
him. Pity, sympathy, and nursing always do. They are not 
conducive to good spirits, or rather, what is still more essential, 
high spirits. Among strangers, a man cannot, dare not be 
peevish, fretful, or disagreeable. He must forget his invalid 
individuality. 

My physician there examined me, and confirmed the opinions 
of his predecessors. The first necessity was to commence anew 
with my cold ablutions mornings, immediately upon rising, 
summer and winter, at any temperature, even at zero, the 
room not being heated ; at first only down to the waist, later 
on the entire body. To one who had a decided antipathy 
against cold water, this was an unpleasant order, but what 
was a torture at first, soon became a habit, and latterly a 
delight. I performed my ablutions with a sponge ; others do 
it by wrapping themselves in a wet towel. Standing in a 
large basin, I apply the dripping sponge first to the back of 
my neck, then under the left arm, and next under the right 
arm ; then on the middle of the back ; then I run it over the 
chest and stomach, from the left shoulder down the arm, ditto 
the right ; finally down the left and then the right leg from 
the loins. Wipe off the wet with a soft towel, and then rub 
thoroughly dry with a coarse one. My doctor also caused me 
to resume painting my chest with tincture of iodine during 
the first six weeks. Against fevers I took, in the beginning, 
heavy doses of quinine and cognac. There was an hour or two 
of agony while the battle between the fever on the one hand, 
and the quinine and the cognac on the other hand, went on, 
and then it was all over. But I soon abandoned the taking of 
quinine as an unnecessary torture, and treated further fevers 
with cognac alone. I remember that in desperate cases, kairin 
was administered. 

I found that cognac had other virtues for me. I was subject 
to nervous stupors, accompanied by chills. A generous dose of 
cognac always helped me. I remember that I was so nervous 
that I could sit down and cry like a baby, and my doctor pre- 
scribed aerated water. It was in each case without avail. But 
the cognac helped me. The same service champagne performed 
for me, but that has effects which the cognac did not always 
bring with it to me. 

I at once settled down to a heroic life, in accordance with 
my principles, and all weathers found me out of doors. I 
remember the first time I climbed up one of the most fre- 



256 Mr. Gerxer — The Theory and Practice of the 

quented of the adjoining Alps, a thousand feet or mure above 
the town. I did it in one uninterrupted run, from the lowest 
level of the valley to the summit, without a rest. My lungs 
heaved like a compound engine, and although it was a very 
cold day indeed, I perspired freely. When I took off my cap 
to wipe the drops from my brow, the north wind struck it 
with an arctic chill that nearly took my breath away. All 
this was in conformity with my theory, and I did feel very 
well after it. I gained more vigour in Davos-Platz in a week 
than I had gained at the antipodes in months. My vigour 
came back to me so quickly that nobody noticed the first few 
days of weakness, and few guessed the diseases I carried in 
my breast. I went skating regularly, and skated myself tired 
every day. Unfortunately, the ice did not last long. It is 
difficult to maintain it in such a snow region. 

The process of acclimatisation was the worst part of the 
whole business. Few can come to the High Alps and fall in 
at once or even rapidly with its climatologies! conditions. My 
acclimatisation took months. It is this acclimatisation that 
takes everybody down in the first period of the sojourn in 
hio-h altitudes. There is a week or two of accelerated vigour 
and then comes a relapse, and generally a specific ailment. In 
most of the cases I have observed, the ailment was a catarrh. 
In many others, a sore throat. In others, sore eyes. And so 
on. And it is evident that- no cure can 1 >egin to be effected 
until a period of normal vigour sets it. The moral is that 
patients should go to such places to begin their cure at a time 
of the year when the meteorological conditions are most favour- 
able to a rapid acclimatisation, that is, in the late summer or 
autumn ere the first heavy snow. The latter seldom yields to 
a rejuvenescence of the season. 

As the surroundings become mure and more familiar to the 
patient, his tours become more extended, as well as more 
ambitious. Having ascended the various Alps, and explored 
the highway ten or twelve miles either way, he ventures into 
the side valleys as far as the snow will permit. He even, with 
the aid of a guide, makes a notable ascent in midwinter snow. 
But that is rare. And after each tour, progressive in ambition, 
sets in a higher grade of vigour. 

Sleeping with the window open all the year round, hardens 
the respiratory organs, and the cold ablutions mornings harden 
the nervous system, also bringing with them increased vigour. 
Increased vigour leads to increased appetite, appetite to mental 
energy, the latter to greater physical precocity, and the conse- 
quent exertions bring on still greater vigour. And so on. 



Cure of Phthisis by Hard Mountaineering. 257 

Unfortunately, precocity most often leads to recklessness, and 
then the patient begins a series of experiences. For instance, 
he goes tobogganing, a term borrowed from the Canadians, the 
same as coasting or sledging. He thinks the exercise will do 
him good. So it does, if rationally performed. But our pre- 
cocious patient flies daringly down steep ascents, and hurts 
himself seriously. The consequence is that he must keep quiet, 
if not his bed, and the cure is retarded. Another goes tobog- 
ganing on a bitter cold day, gets himself into a perspiration 
dracjoino- his tobogffin or sled up hill, and comes rushing down 
against the icy air. What is the result '. With me it was a 
serious lung catarrh that lasted two months. Wet cold band- 
ages nights, carefully covered with india-rubber sheeting,* were 
the penalty of my folly. Or patients will seat themselves on 
hay slides and come rushing down with nothing between their 
unmentionables and the snow, so that the former get wet. 
The way back to the hotel is long, and the air is cold. Nature 
administers the inevitable chastisement. 

Variety at the table induces the consumption of a greater 
quantity of food ; exercise, too, whets the appetite, conviviality 
conduces to deeper libations, and so the digestive organs gain 
in vigour. Patients soon become audacious as to gormandis- 
ing, and few refuse lobster salad at the table even when offered 
in the evening. The excellent wines of the Val Tellina, of 
France, Germany, and Hungary, as also the nourishing beer 
of Bavaria, so near and plentiful at Davos-Platz, all pour new 
life into the flagged temperament. Folly brings on a relapse 
here, inevitable fatality a relapse there, but the process of 
improvement marches on. The frame gains in health, and 
the sick lung must yield sooner or later to the new and happy 
influences. The daily exercise, into which climbing enters 
most largely, superinduces a deeper respiration ; and tracts of 
cells are recovered from the disease, brands of tissue snatched 
from the burning. 

I could soon smoke my two, three, and even more cigars a 
day without feeling any effects, during or after the process. 
To dispose at once of the subject of smoking, I found that 
whenever I grew sturdier, the less I cared to smoke at nil. 
though I had been an inveterate smoker in my younger days. 
In others I observed that the better they grew, the more they 
cared to smoke again. 

* On tliis subject, the attention of physicians is invited ti> Section 34 of 
my treatise On the Natweof Heveeaoid ui><l lhr,;nit,, n<>\\- current in the 
Mechanical World, Manchester. The Section is entitled " On the Medical 
Qualities of Heveenoid," contained in the issue dated 1 1th September, 1 88 I. 

No. 4. S Vol. XXII. 



258 Mr. Gekxeh — Tin Theory and Practice of the 

As the novelty of the sojourn begins to decline, and the 
newcomer begins to be more at ease with his fellows, he not 
unfrequently falls into fretfulness and melancholy. To this I 
was especially prone. My doctor, meeting me on the street 
one day, noticed it, and remarked upon it. I must retain my 
spirits, he said. I cut a grimace. He prescribed for me by 
obtaining for me an invitation to a masquerade ball at one of 
the English hotels ! Ignoring the reader's amazement, I will 
■say that I took to the idea at once, and busied myself with 
the preparations until the day came round. This business 
made me happy, and gave my thoughts a merry turn. I had 
no more time for melancholy. The day came round ere I 
knew it ; I went, saw, was seen, chatted, danced, ate and 
drank, and though the exhilaration led a rise in temperature, 
and the dust to a coughing fit — what of that ? For a long 
while after I remembered the pleasant evening, and the plea- 
sure banished melancholy. A second similar occasion followed 
in the course of the season. At such opportunities one makes 
acquaintances, and a larger circle of acquaintanceship brings 
with it a more extended scope of diversion. If the patient, 
under such circumstances, experiences ennui, it is his own 
fault. But the doctors up there now talk of putting a stop to 
this. 

There is quite a pretentious theatre at Davos-Platz. I 
seldom went there, as inactivity in a more or less vitiated air 
for hours at a stretch I shunned. At the same place there 
were high-class concerts, but we had enough of them at our 
own hotel, where we could sit and stroll in the vestibule and 
corridors listening to them, and so we seldom sought them 
elsewhere. At some of the hotels there were readings in 
which the guests took part, and there were numerous enter- 
tainments and performances, professional and amateur, that 
helped to banish melancholy. The great object was to main- 
tain a constant flow 7 of high spirits. 

At home in the hotel, billiards, cards, and other games ; a 
pleasant social intercourse ; literary, scientific, and artistic 
pursuits; and many other diversions passed the hours inter- 
estingly. Everything to be amused, to keep from moping. 
And in this connection let me say that, under such circum- 
stances, everybody owes it to his fellows to keep the peace at 
all times. Everybody must remember always that they are 
all more or less irritable on account of the common pulmonary 
ailment, and much must be overlooked and forgiven. The 
same injunction might be given to all others in their inter- 
course with lung patients, to be charitable and forbearing. 



Cure of Phthisis by Hard Mountaineering. 259 

Disagreeableness is bad for a lung patient ; a raised bile raises 
the pulse with it. The great thing is to keep cool. 

It is an unfortunate affair for a lung patient to fall in love, 
and it is doubly unfortunate that in a resort like Davos-Platz, 
there should be ten times more opportunity to do so than in 
social circles elsewhere. All advice in the matter to the 
unfortunate is of course thrown away ; but he must be made 
to understand that under the circumstances it is as criminal 
for him to link the lot of another to his own miserable one, as 
it is criminal for him to hand his curse down to posterity. He 
has enough to do with himself, and the reader will agree with 
me that he who has shaken off the tuberculosis, has performed 
more than a life's labour. He needs all the strength and 
mental serenity he has or can become possessed of. If it be 
true that none but the brave deserve the fair, it must be also 
true that none but the healthy deserve them. 

I soon began to practise gymnastics up in my room — the 
Niemeyer exercise with a cane. It consists in grasping the 
cane near its ends with both hands, and with extended arms 
raising it from the lowest position below the waist to the 
highest position above the head. Then, crooking the arms, 
lower the cane backwards so as to touch the back below the 
shoulders as far down as possible. Take a deep breath and 
swing back to the original position. Repeat unto fatigue. 
This did me much good. Besides, perform movements at every 
opportunity that serve to expand the diseased parts, and take 
a deep breath. I always felt easier in the chest, especially 
after an exhaustive expectoration consequent upon the exer- 
cise. Of this manner of exercise, I believe Indian club exercise 
to be the most salutary if the patient can stand it. Out in the 
open air, when distressed with an accumulation of mucus 
difficult to expectorate, a hundred yards dash relieved me of 
it and never hurt me. To these gymnastics I afterwards 
added singing, which not alone had a like virtue, but 
raised my spirits. What if I could not sing, or who heard 
me, so long as it was done at an hour when it disturbed 
nobody ? 

And so the spring came round, and the snow began to melt. 
At Davos-Platz there is heavy snow from October to May. I 
say heavy, because a midsummer snowstorm there is not a 
strange phenomenon. I had read a great deal against a so- 
journ in the mountains during the melting of the snow, and 
asked my doctor about it. He counselled me to stay, and I 
stayed. And it did me no harm. The weather was bail, it is 
true, but the newspaper, and letters from absent friends in- 



260 Mi:. Gerneb — The Theory and Practice of the 

formed me that it was worse elsewhere. May and Juno are 
the most beautiful months in the year up on the mountains. 

Often had the thought of a prolonged walk suggested itself 
to me, and when there came a spell of fine weather in the 
midst of a surly period, I unhesitatingly set out alone, 
accoutred only with the barest necessities for my journey.* 
I walked tight hours the first day, about six hours each the 
succeeding four days, and eleven hours the last day. stopping 
at a hotel in the place which happened to be the terminus of 
each day's walk. The distance covered must have been nearly 
ninety miles. And although I had encountered much wind 
and dust, and snow and rain, and heat and distress, I not only 
did not lose flesh, but had gained in health and vigour in every 
respect. I forgot that I was a lung patient. The experience 
had done me a world of good. 

Of course this had to be repeated. And it was repeated. 
I visited more distant points to explore Swiss beauties I had 
often heard of but never seen. I even railroaded to Zurich 
and farther, and back, for a change of scene and air, in order 
to return to my headquarters with a new appreciation of their 
charms. And although mid-spring found them deserted by 
nine-tenths of the guests, they did not seem lonely to me. 
The white snow and the green grass battled over every inch 
of ground, and of course the green carried off the victory over 
the white for once, and the valley developed into a veritable 
garden abloom with myriads of bright flowers, aglow with an 
entrancing fecundity. Brown rifts appeared on the snow-clad 
hills and mountains, and the eye rested lovingly and longingly 
on the lofty summits that seemed to invite their ascent. Soon, 
and the coveted first ascent might be dared. 

At this period I found myself with an increase in weight to 
a point which I had never before touched, ill or well, a grati- 
fying expansion of the chest, and a remarkable robustness. I 
could tramp a distance of five-and-twenty miles almost with- 
out fatigue, and stepped my ten miles in very little more than 
two hours. I climbed a height of a thousand feet in thirty-six 

* The story of this tramp is told in a contribution to the Waveriey 
Magazine, Boston, Mass., U.S.A., entitled "Along the Infant Rhine." My 
second tour, " Along the Turbulent Tainina,'"' and all the mountain ascents 
farther on referred to, are also told at length in narratives published in 
that journal, under the titles "A Lone Ascent of the Jacobehom," " A 
Cloudy Ascent of the Schiahorn," "The Ascent of the Aelplihom," "A 
Midnight Ascent of the Sehwarzhorn," "The Ascent of the Rinnerhorn," 
and " The First Ascent of the Leidbachhorn." The series is included in 
the present year, and may be procured on application to the editor, Moses 
A. Dow, Esq. 



Cure of Phthisis by Hard Mountaituering. 2G1 

minutes, and descended it in fifteen and a half. I ate and 
drank for two, and I told myself, and so did my doctor, that 
my cure was assured. 

I sat on the terrace of my hotel watching the changes of the 
fitful spring weather, growing more uncomfortable and restless 
daily, and critically regarding the snow-tields still shrouding 
the mountain pyramids. One fine June morning, alone, I set 
forth to conquer one of these monarchs, and after much puffing 
and perspiring, but without a rest, I gained an intermediate 
summit. I quivered with nervous excitement. The rest of 
my way lay over and through deep snow, and when I had at 
last reached the actual summit of the group, it was with 
swimming eyes, fiercely beating heart, and every fibre throb- 
bing. My feet were wet to the knees. I could neither swallow 
food nor drink, nor did I care to smoke, but I feverishly de- 
voured quantities of snow. I did not rest at my goal a minute ; 
I felt like a drenched poodle shivering in the wind ; an uncon- 
querable restlessness drove me on. The desolate loneliness 
about me, and the sense of being so far from human beating 
hearts, filled me with a vague terror. So I descended the 
painfully conquered giant, and reached my hotel like one hi a 
dream after having been over eight hours afoot. A glass of 
cognac revived me, and then I felt like a smoke. In less than 
half-an-hour I had recovered entirely, and but for my flushed 
face, nobody would have known what I had been through. 
This escapade, as you will call it, was followed not even by a 
stiffness or a soreness, let alone by a still more evil effect. On 
the contrar}?-, it seemed as though a new lease of vigour had 
been granted me, and I told myself that rest was poison and 
hardship meat for me. My doctor examined me, and pro- 
nounced me radically improved. This confirmation of my 
theories made me an astute disciple of the doctrine of the cure 
of Consumption by hard mountaineering. 

My next experience was suggestive. I dared another con- 
siderable ascent, though not alone this time. The morning 
was cloudy, and the atmosphere was sultry and heavy. Ere 
long, it rained. Every valley looked a pot full of mist and 
clouds. It seemed as though the marrow of my bones had 
been replaced by lead, and the entire ascent was one desperate 
struggle against an overpowering lethargy. I was wet to the 
skin with perspiration and the drizzling rain. My lungs 
heaved tumultuously. But the summit was gained, and this 
time I had appetite for food and wine, and even for tobacco. 
On the way I had allayed the turbulency of my blood with 
bromide of ammonia. This tour showed no evil effects for a 



262 Mr. Gerneb — The Theory and Practice of the 

day ; then came a mouthful of blood and an intense pain in 
every fibre of my lungs. I was frightened, and trembled for 
myself and my theory. My doctor commanded absolute rest 
for a week, but I forgot all about my troubles on the afternoon 
of the same day, and drank two litres of beer in merry com- 
pany before sunset, to the amazement of my friends and my 
doctor. The latter examined me carefully toward the end of 
a week, and found that a most remarkable improvement had 
set in, and that especially the capillary bronchitis had been 
almost driven out of the field. The moral pointed at by this 
experience was too plain to be misunderstood, and so I there- 
after underwent a periodical hardship. 

A month later, with an experienced guide, I made the ascent 
of a still more formidable peak requiring four hours and a half 
from base to summit, without much accompanying distress, and 
feeling excellent when the victory was won. The descent lay 
over a glacier, and then came two hours of rubble, and a fur- 
ther two hours of hard tramping. This ten hour exertion I 
forgot all about within an hour after it was over, and at mid- 
night on the second day after I was once more on my feet and 
accoutred to ascend the celebrated Schwarzhorn. The night 
was so dark that I could literally not see my outstretched 
gloved hand, and a fine drizzle chilled me through and through. 
My nerves were unstrung and my stomach was rebellious. No 
sane man would have thought of persisting in the ascent under 
the circumstances, but I set my teeth, and by dint of super- 
human effort and much cognac, though I vomited several times 
on the way, and my wrists pained with nervous trepidation, I 
kept up with my companions, and sunrise found me with the 
coveted laurel gained. The grandest view in the Grisons 
awaited me, and the clouds kindly broke to let me have the 
benefit of it, but I had but one wish : to sink down on the 
snow, close my eyes and be let alone. The guide poured half 
a pint of Montagner into me, but my stomach refused it. 
When, half-an-hour later, the descent was begun, I was the 
most precocious and spirited of the party, and had entirely 
forgotten how ill I had been. After dinner that day I was 
altogether myself again. When my doctor next examined me, 
the verdict was a further decided improvement in the very 
core of my trouble. Everybody wondered at me, but I knew 
why it should have been so. 

I now rested for an entire month, and then I did a thing the 
like of which I had never before done in my life, and never 
expect to do again. At eleven o'clock one moonlit evening I 
set out with a guide to ascend a horn of which there was no 



Care of Phthisis by Hard Mountaineering. 263 

ascent on record. I felt ready for anything. An hour after 
midnight we had the last tree below us, at an altitude of about 
7,000 feet. We were wet through with the dew, and the wind 
made us think that we were in the arctic regions. Rest seemed 
death, but we needed it too sorely. When we resumed our 
journey, we were frozen nearly stiff', though it was midsummer. 
We pushed on, and sunrise found us on a summit which lay 
between us and our destination, and at this station we enjoyed 
a hearty breakfast. After the meal, in excellent spirits and 
abrace in every fibre, we turned our attention to the real work 
in hand. Three hours of hard and perilous effort ensued, more 
than enough to try the sternest nature, and my guide on that 
occasion will smile in derision at a reference to my being con- 
sumptive. I was the proudest man in whole Switzerland when 
we stood on the fearful summit. The descent I shall never 
forget. Twice I looked death in the eye, and when the danger 
was over, a nervous reaction upset my stomach and myself so 
that it was some time before I could resume the journey. The 
march home, through a broiling sun, was very hard on me. 
The adventure lasted fourteen and a half hours. I must deny 
that I felt much used up, and the next night's sleep restored 
me entirely. My doctor had again to declare that the adven- 
ture had done me more good than harm. I will not particu- 
larise any more of these exploits. At the end of the season I 
felt so well, hearty, and sound, that I never for an instant 
doubted my complete re-convalescence. My doctor intimated 
that the last vestige of capillary bronchitis had disappeared. 
I propose now to go into a number of medicamental considera- 
tions. 

It was my habit at Davos-Platz to drink from one to two 
quarts of beer per diem, although I must confess that, not- 
withstanding I did so with my physician's permission, and 
indeed at his recommendation, I cannot in turn recommend 
the practice to others. It depends upon the individual con- 
stitution. I find that beer, drunk before sundown, makes me 
drowsy for the rest of the day, while in the evening it exhila- 
rates me and then conduces to sleep at night. I am, therefore, 
inclined to recommend beer drinking after supper only. 

To drink mineral water during the spring and winter 
months I think injurious, because it chills the stomach, but I 
believe in drinking it during the summer and early autumn, 
when it is a capital refreshment, if nothing else. The waters 
of Weissenburg, in the Bernese Highlands, arc the most cele- 
brated for this purpose. I have not tried their virtue suffi- 
ciently to recommend them confidently, but the theory upon 



26.4 Mjl Gerner — Th< Theory and Practice of the 

which they are taken seems to me to be reasonable. The 
calcareous constituents are communicated by the blood to the 
Lungs, and there deposited, conducing - to a process of calcifica- 
tion of the tubercularly diseased parts. In how far this pro- 
cess is purely problematical, I leave to the more learned to 
decide. 

All the rubl >ish that is advertised by ignorant and unprin- 
cipled quacks, and even by persons of repute, and said to be 
curative, I have given a fair trial, and it is perhaps needless to 
say that I condemn it utterly. I have also answered a number 
of advertisements of professed consumption-curers, and would 
advise the public to save their postage in the first instance, 
unless one feels inclined to invest in an advertised work on 
the subject from a reputable source. Of these I will say, in 
general, that if the author professes to cure consumption by a 
specific cure, the work is to be distrusted. 

As to diet, the lung patient needs in my opinion not to be 
dieted at all. I say unqualifiedly, let him eat what he likes, 
and as much as he likes, when he likes. The more the better. 
He too often is not inclined to eat anything at the regular 
hours, and whatever his stomach can endure, his lungs cer- 
tainly will. It is evident that the most nourishing food is the 
best, but is oftenest the least palatable. I believe in plenty of 
sour and fat, in salads, raw fruit, ice cream, pickled dishes, 
strong broths, fish, oysters, and roasts, as against most vege- 
tables, cereals, boiled dishes, pastry, farinas, sweets, common 
soups, and bread. 

Iodine is a favourite prescription with physicians, but its 
effect is too one-sided and doubtful as compared with another 
and more extensively effective remedy. I have in mind what 
is popularly known in pulmonary circles as green soap, being 
a soft soap impregnated with a strong alkali. This simple 
remedy was soon brought to my notice by my physician. It 
i.s applied to the chest and rubbed on by hand. The alkali 
penetrates the skin and is absorbed by the lungs, tending, like 
the waters <>\' Weissenburg, to the calcification of the diseased 
parts, besides having the irritating and invigorating effect of 
iodine. The application should be made in the evenings. 
After the putting on of the soap in a thin layer, it should be 
made to froth. This done, pull a woollen shirt over it and go 
to bed. The next morning, wash it off, and rub as dry as the 
solely irritated skin will permit. Pains do not usually come 
till the fourth application. Persevere at the rate of three 
times a week till the recurring pain becomes intolerable, then 
reduce to twice a week, or yet widen the periods if you still 






Cure of Phthisis by Hard Mountaineering. 265 

cannot sleep for pain. This practice should be persisted in 
from the first snow in autumn, through the winter and spring, 
until the first warm indications. While there is hope and 
necessity, the patient will summon sufficient fortitude to his 
aid to use and persist in this most efficient of remedies. 

Another very great point in the cure of consumption in its 
primary stages, and of capillary bronchitis in any stage, and 
on which I desire to lay very great stress indeed, all opposition 
to the contrary notwithstanding, is the incessant use, i. e., in- 
halation of creasote. Let us hear no more of those little 
murderous steam inhalators which saturate the lungs with a 
maleficial moisture. The purpose of creasote is fourfold; in 
the first place, it dehydrates the air that is being inhaled ; in 
the second place, it dehydrates the lungs ; in the third place, it 
is poisonous to the infusorial influences, if any, at work in the 
diseased parts ; and in the fourth place, it has valuable disin- 
fecting properties. It thus tends directly to the eradication 
of the tuberculosis as well as of capillary bronchitis. It should 
be inhaled by means of an inhalator which can be worn at all 
times without inconvenience or hindrance to doing something 
else at the same time. Such instruments are to be had every- 
where ; ask for antiseptic respirators or inhalators. The 
respirator should be worn at every opportunity. It is capped 
double, one cap being hinged upon the other, and both per- 
forated sieve-like ; they hold between them wadding moistened 
with creasote. There are two kinds, one fitting only over the 
mouth, and the other over the mouth and nose both. In the 
former instance, the respiration should be through the instru- 
ment and the mouth, and the exhalation or discharge through 
the nose. In the second instance, the respiration is as usual, 
or at will. The latter cannot with comfort be worn during 
the night, and the former becomes useless since the sleeper 
will naturally both respire and exhale through the nose. I 
fail to see what good it can do to inhale creasote for a period 
as little as or less than half-an-hour a day, as I have observed 
practised. The inhalation should be as constant as possible, 
and during not less, if possible, than six hours a day, while at 
all necessary. I found that the practice reduced my cough 
and expectoration to a minimum in a £ew weeks. In other 
cases it did the same in teD days. Let me emphasise the use 
and virtue of creasote, and recommend it to the reader's most 
thoughtful consideration. I can, and do vouch for it. The 
only instance in which its use should be discontinued is on the 
appearance of congestive symptoms. 

The autumn at Davos-Platz, after that adventurous summer, 



266 Mr. Gerner — The Theory and Practice of the 

did not find me in possession of any gain of weight, but I laid 
no great stress on that. My weight, in comparison to my 
height and the circumference of my chest, was satisfactory. 
What grave me the greatest concern was that I blew so little 
on the spirometer. I could never get above 2,600 cubic centi- 
metres, while persons whom I considered to be more ill than I 
was, blew far above that. I did not realise then that I was 
indeed lower than they, and that the spirometer was a faithful 
and reliable reporter. It dawned upon me when my doctor 
admitted to me that I had a cavity in the upper part of my 
right lung, a circumstance I might have known long ago, and 
was, in fact, prepared to hear of, but it gave me a little shock 
nevertheless. 

"With the first snow came a change for the worse. I had a 
return of fevers just before sunset daily, my cough grew worse, 
my expectoration more plentiful, and I became languid ami 
nervous. I thought to combat these evils by going toboggin- 
ing and tumbling about in the fresh air all day, but the result 
was a fresh lung catarrh, and its consequent distress. I felt 
that I was sinking rapidly, and wrung from my doctor that 
there was a full return of capillary bronchitis and a fatal 
spread of the tuberculosis. I struggled against this reverse 
with all my might, but in vain, and I was very much dis- 
couraged. My spirits fell to zero, and once more home-sick- 
ness and a burning desire to plunge into the whirl of an active 
business life overcame me. 

My physician had always promised me a complete cure 
within the year, but I was now no longer to be deluded, and 
so he had to confess that I was, and had been from the start, 
hopelessly consumptive, but that he had hoped against hope, 
seeing my energy, spirit, and physical powers. My exertions 
had stemmed the tide of disease, but now I ought to prepare 
myself to pass the remainder of my life in the High Alps. 
But I got it into my head that I might just as well go under 
at home, and accordingly bade Davos-Platz farewell. 

Nobody but he who comes to London after a protracted 
sojourn in the High Alps can realise the terror that seized 
upon me when I saw the dense cloud of smoke that hovered 
over England, from oft' Dover, and when I was fairly within 
the precincts of London, a sickening sensation overcame me, 
and I seemed to gasp for breath in vain. For a whole week I 
suffered day and night with frightful coughing fits, bringing 
up unheard of quantities of expectoration, and I told myself 
that another such a week would finish me. I dosed myself 
with strong Dover's powders, only to awake the next morning 



Cure of Phthisis by Hard Mountaineering. 267 

with a dull pain in the head and chest. Whenever I ventured 
out into the street, or into an unheated room, I coughed vio- 
lently. I never before realised how deadly moist air was for 
my diseased lungs. I , 3 at over the open fire for hours at a 
stretch, and breathed easier, because the air was dry there. 
From this condition of things I roused and saved myself by 
the incessant use of creasote, and I faced all weathers and 
atmospheres with it with impunity ; it furnished my lungs 
with an air that was grateful for them to breathe. Soon, 
when I had become somewhat acclimatised, I was able to do 
without creasote. I enjoyed promenading about, in spite of 
mist and smoke. But my general condition, so far from being- 
satisfactory, got worse. I had one relapse after another, with 
pains in the chest, dizziness in the head, and spells of extreme 
enervation. The latter' I tried to meet with quinine tonics, 
but they only served to raise my temperature. One thing- 
alone I had reason to congratulate myself upon, and that was 
the absence of fever, during the entire winter that followed. 
Severe coughing fits I was never free from, but matters on 
the whole went well with me until the spring came. I could 
never sympathise with the poet Thomson's raptures over the 
"ethereal mildness" of "gentle" spring, and every lung patient 
will agree with me, that of all the seasons of the year, this is 
the most deleterious to him. The blustering east winds that 
the month of March brings with it are intolerable. Rather 
the black mist and the yellow fog than those winds. I con- 
tracted all imaginable ills in the way of catarrhs and throat 
affections, and the climax was capped when I began to spit 
blood at intervals, until one day I burst a blood-vessel, and 
my right lung was suffused with blood. For eight and thirty 
hours I expectorated it, in clots and drops ; I should say that 
it amounted to a pint altogether. My London physician pre- 
scribed ergotine, which stayed the flow, but I recovered slowly. 
He ordered me to discontinue my cold ablutions in the morn- 
ings, and to keep very quiet in future. Having reached this 
stage, I had nothing more to hope for, and nothing remained 
forme but to surround myself with the most beneficial con- 
ditions in order to prolong my life as far as possible. 

My expectoration was at this time, and has since been, 
almost uniformly snow-white, flocculent, tubercular pus, alter- 
nately much and little, varying from half a wine glassful to 
six or eight flakes the size of a lmxel-nut per diem, accom- 
panied or unaccompanied off and on by considerable quantities 
of slime, up to as much as a pint per diem in extreme instances. 

As the summer advanced, which meant an advance of time 



268 Mr. Gerxer — The Theory and Practice of the 

with me as regards the progress of the disease, I began to feel 
the ravages of the process of destruction more and more. I 
noticed, when lying down quietly and breathing regularly, 
that my right chest did not rise and fall as the left did, and I 
fancied that all the breathing I did was on the left side only. 
This finally became a certainty with me, and it was confirmed 
in an examination of me by my physician, who told me that 
my right lung had become an entirely inactive and useless 
member — what there was left of it. The remnant was a 
festering, diseased mass. My left lung was declared to be in 
an advanced stage of tubercular decay, the disease advancing 
from above and from the right. Spells of acute pain in my 
left lung have fixed the two centres for me well in my mind. 
My expectorations are becoming more frequently associated 
with a putrid taste in the mouth, regularly every morning, 
and at times during the day. I sutler more and more from 
extreme shortness of breath, not brought on by anything par- 
ticular, but quite spontaneous. Choking coughing fits come 
along quite frequently, and several times during the hour the 
breath comes so short and fast as to produce manifestations 
not unlike the hysterical sobbing in a child after a prolonged 
crying fit. Stairs are Tw inning to become almost unmountable, 
and I am incapable of any uncommon physical exertion. The 
idea of making an ascent now such as I made a year ago, has 
become the realisation of a present impossibility. Since I left 
Davos-Platz, I have lost sixteen pounds in weight. Blood- 
spitting is of almost daily occurrence, and every now and then 
there is a more or less slight or serious haemorrhage. I recover 
quickly from them, however ; always within twenty -iour hours. 
I think there is no worse place in the whole world for the 
lung patient during the midwinter months than London, but 
the converse of the proposition — viz., that the patient can do 
worse than pass his summer in London, is equally true. In 
fact, it would be difficult to my mind to find him a better 
locality in the whole wide world, so far as I know of it. I 
suppose this applies to every other large city in the United 
Kingdom. I say city, because the precinct in which the 
patient should move, should be completely paved, for when 
he is brought into contact with the exudations from unpaved 
roads and fields, his temperature will be heightened imme- 
diately, and in the course of a few days there will assuredly 
be a relapse. I am speaking of Great Britain and Ireland, as 
lying embraced within a moister climate where the evapora- 
tion is greater, and I will not have my statement refuted by 
statistics of pulmonary mortality, for the reason that the 






Cure of Phthisis by Hard Mountaineering. 209 

causes which tend to produce consumption are quite different 
affairs from the circumstances which tend to aggravate the 
disease. London in summer is, in comparison to the other 
great cities of the world, delightfully cool and balmy, and Mas 
not for a single day intolerable to me, though I regard heat as 
one of the phthisician's greatest foes. I have lately removed 
my residence from out of the confines of the metropolis, and 
my experience there bears me out in the above opinions. I 
have a fever, or at least a feverishness, every day, and my 
temperature has risen considerably and permanently. The 
greater clearness of the atmosphere is my only consolation, but 
even that does not lessen the violence and frequency of my 
coughing fits, nor does it heighten my energies. 

In reviewing what I have written thus far, I find that I 
stand committed to the opinion that, if the patient cannot or 
will not live in high mountain regions, he cannot do better 
than to spend his summer (from May to September) in London, 
and his winter (from October to April) in New York, and I 
will not say no to that, but I should only recommend it in cases 
where all hope of a cure, through the agency of hard moun- 
taineering, is gone. 

A word about the gases in the tunnels of the underground 
railway in London. So long as they are entirely carbonaceous, 
and not sulphurous, I am not certain that they have hurt me. 
I have travelled over the best part of the roads nearly every 
day, and I do not remember once experiencing a serious dis- 
tress, or at least not a distress which I could directly trace to 
my surroundings. I felt that my lungs were surcharged with 
the gases, and I found them not unbeneficent and I may even 
say grateful breathing. It was only on very warm days that 
I found the tunnels intolerable ; the heat in the carriages is 
then stifling. 

One more experience will I touch upon, that with pancreatic 
emulsion. I tried it during the past few months. At first I 
took it as prescribed, and then I ate it from the spoon, allow- 
ing it to disintegrate on the tongue, and to become thoroughly 
incorporated with the saliva ere I swallowed it. Its effect 
upon me was a gradual loss of appetite and a disturbance of 
the digestion, so that I was compelled to discontinue it. But 
I believe that it is the best preparation for the consumptive 
patient extant, and as long as it does not interfere with the 
digestion, I heartily recommend its use. 

The reader will agree with me that I am justified in advo- 
cating the practice of hard mountaineering to all who have the 
misfortune to be my fellows in suffering. I should not, of 



2i Mr. Gerxer — The Theory annd Practice of the 

course, preach it to those in whom any greater effort produces 
a congestion or inflammation and possible haemorrhage, and 
yet I have not noticed that it is this kind of an effort which 
conduces to congestions. I hold that hard mountaineering 
and physical hardening can do the not too far advanced lung 
patient no harm, and my experience shows that these have in 
them the elements of a cure where a cure is possible. To the 
lung patient at home I recommend the practice of as many of 
the elements of the appended programme as his surroundings 
will permit of. 

There are a great many other points I might dwell upon to 
advantage, but their consideration would lead me beyond my 
own experience, and that is not my purpose. I have not pro- 
tocoled this so much to promulgate my opinions, as to relate 
my experiences. I have, it is true, ventilated some of my 
opinions, but, it must be confessed, only where they conformed 
to my experiences. Here the narrative of my experience ends, 
and upon that experience is based what I know about con- 
sumption. You will perhaps say that that is precious little ; 
yet I trust that this essay has been written not altogether in 
vain. It remains for me to append a brief summary of what 
I consider, in general, to be the conditions and remedies 
necessary to the cure of consumption, as the outgrowth of 
my experience. I shall not indulge in any unnecessary reitera- 
tions, and therefore refer the reader back to what I have 
already said on the subjects of diet, green soap, creasote, and 
all other considerations not hereinafter touched upon. 
The air that the lung patient moves in should be — 

First, />"/■'■ ; 

Second, still, or nearly so ; 

Third, th'i a. as that compels an accelerated action of 
the lungs in the effort to inhale the requisite 
quantity of air ; 

Fourth, mil, since warmth enervates; 

Fifth, and last, but not least, dry. 
The surroundings of the patient should afford opportunities 
for varied out door exercise, vigorous walking and hard climb- 
ing. I hold that mere promenading or an ascent so gentle that 
it does not quicken breathing, unless there is danger of a con- 
gestion, to be insufficient. The lungs should be brought to 
heave. When' there is action, the pus is ejected, which is the 
first necessity, and obviates the need of taking pastilles, which 
are liable to upset the stomach, or pectorals, which are apt to 
unstring the nerves. The most efficacious expectorants are 
hilarity, fresh air, exercise, and a sudden change of tempera- 



Care of Phthisis by Hard MountaineeriTig. 271 

ture. In case of very violent coughing fits of long duration I 
believe in a strong Dover's powder. 

The patient should drink plenty of wine at every meal, and 
red wine at that. The latter keeps the stomach in order and 
the head clear. Taken between meals, it sours the stomach. 
He should drink beer, of choice Culmbacher, Augsburger, 
Guinness' stout ; in fact, the stronger beers. I prefer that it 
should be taken only after supper. If thirsty in the day 
time, let him drink brandy and water. The patient should 
drink pure cognac whenever he feels that it is necessary to 
do so : in the extremes of fever and frost, and in bad nervous 
spells. Always after a greater exertion ; or in its stead in 
that case, champagne. After a walk in the cold, and before 
the mid-day meal, I found a glass of sherry or its equivalent 
grateful. Preferably to French brandy under all circum- 
stances, I would recommend old Kentucky rye whisky. 
Scotch and Irish whiskies answer not quite as well as either. 

The patient should smoke as little 'as possible, and abstain 
from indulgence in all stronger drugs, as well as from pas- 
times and pursuits too exciting, such as gambling for high 
stakes. Billiards, croquet, skittles, and the like are legitimate 
amusements ; lawn tennis or rowing are too hard on him. 
He should battle against enervation, listlessness, and lethargy 
always, and instanter. Move about. If the trouble becomes 
chronic, undertake a greater hardship. 

The patient should go to bed as early as possible, but of 
course not too soon after a late supper. Have a pleasant 
evening before you retire. I am not in favour of jumping 
out of bed immediately upon awaking, (live the system time 
to come round, and first gather your senses. Do all the 
coughing and expectoration you have to do before you rise. 
Then drink a pint of milk. Then rise. Sally out into the 
fresh, bracing morning air as soon as possible. If the patient 
is inclined to be at all nervous, he should confine himself to 
one cup of cofiee or tea per diem, and that for breakfast. 
From June to October, drink Weissenburg water or its equiva- 
lent — two tumblerfuls a day — one in bed before rising, before 
the milk, the other after breakfast. Eat plenty of raw fruit, 
by preference for breakfast. In the grape season, eat as many 
grapes as you can stand for breakfast, or at least before the 
mid-day meal. 

High spirits are as necessary as fresh air and exercise. A 
jolly good laugh is the best thing that can happen to a patient. 
Forget that you are ill, remembering only your duties to your- 
self as a patient. Melancholy is poison. The hypochondriac 



27-2 Mi:. Gerner — The Theory and Practice of the 

is never cured. Keep cool. Do not offend if you can help it. 
Do not be offended. Divert and enjoy yourself according to 
your tastes and tendencies. But do not debauch. Teach your 
heart that love and consumption do not go together. Quarrel 
with Cupid, but not with sociability. 

When you enter a room, see that it is properly ventilated. 
If it is not, remedy the want. If you cannot do that, leave. 
Avoid being in the same room with too many people. There- 
fore, do not go to the theatre, to a concert indoors, or other 
like entertainment. Insist upon the proper degree of ventila- 
tion in a waiting room, omnibus, railway carriage, or cabin : 
you have undoubtedly the first right. The patient should 
sleep nights with his window open all the year round. After 
rising in the morning, strip to the skin in an unheated room, 
and sponge down cold: dry carefully with a coarse towel. 
For reasons that will suggest themselves to common sense 
and convenience, the patient should provide himself with a 
hand-euspador for the night, and this should be kept carefully 
disinfected with creasote, carbolic acid, or the like. All cuspa- 
dors should be thus treated. While expectorating tubercular 
mucus, do not let the air you exhale be breathed by anybody 
else. Much less, do not kiss anybody until you are well over 
the expectoration. If you expectorate almost constantly, or 
your breath is offensive, do not kiss anybody, and do not lei 
others breathe the air you exhale. Whatever yon do, do not 
acquire the nasty practice of expectorating into your handker- 
chief. It is much less disgusting in your case to use the 
cuspador. Think of the distribution of the tubercular poison 
throughout the wash of an entire hotel or house, or a number 
of houses. 

The patient should practise rational gymnastics in private 
making such movements as to best inflate the diseased parts. 
If opportunity is ottered, sing loud, but not too much. Ex- 
perience will teach you when to stop. Ten minutes is gener- 
ally enough. The exhilarating qualities of vocal exercise 
cannot be over-estimated. Whistling serves no purpose. 
Purchase a maxima thermometer, and measure the degree of 
fever you have, or imagine you have, with it, and not by the 
pulse, which cannot be relied upon. ( Ibserve periodically how 
much you weigh. If y<>u have gained in weight, it will make 
you happy, and to be happy is a desirable condition. If you 
have lost, you will take it as a danger signal, and behave 
accordingly. Observe whether all your expectoration floats 
in water or not; if any of it sinks, that phenomenon is a 
symptom of tuberculosis puhuonalis. 



Cure of Phthisis by Hard Motuntaineering. 273 

When you feel enervated, take a tablespoonful of china 
wine tincture, or its medicamental equivalent, in a wineglass- 
ful of water ; you will soon use yourself to like this as a 
beverage in lieu of other bitters. In cases of great enervation 
try pancreatic emulsion. When your chest pains you rub 
with oil of turpentine. When your throat is sore, brush it 
with a 3 per cent solution of tannin in glycerine, or gargle 
with carbolic acid water — twelve drops in a small tumblerful. 
When you are very nervous, take half a dram of bromide of 
ammonia. If you feel nauseous of a morning, dip your tongue 
in bicarbonate of soda. When you feel your temperature rise, 
or your energies flag, drink a stiff glass of pure whisky ; take 
it in one draught. 

The patient should, as already intimated, move about in the 
fresh air as much as possible, but he should stay indoors, 
unless he will wear a creasote inhalator while without, 
when — 

First, it is windy. 

Second, it rains. 

Third, it is broiling hot. 

Fourth, it is smoky. 

Fifth, he is feverish. In this case he must not go 
out at all until it is over. 
Riding and driving are very well when you are absolutely 
too ill or weak to walk. Skating and bicycling are always 
salutary unless you have a bad cold. Do not smoke while 
moving in the fresh air. Beware of catching a fresh cold. 
To this end, do not effeminate the system, but harden it 
judiciously, as indicated. 

Last, but not least, have a good physician, whom you can 
have to hand at once if need be. See that he is conscientious, 
painstaking, self-sacrificing, candid, liberal minded, and above 
all, learned in his profession, especially in the nature and 
treatment of lung disease. 

The conclusion at which I have arrived, after years of 
diligent study and experiment, is that tuberculosis pulmonalis, 
or consumption, or phthisis, when it has reached the stage of 
tubercular suppuration is incurable. I do not merely desire 
to convey by this that there is no known cure for it, but I 
mean to assert that no cure for it will ever be discovered. 
The reason is plain: consumption is an ulceration of the lungs 
and there is but one cure for an ulcer, and that is a surgical 
operation. It is evident that no such operation can be per- 
formed upon the lungs. There can be no doubt that every 
specific known to pharmacy has been tried, and in vain. All 
No. 4. T Vol. XXII. 



274 Mb. Nairxe — Abdominal Section as Part of the Surgical 

these are unpleasant truths, and hard truths, but they are 
truths nevertheless. 

Yet this is still no reason for despair. The presence of as 
many as possible of the conditions, and the practice of as 
many as possible of the precautions I have hereinbefore stated, 
will give the patient a long lease of life, and the dread foe 
may be kept under control until a ripe old age. If the disease 
is still in an early stage, and a cure is still possible, the prac- 
tice of what I have advocated will effect it. If it is too late, 
the same practice will ameliorate it, and preserve the sufferer 
in comfort during as many years as possible. 

" See the blind beggar dance, the cripple sing, 
The sot a hero, lunatic a king " — 
The crushed phthisician with his cruel ill 
Content in dragging out existence still. 

That this memoir may deliver at least one sufferer out of 
the hands of ignorant and unconscionable quacks, is the sin- 
cerest and disinterested hope of one who has examined every- 
thing, and has found nothing good to hold fast to. The 
patient who will be deluded by the clever rhetoric of the 
black sheep of the medical fraternity, to be made the victim 
of their absurd, useless, and, indeed, harmful theories and 
treatments, will invariably find in the end that he has been 
tricked out of his money. 

In conclusion, let me beg the reader to take the old adage 
of a stitch in time saving nine fervently to heart, and to give 
me credit for the most disinterested of motives in this record 
of what I know about Consumption. 



ABDOMINAL SECTION AS PART OF THE SURGICAL 
TREATMENT OF SOME DISEASES OF THE AB- 
DOMINAL ORGANS. 

By J. STUART NAIRNE, F.F.P.S.G. 
(A Paper read before the Glasgow Southern Medical Society.) 

V. Hemorrhage — Continued. 
The Cautery. — In regard to the use of the cautery for 
restraining haemorrhage generally, but especially in the pedicle 
of an ovarian tumour, I must say nothing could be more 
foolish than the way in which I have sometimes seen it used. 



Treatment of some Diseases of the Abdominal Organs. 275 

For checking bleeding from surfaces, the application of the 
black hot cautery is most invaluable, and I have frequently 
done excisions of the breast and amputation of limbs without 
the application of a single ligature, by merely searing the 
parts. But I have seen a pedicle of an ovarian tumour, not quite 
so thick as one's little finger, diligently tied, and then carefully 
burned through while an assistant held up the heavy sac. I 
do not object to care and deliberation ; but this was simply 
waste of time, besides increasing the risk of sloughing of the 
stump. Worse still than a waste of time, I have seen the 
actual cautery used to cut through a thick pedicle without 
previous compression, without the use of a cautery clamp or 
any proper means of keeping the heat from injuring the sub- 
jacent and neighbouring parts. I have never seen the actual 
cautery applied, and I do not believe that any one does apply 
the actual cautery, with the single exception of Dr. Keith, with 
an intelligent view as to its rationale in the treatment of the 
pedicle for the suppression and prevention of haemorrhage. 

The application of the actual cautery to the pedicle of a 
tumour requires the use of a cautery clamp. In the Medical 
Times and Gazette, 21st January, 1862, Mr. Clay describes his 
adhesion clamp. The introduction of this apparatus very 
speedily gave rise to the usual amount of discussion as to 
priority of invention. In 1865, Baker Brown illustrated the 
use of the actual cauteiy in ovariotomy. Obstct. Transac., 
vii and viii. 

In 1864, Sir Spencer Wells had done 123 cases of ovariotomy, 
Clay 110, Baker Brown 74, and Keith 20. Of these, Clay and 
Keith had the least mortality, 30 per cent each ; Wells had 32 
per cent, and Baker Brown 43. 

The question as to the cautery and cautery clamp introduc- 
tion lay between Clay and Brown. It is possible, perhaps 
even probable, that they had both come at the thing indepen- 
dently of each other ; but, at any rate, Clay, in the Brit. Med. 
Journal (1866) has made out the most plausible case. Baker 
Brown, however, pushed more on, and urged more forcibly 
the use of the cautery and clamp as part of intra-peritoneal 
treatment. 

While Clay and Brown were using the cautery and closing 
the abdominal cavity, Wells was using the simple clamp, and 
making an extra-peritoneal operation. This embraces the 
period between 1865 and 1867 ; a stormy, wild period, quite 
evidently full of bitter feeling and animosity ; ending some- 
where in a kind of tragedy, melancholy for us in these later 
years to look back on and see how it all did not need to have 



276 Mr. Nairne — Abdominal Section as Part of the Surgical 

been ; and that in the turmoil, as it were, the fundamental 
principles of life-saving surgery were partly lost sight of. 
Every man pursued his own course. Spencer Wells had 
already come to the front, and was doing more work than any 
of the others. In the Brit. Med. Journal for 1866, he 
treated of the various methods of dealing with the pedicle. 
At this time, at the end of 1866, he had done 196 operations. 
Of this number, his first cautery case was done in June, 1866 ; 
and the whole number of cautery cases was six. Of these, 
3 recovered well, 1 was convalescent (died one month after 
operation of peritonitis from an accident), and 2 died. The 
cautery was not a favourite treatment by this distinguished 
surgeon. In 1867 he treated more cases after this fashion — viz., 
14, of whom 2 only died. In 1868 he did not use the cautery 
once, and in fact, did not use it again till December, 1869, in a 
case that recovered. That was the last cautery case of Sir 
Spencer Wells ; and from that time till now he has secured 
the pedicle either with the clamp or by ligature. In 1869 
Baker Brown ended his career, and the adhesion clamp and 
cautery iron of Clay were soon practically forgotten. This is 
the inevitable fate of all innovations in practice that are not 
expiscated clearly on the foundation of principle. Had there 
been promulgated the general principle in surgery, that parts 
restored as nearly as possible to their original condition after 
an operation would be more likely to heal, with half the vigour 
that the war was carried on as to who made or used the first 
clamp or cautery, it would have been much more to the benefit 
of suffering humanity. A principle clearly established, remains 
for ever to guide all men through their work ; but mere 
mechanical arrangements are bound to be constantly variable, 
according to the extent and capability of every man. 

Dr. Keith writes admiringly of Baker Brown and his work. 
" For some time past it has seemed to me that had Baker 
Brown lived, the history of this operation since 1864 would 
have been different. His own method of dealing with the 
pedicle at once lowered the mortality to one-half of that with 
the clamp; and it was becoming practised in London when 
illness came to him, and death. The man and his method 
were quickly forgotten; no one would have the lesson his 
work gave. All were strangely blind in those days to its 
value. Should I not rather say we were all strongly 
prejudiced ? In truth, there is no more startling page in 
surgical history than that in which his latest results are 
given. On one page we have nothing but failures ; on the 
other, by a simple change in the method of operating, an 



Treatment of some Diseases of the Abdominal Organs. 277 

almost uninterrupted line of success. During the whole of 
his professional life he seems to have tried hard to cure 
ovarian disease. From 1851 to 1864 he made many efforts 
and tried many ways, all in vain, till he adopted the cautery. 
His published results show a mortality of less than one in ten 
in completed cases. * I have read somewhere that he lost but 
four of his last fifty operations. Some years afterwards — 
unable to get my mortality much under the one in five, for 
I was then ignorant of drainage — I took to Mr. Brown's 
method in a sort of despair." (Brit Med. Jour., July 31, 1880.) 

This was between 1870 and 1872. Dr. Keith's second series 
of 50 cases were published in the Lancet of Aug. 20, 1870, of 
whom 16 died — a mortality of 32 per cent. The third series 
of 50 were published in the Lancet of Nov. 16, 1872, and com- 
prised cases treated by the cautery ; of these 8 died — a mor- 
tality of 16 per cent. 

As Dr. Keith says himself, in the paper above referred to, 
this treatment was adopted only in the worst cases, or in those 
not suitable for the clamp, so that it was carried out irregularly. 
The results, however, of the first fifty cautery cases alone, pub- 
lished in the Lancet, gave a mortality one-half again of that 
noted above — viz., 8 per cent, and the results since then were 
still better. 

Here, then, in 1870, we find a re-inauguration of the cautery 
which carried along with it the true foundation of success in 
abdominal operations — viz., absolute purity in the operation, 
and complete closure of the abdominal cavity. Since these 
two points have been aimed at, greater success has accom- 
panied every operator, whatever method he has adopted in 
securing the pedicle, so be that the operator had become 
familiar with his own style — had become acquainted with 
every little detail in his own plan, and had sufficient con- 
fidence in his own work to make him deliberate and cautious. 
Sir Spencer Wells never used the cautery much. He did not 
like it, and he had no confidence in it. A man can rarely do 
anything in the working of which he has no confidence. The 
cautery is not applicable to thin broad pedicles, or pedicles 
where there are large blood-vessels, and he feared bleeding ; in 
fact, in the third series of 50 cases detailed by Dr. Keith, one- 
third of the cautery cases bled, but notwithstanding the addi- 

*In 1864 Baker Brown had done 74 cases with 32 of a mortality, giving 
therefore about 43 per cent. This was before the adoption of the cautery. 
[n 1869 he tabulates 111 operations (Med. Chir. Review, Jan. 1869), so that 
from 1864 till the end of 1S6S lie had done 37 cases, treated eliietly by the 
cautery. These figures differ from those quoted by Dr. Keith. 



278 Mr. Nairxe — Abdominal Section as Part of the Surgical 



tional work necessary to check this, the numerical recoveries 
were greater than by the other methods. Altogether, Sir 
Spencer "Wells, out of 1,000 cases, has used the cautery 16 
times ; of these, 14 recovered, giving a per centage mortality 
of 12 - o. The third table (Ovarian and Uterine Tumours, p. 
327) is one of the most admirable pieces of work that any 
man could submit to his professional brethren. Without fear, 
and extenuating nothing, for there is nothing to extenuate nor 
fear, he puts down plainly the simple facts, which will remain 
to teach every one for ever. 

Various Modes of Dealing with the Pedicle and 
Attachments of the Tumour. 

The Wlwle Series of 1,000 Cases. 





Cases. 


Recovered 


Died. 


Mortality 
Per Cent. 


Clamp, ...... 


623 


497 


126 


20-22 


Pin and ligature acting as clamp, 




17 


11 


6 


35 23 


Clamp and ligature, . 




49 


34 


15 


30 61 


Ligature returned, 








260 


191 


59 


26-53 


Ligature brought out, 








14 


6 


8 


57-14 


Cautery, . 








16 


14 


2 


12-5 


Cautery and ligature, 








14 


10 


4 


28-57 


Ecraseur and pin, 








o 


2 






Forceps and ligature, 








1 




i 


100-00 


No ligature — Enucleation, 








3 


3 






Cyst wall sewed to abdominal wall, 




1 




1 


10000 










1,000 


76S 


232 


23-2 



Sir Spencer Wells has been severely blamed for persisting 
in the use of the clamp in the face of his own statistics. It 
is not right for any one to take for granted that a man does 
not value human life so much as they do, because he differs 
from them in opinion or practice. No one could read the 
noble work of Sir Spencer Wells without perceiving that here 
is an honest, fearless man, who will do what he conceives to 
be right in spite of any one ; that he was one born to be a 
leader, and that through his unparalleled energy and daring 
he 1ms done more to clear away the obstacles that lay so 
thickly around abdominal operations than almost all the others 
put together. He has, in fact, cleared the way.* 

He can speak right eloquently for himself, and in words that 
are worth quoting here : "As to the pedicle, there was more hesi- 

* And is clearing and leading it still. In the Brit. Med. Jour., June, 1884, 
he advocates the operation of pneiunotomy in certain conditions of the lung. 



Treatment of some Diseases of the Abdominal Organs. 279 

tation. No one knew exactly what should be done. I tied it, 
and kept the ligatures out through the wound, as others had 
advised. I tied it, and let it drop into the abdomen. I fixed 
it in the wound with a ligature and pins. I secured it outside 
the wound with a clamp. I cauterised it and left it in situ. 
I combined the cautery and ligature. I made a solitary essay 
with the ecraseur, and I conjoined and modified most of these 
procedures. . . . Circumstances sometimes took away the 
ground of option, as when the pedicle was too short to be 
brought out of the wound and clamped. But upon the whole, 
in accordance with what was the then belief, that a tied pedicle, 
whether enclosed or left to drain through an aperture, must 
undergo the process of gangrene and sloughing, the notion of 
extra peritoneal treatment was theoretically right, and it was 
this conviction, together with some practical objections to the 
ligature and cautery, that led me to give the preference to 
fixation externally by the clamp. The greater part of the 
pedicles during this section of my operative work were treated 
in this way. There were no statistics to judge by, but I 
seemed to be doing better with it ; and later on when numbers 
augmented, they proved that the mortality in these cases was 
less than the general average, and vastly lower than that given 
by the ligature. " It is true that the cases I did with the 
cautery turned out well, but they were few in number ; and 
though Baker Brown was doing concurrently still better with 
it, I was not assured of the fact at the time. Besides, it is not 
in the nature of things that one man can guarantee himself 
the same success as another in adopting his practice, especially 
when that practice is a matter of manipulation.-^ And, 
further, I must admit such a want of confidence in the 
efficacy of the cautery as would have morally incapacitated 
me from continuing the operation by such means. Wnether 
right or wrong, then, the clamp gained its ascendency, and I 
continued to use it. It has since been imputed to me that by 
so doing I retarded the progress of ovariotomy, that I deterred 
others from venturing upon an operation involving so fearful 
a mortality as that of one in four or five. But it is easy to 
make such reflections retrospectively, and I can only retort 
that without the leading of the clamp, and the support which 
the clamp results gave to the trial of other surgical expedients, 
some of those who are the successful ovariotomists of to-day 
would never have been ovariotomists at all " (pp. 201, 202). To 
apply the cautery, then, in proper cases, requires considerable 
dexterity. Dr. Keith has himself described how he does it. 
+ The italics are mine. — J. s. n. 



2^0 Mk. Nairne — Abdominal Section as Part of the Surgical 

The tumour being removed, and the pedicle firmly compressed 
by Baker Brown's clamp, the part of the pedicle projecting 
above the blades is slowly burned through on a level with the 
clamp. This process, according to the thickness of the stump, 
takes from three to five minutes. When the clamp has been 
loosened, the part that has been compressed has almost the 
appearance of parchment. If this has been properly produced, 
no bleeding ever takes place. This is essentially a matter for 
experience, for Dr. Keith states that at first nearly one-third 
of his cautery casus bled. If there should be any bleeding, the 
same thing has to be done over again. Should there be no 
bleeding, the pedicle is dropped into the pelvis, and the abdo- 
men closed. 

" Recently (Mr. Alban Doran, St. Bartholomew's Hospital 
Reports, 1877) ligature has been adopted in hundreds of suc- 
cessful cases where the pedicle has been found too short for 
the clamp to be safely applied. Ligatures of bleeding vessels 
in omentum are also cut short. As many as forty ligatures 
have been left in the abdominal cavity without any evil 
effects." 

Mr. Lawson Tait's experience in putting a ligature on a 
pedicle for intra-peritoneal operation is certainly the first. He 
ties invariably with the Staffordshire knot, figured in Plate I. 
Since I have seen him use it, I have tied no other knot, and I 
do not think there could possibly be a better. I may quote 
his own description of how it is done : " An ordinary handled 
needle, armed with a long piece of the silk required, is passed 
through the pedicle and then withdrawn, so as to leave a loop 
on the distal side. This loop is then drawn over the ovary or 
tumour, and one of the free ends drawn through it, so that one 
end is, above, while the other is under the retracted loop. 
Both ends being seized in the hand, they are drawn through 
the pedicle, against which the thumb and forefinger of the left 
hand are pressed as a fulcrum till complete constriction is 
made. A simple hitch is then made and tightened, and that 
is followed by another, as in ordinary ligature tying. . . 
The advantages of this knot over all others are, that while it 
ties the pedicle in two halves, these halves are compressed 
really into one surface." (Diseases of the Ovaries. Lawson 
Tait. 1883. P. 287.) 

So far, then, as intra-peritoneal treatment is concerned, there 
are two good methods of procedure — the best not yet deter- 
mined — the cautery and ligature. Doubtless, it is easier and 
quicker to tie, and it is plain that this is bound to be the 
favourite method for some time at least. But care and 



Treatment of some Diseases of the Abdominal Organs. 281 

rapidity are not everything, and unless with the most extreme 
care an ordinary operator will be sure to kill his patient with 
the ligature by the introduction of septic material. In the 
first 500 cases reported by Sir Spencer Wells, there are 57 
operations with ligature returned, 28 deaths, a mortality of 
4912 per cent. In the second 500, 203 cases with ligature 
returned, 41 deaths, a mortality of 2019 per cent. In August, 
1878, he did his last clamp case,* giving a total of 89 cases 
done intra-peritoneal by ligature, of whom 10 died, giving 11 2 
per cent mortality. 

A table from Mr. Lawson Tait's book, p. 275, gives the fol- 
lowing statistics : — 

Per Cent Mortality. 
Ligature non-antiseptic (187 cases), . . 3 "7 4 

Ligature antiseptic (52 cases), . . . 3'84 

Clamps non-antiseptic (36 cases), . . . 25"00 

Clamps antiseptic (26 cases), . . . 27*00 

This opens up the whole question of antisepticism, which 
will be more fully considered farther on. It is sufficient in 
the meantime to notice that to have success with the ligature 
there must be some special precautions. 

When we are able in all cases to close the abdominal cavity 
so as to exclude the risks of septicemia, and render needless 
any cause for drainage, we shall have reached the perfection 
of abdominal surgery. The elements of this perfection may 
very clearly be stated as — 1st. An operation that does not con- 
vey any septic material, nor allow of any sepsis from without. 
2nd. A method of restraining; haemorrhage without the de- 
struction of parts. 3rd. A method of securing healing by first 
intention. A very special requisite one can see then would 
be a method of securing the pedicle of a tumour in all cases 
safely, antiseptically, intra-peritoneally. The nearest approach 
to gaining all three points is the searing with the cautery iron 
and the use of the cautery clamp ; the next is the antiseptic 
ligature cut short and dropped. The part that is strangulated 
or burned has a chance to die, and consequently to form a 
slough, which must be cast off somehow. In one case reported 
by Hegar, the slough found its way into the bowel, and so out. 
It is quite evident, then, that extra-peritoneal treatment of the 
pedicle or stump of tumour cannot be done entirely away with 
till we have perfect methods of operating and of conducting 
after treatment. The majority of cases of ovarian tumour are 
conducted best by intra-peritoneal treatment of the pedicle, 
with or without drainage ; and so far, at any rate, on the other 
* Up till June, 1880. 



282 Mr. jNairne — Abdominal Section as Part of the Surgical 

hand, the majority of cases of other kinds of tumours, as of 
fibroid of the uterus, are treated more successfully extra- 
peritoncally also with or without drainage. But no one can 
lay down a rule. Every case must be decided on its own 
merits. The leaving on of a clamp of any kind means an 
extra -peritoneal treatment of the part clamped. The part 
embraced by the clamp is so deprived of its blood supply that 
separation of it as a slough is what is expected and aimed at : 
a thing that leaves rather an alarming looking gap in the 
abdominal parietes. This treatment gives a tedious convales- 
cence and continual danger of septicaemia from absorption, 
how carefully soever the case be attended to, or how much 
the stump may be tanned by the application of the perchloride 
of iron. 

Supposing, however, that the pedicle of a tumour requires 
clamping externally, we have the choice of a variety of instru- 
ments. The ordinary clamp of Dr. Clay of Birmingham, of 
Baker Brown, or of Sir Spencer Wells — the calliper clamp will 
do. The legs of the calliper clamp are forced together by 
means of a powerful pair of forceps, and then pinched firmly 
together on the arc of a circle. The objection to this kind is 
the unequal compression of the parts, the part in the apex of 
the triangle being evidently much more compressed than the 
part near the arc before the legs can be anything like parallel. 
Then there is the ordinary twisted wire ligature — Koeberle's 
serre-nceud — and Tait's wire clamp. Tait's wire clamp is 
figured and described in Plate II. This is an excellent instru- 
ment, -end easily wrought by any one who has a turn for 
mechanics. To a large number, however, the variety of parts 
will be confusing ; and in a very thick stump the wires will 
not work smoothly through the first collar. In Plate I,* I 
have figured two wire clamps which, in some measure, are free 
from these defects. In Fig. 1, the screw E, with tube r, are 
taken away, and the parts M and A are left along with the 
loop b as an external support. In Fig. 2 the screw E can be 
taken away with its nut, leaving nothing but the loop of wire 
C, with small collar A. In these clamps there is no troublesome 
arrangement of parts. The wire is simply carried round the 
base, pulled tight, laid in the groove of the collar, and pinched 
there. The handle is then turned, and the wire travels practi- 
cally in a straight line, so that as thick and strong a wire as 
may be necessary can be used. When sufficient compression 
has been obtained, the fixing pinching screw C on Fig. 1 and B 
on Fig. 2 is screwed down, and the operation is completed. 
* Number for Jim e. 



Treatment of some Diseases of the Abdominal Organs. 283 

The wire clamp restrains haemorrhage perfectly ; but if used 
injudiciously, or screwed up too quickly, it is sure to act as an 
ecraseur and cut the tissues. In one case in which I removed 
a large fibro-cystic tumour of the uterus, there was no bleeding 
whatever from the pedicle, which measured nearly three inches 
in diameter, for nine hours. At the end of this time, a vessel 
in the very centre bled, but a turn of the screw checked it at 
once. 

Modified Ecraseur. — Sometimes a tumour is so large as to 
render working about it quite impracticable ; and the pedicle 
of it may be so thick that even the largest pair of pressure 
forceps are insufficient to grasp it and control bleeding, so as 
to permit of its being cut away. Mr. Tait, with his usual 
ingeniousness, in my presence made use of an ecraseur with 
a thick piece of twine, by which he kept up sufficient con- 
striction to control haemorrhage till the tumour was cut away 
and a clamp applied. Acting on this hint, I have had made 
for me a movable head to my ecraseur, permitting the use of 
a good thick cord, without the risk of bruising or cutting into 
the tissue with the point of th& ecraseur. This instrument is 
shown in plate I, fig. 4. The rope is easily applied, easily 
slipped through the holes of the head and then tied over the 
travelling nut of the ecraseur. Perfect control of the vessels 
is obtained by this means. I recently performed an operation 
for removal of an uterine tumour weighing over nineteen 
pounds. Almost the whole cavity of the abdomen and pelvis 
was filled with a solid, universally adherent tumour. But, on 
passing the rope behind it, I was enabled to cut the mass off 
sufficiently low to allow of working room. Dr. Alex. 
Patterson kindly assisted me at this operation, and he can 
testify that the haemorrhage was perfectly controlled and the 
patient lost hardly one drop of blood from the stump. Oper- 
ators know very well that many large solid tumours have 
very slight vascular connections, and it is wonderful what a 
small loss of blood there is in removing them even with very 
inefficient methods of restraining haemorrhage ; but this was 
not the case in this instance, and I have no doubt fatal bleed- 
ing would have at once ensued had I cut off the tumour 
without this previous constriction. Indeed, the use of such 
an apparatus as this is quite invaluable. You can do without 
an additional assistant ; the rope is so easily slipped over or 
behind a tumour, and being so thick it cannot cut the tissue, 
while the slightly curved head prevents any penetration by 
the point of the ecraseur. The diameter of a stump is then 
reduced safely to much smaller limits, and then you can put 



284 Mr. Xairxe — Abdominal Section, as Part of the Surgical 

on the ordinary clamp. Every step is thus rendered almost 
bloodless. 

Sponge Pressure. — In many instances the haemorrhage is 
uncontrollable either because you cannot get at the source of 
it, or if you can get to it you are unable to fix a ligature or 
attach a pair of compressing forceps. You must then be 
contented to apply sponge pressure and wait for a few 
minutes. In one case quoted by Mr. Tait, some large pelvic 
vessels were ruptured and blood was poured out so rapidly 
that death was only averted for a short time by stuffing the 
pelvis with a towel. One would not like such an accident to 
occur with himself, but it may happen with anybody. Sir 
Spencer Wells details a case of his own — he tells all his own 
cases, good and bad — where it was absolutely impossible to 
check the bleeding from an incision into the liver in the 
separation of a tumour, and the patient died forthwith. If, 
however, no very large vessels have been injured, sponge 
pressure and a little patience may succeed. It is really 
wonderful how often it does succeed in putting a stop to 
bleeding. I would have no hesitation from what I now know, 
if I were driven to extremity, and could neither apply a 
ligature nor forceps, to apply a sponge accurately over the 
bleeding part and close the abdominal cavity, putting also 
accurate pressure on the parietes outside. In the course of 
five or six hours, I would probably open and remove the 
sponge. There could be no more fear of septicaemia from an 
antiseptic sponge in the cavity of the abdomen than from the 
presence of a pair or several pairs of forceps. In one instance 
Sir Spencer Wells, by accident, left a pair of pressure forceps 
in for thirty-six hours. They were removed, and the patient 
was none the worse. Tait was unable on one occasion to 
control bleeding deep down in the pelvis. He fixed on several 
pairs of forceps, stitched up the abdomen, opened out several 
hours afterwards, and removed the forceps with the satisfac- 
tion of finding that the bleeding had ceased. Precedent is a 
at encouragement; but, even although these cases had not 
turned out favourably, you would be bound to take some 
such means or any means to prevent your patient dying on 
the spot. In one case I had of removal of an enlarged and 
cystic ovary, the uterus and appendages were so bound down 
by adhesions, and the floor of the pelvis so fixed that I was 
compelled to apply constriction by means of my long ecraseur 
and to leave it in situ for several hours. When it was 
removed the bleeding had ceased. You may depend on it, 
oozing is the most dreadful thino- to have to do with ; should 



Treatment of some Diseases of the Abdominal Organs. 285 

it have no spontaneous tendency to cease, it will invariably 
prove fatal unless you do attend to it. 

Perchloride of Iron. — The local use of perchloride of iron 
requires considerable care. It is specially useful for oozing, 
and as a rule is inapplicable to arterial haemorrhage. The 
free acid in the preparation is a great objection. Marion 
Sims used a preparation by Deleau of Paris, when he was in 
Paris, which was styptic and unirritating ; but when he could 
get it he used the persulphate of iron prepared by Squibb of 
New York, the styptic properties of which he thought superior 
to all other preparations, with less irritation of the neighbour- 
ing parts. The crystals of the perchloride of iron, however, 
dissolved in a little glycerine or pure water, makes a capital 
chemical styptic, and with so little irritative tendency as to 
be applicable to haemorrhages in the abdomen. But on the 
whole, the daubing of surfaces with any chemical agent is a 
clumsy, and frequently unsatisfactory method of controlling 
haemorrhage, except, perhaps, in the case of excision of piles 
or destruction of polypi. 

In extra-peritoneal treatment of the pedicle, however, its 
free application to the stump is imperative. It completely 
tans it, and prevents the putrefactive decomposition of the 
slough. 

Loss of blood during and after operation must be credited 
with a large number of deaths ; but it is astonishing the quan- 
tity of blood some patients will lose and yet recover. In Dr. 
Peaslee's case of double ovariotomy, reported some years ago, 
more than a hundred vessels were tied, and after all there 
was about a pint of blood in the pelvis. The operation lasted 
for five hours, and yet the patient recovered. Some of Dr. 
Keith's cases recently reported were very similar ; pulse in 
the wrist entirely gone for some time, and yet followed by 
recovery. Nil desperandum. An operation, if advanced too 
far to stop reasonably, must never be left unfinished. Every- 
thing must be completed in the most workmanlike manner. 
Vessels must be tied, bleeding must be checked. The very 
salvation of the patient may depend upon the smallest vessel. 
In an operation of this kind one might very properly and 
emphatically say — "Take care of the smaller hsemorrhages, 
the lar^e will take care of themselves." 



286 Reviews. 

REVIEWS. 



Die Fettle ibigkeit (Corpulent) wnd ihre Behandlwng nach 
physiologischen Grwndsdtzen. Von Dr. Wilhelm Ebstein. 
Wiesbaden: J. F. Bergraann. 1884. 

Corpulence and its Treatment on Physiological Principles. 
By Dr. Wilhelm Ebsteix. Translated by Prof. A. H 
Keaxe, B.A. Wiesbaden : J. F. Bergmann. 1884. 

Prof. Ebsteix gives us here an extension of an address 
delivered before the seventh general meeting of the Lower 
Saxon Medical Association in Brunswick, on 3rd June. In 
preparing it for publication, he has so worded it as to adapt it 
" to the capacity of non-medical readers, and above all, to that 
of the scientifically educated circles," a circumstance which 
may possibly account for some of the eccentricities of diction 
noticeable in Professor Keane's translation. 

Ebstein's system of treatment may be described as Banting- 
ism, with these important differences — he enjoins the free use 
of fat, and allows lecmnrinous vegetables. He bases his method 
on the physiological principles laid down by Voit in his works 
on " Tissue change and Nutrition," and on " Diet in Public 
Institutions." Contrary to the teaching of Liebig, Voit holds 
that in the special case of the carnivora no fat is formed 
directly from carbo-hydrates ; but when these are accompanied 
by an abundant supply of albumen, the} r cause fat to be 
separated and deposited from that albumen. " For the carbo- 
hydrates, the bulk of which, owing to their relatively large 
proportion of oxygen, is very rapidly changed by combustion 
in the organism to carbonic acid and water, protect a portion 
of the decomposed albumen from total decomposition, and what 
thus survives is the fat so rich in carbon." It is the fat which 
is thus separated from decomposing albumen which is deposited 
in the body, and not that which may be taken with the food; 
indeed, the author states that it has yet to be proved that any 
of the fat taken as food is deposited in that form in health. 
It is true that fats taken as food may indirectly favour the 
formation of fat from decomposing albumen, " but this danger 
is incomparably less than that arising from the consumption 
of the carbo-hydrates, for the fats, which are converted into 
carbonic acid and water far less readily than are the carbo- 
hydrates, do not promote to any appreciable extent the separa- 
tion of fat from the albumen. Like the carbo-hydrates, they 
certainly diminish the decomposition of the albumen. But 



Reviews. 287 

the albumen which is exposed to decomposition with the 
simultaneous consumption of corresponding quantities of fat, 
is completely decomposed without leaving fat behind." 

Having made quite clear (1) that all fat is not formed from 
alimentary fat, for animals deposit more than they consume as 
food ; (2) that it is questionable whether any alimentary fat is 
deposited; (3) that a too plentiful consumption of albumen, with 
a possibly not excessive use of carbo-hydrates favours obesity ; 
(4) that no danger of obesity arises from using fats with 
albuminates : the author proceeds first to expose the errors of 
those systems which have preceded his own, and then to lay 
down his dietetic rules for the treatment of obesity. "The 
regimen must be so arranged that for the rest of his life the 
patient may adopt and adhere to it." Those who have become 
fat from too generous a diet must consume less food, yet there 
must be produced no abnormal craving for food or diminution 
of capacity for work. Basing on Voit's axiomatic observation 
" that the formation of fat is mostly inconsiderable in the case 
of meat eaters, who consume no non-nitrogenous food except 
fat," he permits the moderate use of fat, and of such fatty 
substances as salmon, pate de foie gras, &c. ; these will reconcile 
"the corpulent gourmet to his other sacrifices." The carbo- 
hydrates are excluded — sugar, sweets, potatoes. Bread is per- 
mitted — 3 to 3£ ounces per day. Of vegetables, he allows 
asparagus, spinach, the various kinds of cabbage, and especially 
the leguminous vegetables, the last-mentioned being valuable 
as conveyors of albumen. All meats are allowed, the fat not 
being avoided. " I permit bacon fat, fat roast pork and 
mutton, kidney fat, and when no other fat is at hand, I 
recommend marrow to be added to the soups." The meals 
should be three — breakfast, with tea or coffee without milk 
or sugar, dinner and supper ; no luncheon or afternoon tea." 
" Of alcoholics, I allow at option two or three glasses of light 
wine, either white or red, at dinner. Beer is banned, unless 
the permitted carbo-hydrates be duly restricted." These rules 
he illustrates by giving the diet scale of a patient whom he 
successfully treated. 

" Breakfast. One large cup of black tea — about half a pint — 
without milk or sugar; 2 ounces of white bread or brown 
bread toasted, with plenty of butter. (In winter about half- 
past seven, in summer about six or half-past). 

"Dinner. (Between 2 and 2 - 30 p.m.) Soup, often with 
marrow; from 4 to Qh ounces of roast or boiled meat, 
vegetables in moderation, leguminous preferentially, but also 
cabbages. Owing to their saccharine constituents, turnips 



288 R ietos. 

were almost, and potatoes altogether excluded. After dinner, 
a little fresh fruit when obtainable. For second course, a 
salad, or occasionally some stewed fruit without sugar. 

" Beverage — two or three glasses of light white wine. 

"Immediately after dinner — a large cup of black tea without 
sugar or milk. 

" Supper. (From 7"30 to S p.m.) In winter almost invariably, 
in summer occasionally, a large cup of black tea without milk 
or sugar. An egg or a little fat roast meat, or both, or some 
ham with its fat, Bologna sausage, smoked or fresh fish, 
about one ounce of white bread well buttered, occasionally a 
small quantity of cheese and some fresh fruit." 

Whether Professor Ebstein's interesting views on fat forma- 
tion are practically to be relied on, can be determined only by 
experience, of which, it is to be noted, the author quotes very 
little. There should soon be plenty of evidence as to the 
exact value of this system, as it will doubtless be very 
extensively tried, having the special recommendation that it 
involves less self-denial than the other systems which have 
gone before it. 

The translation, from which we have made a number of 
extracts, is not on the whole a very creditable performance. 
It bears marks of having been hurriedly produced ; witness 
the too numerous typographical errors and awkward German- 
isms which are to be found in it. A want of familiarity with 
medical terms, or an undue desire to be " understanded of the 
people," has betrayed Professor Keane into the occasional use 
of words which are almost grotesque in their slavish adherence 
to ordinary dictionary equivalents — e. g., for abdomen he very 
often uses the word paunch; "the /"/;</' caul may attain a 
thickness" &c, meaning the omentum: "of the entrails the 
liver is usually," &c. ; "emphysis" for emphysema: "enormous 
pinguidity : " " the midriff and basin of the paunch." The 
last mentioned example occurs on p. 58, and is a blunder in 
translation, " hauchdecken " being rendered as if it were 
bauchbecken. There are also other blunders, of which the 
worst occurs at a part in which special accuracy might have 
been looked for, namely, in the dietetic directions, Ebstein 
being made to say that he allows "the various kinds of 
cabbage and especially the leguminous." A leguminous 
cabbage is a decided 1 lotanical novelty ; here " Leguminosen " 
should have been rendered leguminous vegetables, as indeed 
is done in other parts of the work. " Fette Dinge " is trans- 
lated " succulent things : " the frequently occurring noun 
practice is invariably spelled practise : in the paragraph at the 



Reviews. 289 

head of p. 27, Professor Ebstein's meaning is entirely missed ; 
the translator writes of the " exter. fuel vesculosi ; " and repeats 
Ebstein's blunder when he states that liquor potassas is com- 
posed of equal parts of carbonate of potass and distilled 
water ! 



A Manual of Midwifery for Mid i v i res. By Fancouet Barnes, 
M.D., Physician to the Royal Maternity Charity of London, 
&c. Second Edition, pp. 181. London: Smith, Elder & Co. 

A Short Manual for Monthly Nurses. By C. J. Cullixg- 
worth, M.D., Physician to St. Mary's Hospital, Manchester. 
Pp. 79. London : J. & A. Churchill. 

Both the above mentioned manuals have the same object in 
view — the instruction of midwives and monthly nurses — but 
the former is much the larger and more ambitious, if not more 
practical, work of the two. Dr. Cullingworth's book consists 
of but 79 pages, and is written in a simple, easy style, very 
suitable for the class of women for whom it is intended. The 
directions for treatment are very clear, and distinguished by 
their simplicity and common sense. We feel disposed to join 
issue with the author in regard to treatment of the primipar- 
ous perineum. He says : " In the case of patients who have 
not borne children previously, it is an excellent plan diligently 
to foment the perineum from the very outset of labour, so as 
to render the skin softer and more yielding, and lessen the risk 
of tearing." Most of our readers must have had occasion to 
marvel at the wonderful lubricating and softening power of 
the vaginal mucus, so profusely secreted during labour, and 
we firmly believe that the application of hot fluids with the 
necessary manipulation, has a tendency mechanically to remove 
this valuable secretion just when it is most urgently required. 

Quoting the late Dr. Radford, the author gives rather an 
ingenious method of treating pendulous uterus. After advis- 
ing that the patient should be kept on her back, and a broad 
bandage applied, he says, " After the membranes have ruptured, 
and the waters been discharged, this bandage should be applied 
as follows : The end lying upon the bed is to be fastened to the 
side of the bed, so as to constitute a fixed point, while the other 
end is held obliquely by the nurse, and gradually tightened as 
the child descends into the pelvis. The direction of the pres- 
sure will thus be slightly upwards as well as backwards." 

The instructions given for the preparation of a lying-in bed 
constitute a fair sample of the book as a whole, and are so well 

No. 4. U Vol. XXII. 



290 Reviews. 

worth quoting that we give them in full : " The mattress being 
uncovered, a large piece of macintosh sheeting is to be spread 
over it, and upon this a calico sheet folded several times. 
Next to this should come the clean under-sheet, on which the 
patient is to lie, and upon that another piece of waterproof sheet- 
ing, large enough to reach above the hips. Over this upper mac- 
intosh, and ready to be removed with it after the labour is over, 
are to be then placed a folded blanket and, lastly, a folded cotton 
sheet, both of which should reach well above the hips, so as to 
absorb the discharges. Two pillows are then to be put in the 
centre of the bed, so that the patient may lie with the upper 
part of the body directly across the bed, the hips being as near 
the edge as possible. The upper bedclothing during labour 
should consist of a sheet, one blanket, and a thin counterpane, 
which should completely hide from exposure every part of the 
patient's person, except the head and neck. A long roller- 
towel should be fastened to the bedpost at the patient's feet. 
Nurses often make the mistake of fixing this to the post at 
the opposite corner, or even to one of the posts at the bed's 
head. A very little consideration, however, will make the in- 
convenience of this arrangement apparent. By grasping the 
end of a towel, attached in the way I have recommended, the 
patient pulls herself still closer to the edge and foot of the 
bed ; whereas, by pulling at a towel fastened to one of the 
posts on the farther side of the bed, she drags herself away 
from the very position which it is desirable she should pre- 
serve. The same objection, of course, applies to supplying the 
place of the towel by means of the hands of an attendant 
standing on the left side of the bed. This should never be 
encouraged, as it always has a tendency to displace the patient, 
and to render it difficult for the medical attendant to give 
needful assistance." 

Dr. Barnes' book is, we think, pitched scientifically too high 
for the average midwife. It ought not to be expected of her 
that she should be able to diagnose a pelvis wquabiliter justo 
major. We were told lately by the matron of a large mater- 
nity hospital that she frequently found her best nurses " in 
tears" over Barnes' Manual. Possibly even qualified prac- 
titioners of medicine might be found who, if suddenly called 
upon, would have difficulty in giving the cause, nature, and 
results of a spondylolisthetic pelvis or the obliquely distorted 
pelvis of Nsegeld. 

We are struck by the fact that the author does not enjoin 
the midwife to wash her hands carefully, and anoint them 
with some antiseptic substance, before making a vaginal ex- 



Reviews. 291 

amination. He mentions simply lard, cold cream, oil, and 
vaseline. We think that midwives should be specially taught 
to use antiseptics carefully, as from the nature of their duties, 
and the insanitary surroundings where they practise, they 
may be presumed to run special risk of contamination. 

In breech cases, the nurse is recommended to remove the 
after-coming head by putting her fingers in the child's mouth. 
We had thought that this method was quite antiquated, and 
the much safer and more effectual plan of putting a finger on 
each side of the child's nose universally adopted. 

The volume is illustrated by fifty-one woodcuts, most of 
which are very good, and they are of great importance from 
the fact that the text is thereby made plainer, and teaching 
through the eye is often the more effectual plan. 

Probably this is about the best book of its sort we have in 
this country ; but we are of opinion that there is quite room 
for a simple yet thorough manual for midwives in English, 
such as the Germans have in the Lehrbwch of Spath. 



Manual of Diseases of the Ear. By Thomas Barr, M.D., 
Surgeon to the Glasgow Hospital for Diseases of the Ear, 
and Lecturer on Aural Surgery, Anderson's College, &c. 
Pp.530; 115 Illustrations. Glasgow: James Maclehose & 
Sons. 

Perhaps few departments of surgery have furnished so many 
useful handbooks as that of otology. Indeed, this special branch 
has been of late years so written on that several manuals have 
appeared on individual subjects which rightly appertain to, 
and may well be embraced in, the science of otology. " Noises 
in the head," " nasal and post nasal catarrh," " affections of the 
naso-pharynx," "adenoid conditions of the pharynx," are all 
closely related to morbid states of the middle and internal ear. 
On each of these subjects separate essays have appeared. All 
this but proves the rapid strides which aural surgery has made 
during the past decade. The publication, therefore, of a new 
Manual has induced us critically to examine the work before 
us, to satisfy ourselves to its merits, and judge of its claims to 
take rank as a reliable and ready guide both for student and 
practitioner. We may at once say that this Manual of Dr. 
Barr's contains an amount of general information which is 
equalled by few, if any, of its competitors in this field. Its 
comprehensive and practical character is best seen by a glance 
at the table of contents. The work is divided into four parts. 



292 Reviews. 

Part I contains forty-six pages, devoted to the methods of 
examination of an aural case, which include the steps to be 
taken in examining through the external auditory canal ; the 
Eustachian tube ; the mode of examining the auditory nerve 
and labyrinth, and the application of the tuning-fork as a test 
of the hearing distance, and a description of Politzer's Hor- 
messer. We think that the author might have devoted a little 
more space to the value of the tuning-fork as a diagnostic test 
when referring to it. The advantages claimed by Politzer for 
his acumeter over a watch, Dr. Barr tells us, are — (1.) Greater 
uniformity of sound; (2.) The power we possess of making 
pauses in the production of this sound ; (3.) The intensity of 
the click ; (4.) Greater facility of contrasting its click with 
the voice. 

We cannot say that we recommend the specula (Gruber's 
and Politzer's vulcanite) which he has selected for illustration. 
The general practitioner will, we think, find that the best 
stream of light is conveyed by a modified Toynbee's specu- 
lum, with the tubular end made circular, and the outer portion 
of the funnel wide. These specula are best made, for purposes 
of diagnosis, of silver. So, in practice, the spectacle framed 
mirror will be found far more convenient than the one with 
the head band, figured at page 6, or the hand mirror, page 7. 
Brunton's speculum we may look on as out of date. It is not 
to be recommended to any man wishing to become an expert 
manipulator. We object — even though it be copied from 
Politzer's work — to the engraving at page 24, showing the 
method of Politzerising the tympanum. We contend that the 
bag should be held horizontally, and not vertically, when air 
is intended to enter the tympanum. An inexperienced prac- 
titioner may, by violent compression, injure the delicate 
ethmoidal cells, and cause a frontal catarrh by the latter 
method. There are three capital chapters on the " Causes of 
Ear Disease," " Diseases of the Nose and Throat," affecting the 
ear, and a concise summary of the methods of treatment, in- 
cluding paracentesis of the membrane and galvanisation, with 
directions for the use of the galvano-cautery, both for the ear 
and nasal passages. We miss in this portion of the work more 
special allusion to various instruments for the removal of 
polypi and operations on the mastoid process, which, in a work 
intended as a practitioner's guide, might have been usefully 
inserted. Parts II and III are devoted to affections of the 
external and middle ear. 

The practitioner will find in this portion of the work most 
valuable information to guide him in the diagnosis and treat- 



Reviews. 293 

ment of those commonly occurring, and most tedious, func- 
tional and organic troubles which arise from Eustachian and 
throat complications. We specially commend the chapter 
devoted to chronic suppurative disease of the middle ear, and 
the consequences of caries and necrosis in producing cerebral 
and cerebellar inflammation and abscess. Some excellent 
plates represent different diseased states of the temporal bone. 
A number of useful formulas complete the work. In this rapid 
survey of the book we are not to be understood as in any 
measure doing justice to the excellent information it contains, 
the clear and concise manner in which it is imparted, and the 
evidence afforded throughout its pages of the practical know- 
ledge of the author. Glasgow has every reason to be proud 
of the position held by her surgeons in otological work and 
research. She has lost recently one who might fairly be 
styled the facile princeps of British aurists in the person of 
Patterson Cassells. In the great work of Politzer, translated 
by him, he has left a permanent record of his devotion to the 
branch of surgery which he worked so arduously and success- 
fully. We may, however, congratulate the Medical School of 
Glasgow in having a successor to Cassells who promises fully 
to maintain its reputation in this special field. 

This Manual of Dr. Barr's, complete as it is in useful and 
practical information, clearly and concisely imparted, is as 
valuable and condensed a summary of otological work as exists 
in the English language. It is neatly bound, convenient in 
size, clearly printed on good paper, and the illustrations are 
well executed. Altogether, it reflects credit both on the author 
and publisher. 



1. A Manual of Hypodermatic Medication. By Roberts 
Bartholow, M.A., M.D. Fourth Edition. Philadelphia: 
J. B. Lippincott & Co. 1882. 

2. Manuel des Injections Sous-cwtanees. Par Bourxeville 
et Bricon. Paris : A. Delahaye & E. Lecrosnier. 1883. 

The title of Dr. Bartholow's book at once challenges criticism. 
In the preface it is stated that the substitution of the term 
hypodermatic, for the familiar word hypodermic, is "urgently 
demanded in the interests of a correct nomenclature," and 
doubtless the former term is classically correct, — it scarcely 
needed the authority of " that eminent philologist and 
oriental scholar, Mr. Fitzedward Hall, D.C.L.," to assure us of 
that. But we question very much the propriety of touching 



294 Reviews. 

an old landmark without a more "urgent demand" than 
exists in this case ; particularly as the author apparently finds 
some difficulty in extending his reform to such allied words as 
< n dermic and epidermic, which need trimming quite as much 
as hypodermic, and which he uses in their old form; and 
further, it is not easy to see how any one setting up as a 
purist in this matter, as Dr. Bartholow does, can permit 
himself to write such an utter barbarism as " subdermic!' 
The author is certainly not seen at his best as a philologist. 

Apart from such considerations there is little but praise to 
award to this book. It is full, systematic, and apparently 
accurate. The author begins with an interesting history of 
subcutaneous medication, and an account of this method of 
administering drugs, the solution, the instrument, and the 
mode of injecting. Here he gives evidence of wide reading and 
ample experience, though it tends to make one mistrustful of 
the author's accuracy to find Eulenburg's much-quoted name 
spelt incorrectly throughout the entire work. The practical 
hints which the author gives are of great importance ; but he 
omits one of the most important of all — to make certain that 
the instrument used is accurately graduated. A year or two 
ago a contributor to this Joormd wrote that, of five instru- 
ments examined by him, only one was correct ; one which was 
graduated to hold 15 minims held 22, and another indicating 
22 held 15 — discrepancies which might occasion both dis- 
appointment and accident in the administration of powerful 
drugs. 

The author prefers extemporaneous to permanent solutions, 
and advises the use of pellets, tablets, or powders, each con- 
taining a dose. In this we believe he is wrong ; permanent 
solutions are handier, and if properly made and kept, never 
give rise to the " hard nodules and the points of suppuration 
ainl sloughing," which he associates with them. One of the 
undoubted drawbacks to permanent solutions is their liability to 
decomposition and to the growth of a fungus, the penicillium. 
" This plant grows partly at the expense of the alkaloid, 
and hence, whilst the solution increases in turbidity, it declines 
in power." The addition of antiseptics to the solution is 
suggested as a preventive of this — 2 to 8 minims of carbolic 
acid to the ounce ; or 2 to 4 grains of salicylic acid to the 
ounce ; or resorcin may be substituted for the salicylic acid. 

A tolerably uniform order is followed in the discussion of 
the various individual drugs. Thus, with regard to morphia, 
there is described first the preparation, that which is recom- 
mended being the sulphate, on account of its stability and 



Reviews. 295 

solubility ; then dose, physiological actions, accidents, therapy, 
antagonism, the opium or morphia habit and its treatment. 
And a somewhat similar plan is follow ed in treating of the 
other drugs used hypodermically. The sections on antagonism 
are particularly interesting, and are well worth study ; they 
are transferred almost word for word from the author's well 
known work on that subject. 

On the whole this may be recommended as the handiest 
and best work in English on hypodermic medication. 

2. To those who are sufficiently familiar with the French 
language, Bourneville and Bricon's Manuel, one of the 
publications of the Progres Medical, will prove even more 
satisfactory than the foregoing. It does not treat of pre- 
liminary matters quite so fully as Bartholow's work, but it 
discusses a vastly larger number of drugs as used hypo- 
dermically, and is thus of more value to one who is already 
familiar with the method. The names of its authors are a 
sufficient guarantee of the accuracy and general reliability of 
this excellent manual. 



Caffeine bei Herzkrankheiten. Yon Professor Dr. Franz 
Riegel. Weisbaden : J. F. Bergmann. 1884. 

This is a very careful study of the action and uses of the 
caffeine preparations in heart diseases. It is reprinted from 
the transactions of the third Congress for Internal Medicine, 
1884, and is accompanied by various diagrams and numerous 
pulse-tracings. 

Professor Riegel has a high opinion of the caffeine prepara- 
tions, and writes very favourably of them. At the end of this 
pamphlet he thus sums up the principal results of his 
investigations. 

" 1. Caffeine is to be regarded as a regulator of the heart's 
action, and a diuretic in the same sense as digitalis. 

" 2. In appropriate dose, and when a suitable preparation is 
usecL it increases the force of the heart's contractions, slows the 
heart's action, and increases the arterial blood pressure. These 
effects appear very quickly after administration of the remedy. 

" 3. It acts rapidly as a diuretic. 

"4. The indications for the use of caffeine coincide in 
general with those for the use of digitalis. 

" 5. It acts best when administered in frequently repeated 
small doses, not in one large dose. In the majority of cases 
1 gramme to 1*5 gramme (loi to 23 grains) of a double 



296 Revieivs. 

salt of caffeine, given daily, will suffice, though it is better 
to begin with smaller doses. 

" 6. Caffeine differs in action from digitalis chiefly in this 
respect, that it acts much more quickly, and is not 
cumulative in its effects. 

" 7. In many cases in which digitalis fails, caffeine is still 
effective ; in cases, therefore, in which the former drug has 
proved inoperative, the latter is indicated. 

" 8. The simultaneous administration of narcotic drugs, 
especially morphia, is not to be recommended ; caffeine itself, 
inasmuch as it removes the disturbances of compensation, is 
the best narcotic in such cases. 

" 9. Caffeine is in general well borne by the patient, often 
better borne than digitalis. This is specially true of the very 
.soluble double salts, the double benzoate, salicylate, or amylate 
of caffeine and soda ; these salts also, on account of their ready 
solubility, are particularly well adapted for subcutaneous 
injection." 

It is interesting to find that Riegel's experience as to the 
most reliable form in which to prescribe caffeine, is quite in 
accord with that of other competent observers. It cannot be 
too widely known that experiments with, or results obtained 
by the use of the so-called citrate of caffeine are utterly 
misleading as to the true power of the drug ; and that the 
preparation sold as citrate is simply a variable mixture of 
citric acid and caffeine, and therefore not trustworthy. For 
interesting and precise information regarding caffeine com- 
binations, and directions for the easy preparation of the above 
mentioned double salts, the reader is advised to consult a 
translation and condensation of a valuable paper by Tanret in 
this Journal, vol. xvii, p. 301. See also last number, p. 238. 



Materia Medica: A Manual for the Use of Students. By 
Isambard Owen, M.D. London : J. & A. Churchill. 1883. 

If the medical student of to-day fails to carry about in, his 
mind all the essential facts of the subjects he is required to 
study, this cannot be said to be due to any want of "aids," 
" guides," " manuals," " handbooks," and so on, in which every 
one of these subjects has been compressed into the smallest 
possible bulk, and so systematized as to be easily remembered. 
So long as admission to the profession is by examination only, 
it is to be expected that the aspirant to the possession of a 
diploma will frequently resort to these aids to memory. And 



Reviews. 297 

this is not to be altogether decried, if the student does not 
trust wholly to such guides, but uses them simply as a means 
of refreshing his memory and recalling facts learned from 
larger and fuller treatises. Further, in dealing with such a 
subject as materia medica, which presents a mass of dry and 
apparently unconnected facts for digestion, any work which 
simplifies the study, or arranges it in a scientific way, will be 
welcomed as of distinct value. 

Dr. Owen's Manual is one of many similar works which 
have recently appeared — in all of which the importance of the 
dry facts of materia medica, and the necessity for properly 
arranging them, have been amply recognised. It is one of the 
best works of its kind, and may be recommended as full and 
reliable in the information it conveys. The author's intention, 
to place before the student the outlines of the subject "in such 
a manner that they may be clearly grasped and readily com- 
mitted to memory," has been successfully carried out. 



The Different Aspects of Family Phthisis in Relation espe- 
cially to Heredity and Life Assv.rance. By Reginald E. 
Thompson, M.D. London : Smith, Elder & Co. 1884. 

This work is stated by the author to be based on evidence 
derived from the records of the Hospital for Consumption 
and Diseases of the Chest at Brompton. The material at 
command in that hospital must be recognised as unexcelled 
in this country, and it may be at once stated that our author 
seems to us to have made use of it in an honest and workman- 
like fashion. The first part of the work is taken up with the 
massing of facts as to the influence of heredity in its various 
forms. We have first a comparison between the general 
features of acquired phthisis and hereditary phthisis, and 
then a comparison of the various forms of hereditary phthisis 
among themselves. It is impossible, in the short space at^bur 
command, to give anything like a sufficient resume of the 
well argued conclusions to which the author comes, but we 
may briefly indicate a few of the main points, referring our 
readers to the work itself for evidence. 

There can be no question that heredity plays an important 
part in the causation of phthisis. Not only are persons with 
a hereditary taint more disposed to the disease, but they are 
liable to attack earlier in life. In a certain sense it may be 
said that females in general are hereditarily predisposed to 
phthisis, inasmuch as, even in cases where the disease is 



298 Reviews. 

acquired, they are attacked on an average earlier in life than 
males, and succumb more readily. In other words, females 
are constitutionally more susceptible than males, and when 
attacked, offer less resistance. This has to be borne in mind 
in estimating the influence of inheritance, for inheritance has 
the effect of placing the male in a position similar to that of 
the female, reducing his power of resisting the disease. 
In this sense heredity has a more potent influence on the 
male than the female. This applies especially to inheritance 
from the mother as compared with that from the father ; for 
though the paternal influence seems to extend to a later 
period of life, the maternal influence is more intense, causing 
a liability earlier in life, and a greater virulence in the disease. 
The influence of atavism is not overlooked, and it is to be 
remembered that in phthisis, as in other forms of disease, 
either parent, but especially the mother, may transmit the 
disease without personally having been affected. 

In the chapter on life insurance, the practical influence of 
inheritance on the expectation of life is worked out in an in- 
genious fashion, and working rules are suggested by which to 
deal with cases in actual insurance practice. We observe that 
the author favours the plan by which, instead of adding to the 
premium payable by the person with a phthisical heredity, the 
amount payable at death is reduced in certain proportions for 
a number of years after insurance. Thus, a young man of 29 
applies for insurance with such a family history as to induce 
the medical examiner to suggest the addition of 7 years to his 
life. But instead of this, the company agrees to pay on certain 
principles which we need not enter into, but the practical out- 
come of which would be that, if the patient died in the first 
year after insurance, his heirs would get, in place of £100, 
£49, os., if in the second year £50, 14s., and so on till, if he 
lived 35 years, the full sum of £100 would be due. 

We have no doubt that the book will take its place as a 
standard work on the subject with which it deals. 



Tobies of Materia Mediea. By T. Lauder Brunton, M.D., &c. 
London : Macmillan & Co. 1883. 

This is a new edition of Dr. Brunton's well known and valu- 
able Companion to the Materia Medico, Museum. It is not 
intended to take the place of the usual text-books, but to 
recall to mind, in a systematic way, what has been learnt 
from these. 



Revieivs. 299 

The introduction to the tables is of special value, indicating 
to the student a mode of study by means of which the hetero- 
geneous and apparently unconnected facts of the materia medica 
will be brought out in their true relation to each other. A 
full scheme is sketched which, if closely followed, will give to 
the student a thorough knowledge of any specimen which may 
be presented to him, the name, source, mode of preparation, 
and physical properties of the drug being first noticed ; then 
its reactions, impurities, physiological actions, elimination, 
therapeutics, official preparations, doses, incompatibles, and 
mode of administration. A classification of the articles of the 
materia medica follows, with an index of substances liable to 
be mistaken for one another ; then come a series of questions 
on materia medica and therapeutics, and the tables which form 
the bulk of the work. 

This is a book which may be commended to the notice of all 
who are much in the materia medica museum, and who wish 
to have the object of their study brought before them in a 
systematic, intelligible way. 



A Manual of Diseases of the Throat and Nose, including the 
Pharynx, Larynx, Trachea, (Esophagus, Nose, and Naso- 
pharynx. By Moeell Mackenzie, M.D. Vol. II. Dis- 
eases of the (Esophagus, Nose, and Naso-Pharynx. London : 
J. & A. Churchill. 1884. 

In noticing the first volume of this work shortly after its 
issue in 1880, we were able to express a highly favourable 
opinion of its merits. The second volume now before us 
enables us to confirm this opinion. We have here sections on 
the gullet, the nose, and the naso-pha^Tix, and throughout we 
have the same exhaustive treatment of the subject which was 
observable in the first volume. It is proper in a monograph 
on a special subject that not only the author's own experience 
should be given, but that the literature of the subject should 
be stated. This is the more important when the subject is so 
much of a modern one as that considered in these volumes. It 
is gratifying to notice, therefore, that Dr. Mackenzie seems to 
have read almost everything that has been written on the various 
departments treated of here, and the index of authors quoted 
is a remarkably formidable list. He has not read everything, 
however, and we would call his attention to an omission. 
Under the heading "ulcer of the gullet," he states that "none 
of the cases hitherto recorded present any analogy to the 



300 Reviews. 

simple c perforating ulcer of the stomach.' " In this Journal 
for April 1883, there is a case recorded of undoubted perforating 
ulcer, and several other cases are there referred to. In Coats' 
Manual of Pathology an illustration is given of this specimen, 
which is preserved in the museum of the Western Infirmary. 

There can be no question that this work will take the first 
rank on the subject treated of, and we doubt not of its complete 
success. 



Lectures on the Diseases of Infancy and Childhood. By 
Charles West, M.D. Seventh edition; revised and en- 
larged. London : Longmans, Green & Co. 1884. 

Traite Clinique et 'pratique des Maladies des Enfants. Par F. 
Rilliet et E. Barthez. Troisieme edition. Entitlement 
refondue et considerablement augmentee. Par E. Barthez 
et A. Sanne'. Paris : Felix Alcan. 1884. 

Recherches Cliniques sur les Maladies de Venfance. Par le 
Dr. Henri Roger. Tome second. Paris: Asselin et Cie. 
1883. 

We have no intention of reviewing the works noted above, 
but we have great pleasure in calling the attention of our 
readers to the fresh issues by such well known names in the 
department of the Diseases of Childhood. 

The well known lectures of Dr. West appear in a form 
quite entitled to the description " revised and enlarged." The 
results of many recent investigations are given in the text or 
referred to in foot notes ; and everywhere there is evidence of 
an active mind surveying the advances in a well known field. 
One of the most striking changes is the formal withdrawal by 
the author of his opinion regarding the non-identity of croup 
and diphtheria. This is expressed so well that we quote his 
words : — 

" In all the business of daily life we decide upon the balance 
of evidence ; and this, I think, warrants the belief that for all 
practical purposes membranous laryngitis, or membranous 
croup, must be regarded as the outcome of diphtheria, and 
consequently as essentially different from catarrhal croup or 
catarrhal laryngitis — the laryngitis stridula of French authors, 
of which I shall have to speak in a future lecture. Diph- 
theria, then, is the disease — croup but one of its symptoms ; 
not by any means constant in its occurrence, varying greatly 
in its severity, but at the same time the most frequent, as well 
as the gravest, local manifestation of the affection. I have 



Western Infirmary. 301 

been well nigh fifty years in coming to this conclusion. I do 
not know that my confession of faith loses in value because I 
have been a tardy convert to my creed." P. 413. 

The first volume of a new edition of the great work of 
Rilliet and Barthez awakens great hopes. This is truly called 
the third edition, for although an edition was issued in 1861,. 
it was really a second issue of the second edition. M. Barthez, 
as the surviving author, along with M. Sanne, now attempts a 
complete revision of the work. This revision extends to a 
rearrangement of the classification formerly adopted, which 
always seemed to us somewhat cumbrous and inconvenient; 
they follow now the group of " systems ; " the present volume,. 
in addition to general considerations, takes up the Nervous 
System and the Respiratory System. We have not yet had 
time to go over the various chapters in this volume, but from 
the portions we have examined we are inclined to hope that 
this new edition will be not unworthy of the great reputation 
of the original work, although such a revision is, no doubt, 
attended with great difficulties, and with the danger of losing 
the character of definite personal experience so noticeable in 
the first and second editions. 

M. Roger has now managed to issue the second volume of 
his Recherches Cliniques. This new volume deals with Infan- 
tile Syphilis and Whooping-Cough at great length, and there 
are shorter sections on the Auscultation of the Head and on 
Trenia in Children. On these subjects, the matured opinions 
of such an accomplished worker in this department of medi- 
cine must be received everywhere with the respect due to his 
deservedly great reputation. 



REPORTS OF HOSPITAL AND PRIVATE 
PRACTICE. 



WESTERN INFIRMARY. 

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

From Professor M'Call Anderson's Wards. 

i. — case of generalised psoriasis cured by the applica- 
tion of chrtsophanic acid, according to the method of 
AUSPITZ. — [Reported by Mr. Stafford, M.B., House Physician.] 



302 Hospital Practice. 

"William Stewart, set 15, was admitted to Ward V on June 2, 
1884, suffering from an eruption which covered the scalp, the 
trunk extensively, and to a less degree the limbs. 

Family History. — His mother died of pneumonia, aged 47. 
His father is alive and healthy. A brother, aged 20, is at 
present in one of Dr. Cameron's wards, suffering from disease 
of the elbow joint. The other members of the family — three 
in number — are healthy. His maternal uncle had a similar 
eruption at the age of 13 or 14. When 7 years old he had 
sore eyes, and when very young he had an abscess in the thigh 
which has left a cicatrix. With these exceptions, he has en- 
joyed good health. 

The present ailment first appeared two years ago on the 
back of the head in little white patches, which gradually be- 
came larger, coalesced, and latterly covered the whole scalp. 
About a month afterwards, it appeared on the lower part of 
the back, and in a short time it involved the chest, arms, and 
legs in succession. He improved slowly during the winter, 
but in the following spring it returned, and disappeared last 
winter. The present attack made its appearance at the New 
Year. 

Present Condition. — Patient is a very healthy looking, well 
built lad. The body is extensively covered with typical 
psoriasis patches. The elbows and knees are not markedly 
affected. The whole scalp is thickly covered with white scales, 
and the hair is scanty and easily pulled out. The general 
health being good, and arsenic having been ineffectually ad- 
ministered previous to admission, no internal remedies were 
given, and the skin affection was treated by the method of 
Auspitz, as follows : — 

The scales were removed from a part of the left upper arm 
by means of a warm bath, and friction with pumice stones. 
When dry, the part was painted over with a mixture of chry- 
sophanic acid and chloroform (15 per cent). The chloroform 
evaporated, leaving the acid lying on the skin in a finely 
divided state. It was then fixed by being painted over with 
a thin layer of traumaticine (gutta-percha dissolved in chloro- 
form 10 per cent). 

On the third day after the application, the gutta-percha 
began to peel off in places, and this peeling was apparently 
due to the loosening of the scales, for on the smoother skin 
the gutta-percha remained longer. With the exception of a 
sharp burning sensation at the time of application, this treat- 
ment gave no discomfort. Dr. Anderson thereupon suggested 
that one side of the body only should be treated. On 7th June 



Western Infirmary. 303 

the left side of the trunk, and the affected parts of the left 
arm and leg were painted in the manner described. It re- 
quired to be repeated in four days. This treatment appeared 
almost at once to check any further progress of the eruption 
and to prevent the re-appearance of new spots. 

14-th June. — A small abscess the size of a nut has appeared 
in the right axilla, which is a little painful on movement of 
the arm. It disappeared spontaneously in a few days. Patient 
says he had one like it before which also went away of its own 
accord. 

27th June. — Since the commencement, the treatment has 
been repeated every four or five days. To-day very marked 
improvement is seen on the left side, where the scales have to 
a great extent disappeared, and their disappearance has fol- 
lowed the natural course, i. e., they have disappeared entirely 
from the centres of the patches, leaving them soft and smooth, 
while the edges are marked by a margin of white scales, giving 
a serpiginous appearance to the eruption. Improvement is 
also manifest on the right side, which has never been treated. 
Here the scales have fallen off to a great extent, and there has 
been no sign of fresh outbreaks. It is also noteworthy that 
the greatest improvement on this side is nearest the middle 
line. This is well seen on the back, where the scales were 
exceedingly numerous. For nearly three inches to the right 
of the spine the skin is smooth and free from scales. The 
scalp, too, to which no application was made, has completely 
recovered, and the hair has ceased to come out. 

Treatment was confined to the left side till 9th July, when 
the remains of the spots on the right side were likewise 
attacked. 

18th July. — Dismissed well. 

Remarks by Dr. Anderson. — The treatment adopted in this 
case illustrates two things — 1st, that in this way we can use 
chrysophanic acid externally without staining the linen in 
the very least, thus removing the most serious drawback to its 
use ; and 2nd, that chrysophanic acid, applied externally, has 
both a local and a constitutional effect, the local effect being 
shown by the more speedy improvement on the side operated 
upon, the constitutional by the simultaneous improvement on 
the other side and upon the head, with which none of the acid 
came in contact. 

II. — CASE OF MYXCEDEMA, VERY CONSIDERABLY IMPROVED BY 

treatment. — [Reported by Mr. Stafford, M.B., House Phy- 
sician.] Elizabeth Gibson, ait 20, weaver, was admitted into 



304 Hospital Practice. 

the Western Infirmary 20th May, 1884, complaining of great 
weakness, swelling of the legs and feet, shortness of breath, 
and " shivering in the inside." A year ago, the menses having 
ceased for twelve months, the first symptom of her complaint 
was noticed — viz., swelling of the face and lower extremities. 
It was always very marked in the face on rising in the morn- 
ing, but towards night it had a tendency to diminish in the 
face and to appear in an aggravated form in the legs and feet. 
Her work necessitated her standing nearly the whole day, and 
when she went home in the evening, the legs and feet were 
quite sore and tender. About this time her friends told her 
that she was growing stout. 

She also noticed that she was passing less water than usual, 
sometimes only a small quantity, which was high coloured, 
once in the day. The appetite failed, but she became very 
thirsty. She also began to suffer from headaches, which 
began in the right temporal region, and soon extended over 
the whole forehead. 

She states that the pain caused a swelling to appear on the 
right side of the head, and after its appearance the pain sub- 
sided. The pain generally lasted one or two hours, and was 
usually worst at night. The hair became very loose, and came 
out freely on combing. The skin became harsh and rough, 
especially that of the arms, which was sore and cracked, and 
this condition was irrespective of weather, being as bad on 
mild and warm as on cold and wet days. She never perspired. 
After the above symptoms had lasted for about eight weeks, 
the menses re-appeared, and it was about that time, she thinks, 
that she first experienced the sensation described by her as 
" shivering in the inside." Although at the time it was warm 
summer weather, when at work she would become pale, the 
teeth began to chattel-, and she shook so that she could not do 
her work properly. When she rose in the mornings, the feet 
were quite cold, and she did not get warm till the afternoon. 
She then grew hot all over, and the face became flushed for 
three or four hours. Menstruation was very irregular. She 
sometimes went three months without any flow, but at the 
periods she suffered from extreme lassitude, and occasionally 
fell asleep at her work. 

Six months after the onset of the complaint (at the New 
Year) bodily movements began to be slowly performed. She 
began to speak with a drawl, to such an extent that her 
friends spoke about it. Any slight exertion brought on 
breathlessness, and she says she walked slowly to avoid it. 
Previously her movements and speech had been brisk. As 



Western Infirmary. 305 

the disease advanced, she slowly got weaker, and on the day 
of admission she could scarcely stand. 

Previous History. — When fifteen years old, she had a slight 
attack of scarlet fever, and on going to her work before she 
was well, dropsy ensued. She became very ill for three 
months, and had convulsions at one time for forty-eight hours 
consecutively, but she ultimately made a good recovery. She 
had measles and hooping-cough in infancy. The patient is 
the eldest of a family of ten. Two brothers and two sisters are 
alive and healthy, two were dead born, and two died of measles. 
The causes of death of the rest are not ascertainable. Her mother 
died, aged forty, of phthisis, but her father is alive and well. 

On 26th November, 1883, she was admitted into the wards 
of one of Dr. Anderson's colleagues, and her affection is called 
in the journal "Acute Bright's disease." The report mentions 
pain in the head, swelling of the right arm and leg, shortness 
of breath, amentia, and absence of albumen in the urine. She 
was dismissed 19th January, 1884, "much improved." 

Condition on Ad/mission. — Patient is short and thickset in 
build, and says that her parents and all her brothers and sisters 
are short. Her appearance reminds one of renal dropsy, but 
the cheeks and lips have a slightly livid colour. The features 
are thick and coarse, and the general look stupid and apathetic. 
She complains of excessive weakness. The legs and feet look 
cedematous, but prolonged and firm pressure scarcely yields 
any pitting. The skin, especially of the legs and arms, is very 
coarse. The hands are short and broad, but can hardly be 
called spade-like. She speaks with a slow monotonous drawl. 
She walks slowly and deliberately, with a curious kind of 
" waddle." She takes a long time to write down a few words. 
Notwithstanding these delayed physical movements, she is 
intelligent, and the operations of the mind do not seem to be 
impaired. For a week after admission, she was kept in bed, 
and a placebo given. 

The following treatment was then adopted : — She was sham- 
pooed daily for half-an-hour, olive oil being used. Every third 
day she had alternately the following treatment : — First day, 
a vapour bath ; second da} r , quarter-grain of pilocarpin hypo- 
dermically ; third day, a hot electric bath for half-an-hour. 
She also took a mixture containing arsenic and strychnia. 
Each of these three methods of treatment made her sweat 
profusely. The rough character of the skin was now mm li- 
very evident, for during the shampooing the noise of the 
friction was heard a considerable distance from the bed. and 
the operation made the nurse's hands quite sore. The hypo- 
No. 4. x vol. xxir. 



306 Hospital Practice. 

dermic injection was inserted into the buttock, the part being 
previously frozen with ice and salt. It was noticed that the 
patient's skin took an unusually long time to freeze. In ten 
days improvement began to take place. The most marked 
change, perhaps, being in the condition of the skin. It became 
smooth and soft, and when pinched, felt almost quite natural. 
As regards subjective symptoms, she says that she felt warmer, 
and that the headache and " shivering in the inside " completely 
disappeared. 

8th June. — Menstruation, which had been absent for four 
months, began to-day very freely, and she feels ill and weak. 
All treatment, except the medicine, stopped. 

16th June. — Full treatment was recommenced. 

30th June. — Xo further improvement is noted. She seems 
very comfortable, and is inclined to sleep a good deal. The 
cheeks are usually pale, but sometimes of a bright crimson 
colour. 

7th July. — From the first, patient objected very strongly to 
the electric bath, and for some time used to cry while she was 
in it. She says it "frighted" her, but she had no other ground 
for complaint. To-day, however, she refused to have it any 
longer, and said she would rather leave the hospital than have 
it repeated. It was accordingly stopped, the other treatment 
being continued. 

Hth July. — To-day the first stage of herpes zoster is noticed 
aloncr the course of the left lower intercostal nerves. Patient, 
however, did not feel any pain or inconvenience, and the erup- 
tion was first noticed by the nurse. 

19th July. — Well formed vesicles have appeared in four or 
five small groups. A sensation of heat in the neighbourhood 
is complained of. The eruption was covered with a layer of 
cotton wool. This skin affection probably resulted from the 
use of the arsenic, which is well known to favour the occur- 
rence of zona. 

She left the Hospital on 8th August of her own accord, 
when the following notes were taken : — The swelling of the 
face and feet, which were noticed on admission, in the morn- 
ings, has entirely ceased. She passes varying amounts of 
urine (40 to 60 oz.), normal in character. The appetite is good. 
There is no headache. The skin has become soft and smooth. 
There are no "shiverings in the inside" now. The menses 
have not appeared since loth June. Her movements are now 
more actively performed, but brisk walking brings on the 
breathlessness. Her friends say the drawl is much less than 
it was. There is a sallow look about the complexion, but with 
a little colour in the cheeks. Says she is " an awful lot better." 



Medical Items. 307 

MEDICAL ITEMS. 

UNDER THE DIRECTION OF 

ALEX. NAPIER, M.D. 

Antipyrin, a new Antipyretic. — This is another of those 
synthetically obtained alkaloids, a chinolin derivative, not dis- 
tantly allied to kairin and kairolin. (See this Journal for 
October last.) It was produced first by Dr. Knorr of Erlangen, 
and has been largely experimented with by Prof. Filehne, who 
has, as is well known, been long engaged in the search for an 
ideal antipyretic, one which will reduce the temperature with- 
out prejudicially affecting the system. Antipyrin seems to 
come nearest to such an ideal. 

In the Berliner Klin. Wochenschrift, No. 20, 1884, Dr. Paul 
Guttmann gives an interesting account of a series of experi- 
ments he made with this new drug, in the hospital at Moabit, 
of which he is the head. The cases in which it was given 
were 27 in number, and included patients suffering from pneu- 
monia, enteric fever, scarlatina, relapsing fever, erysipelas, 
small-pox, measles, pleurisy, phlegmon, and phthisis. The 
temperature throughout the experiments was taken every two 
hours during the night, and hourly during the day, usually in 
the rectum, though occasionally in the axilla. The general 
result was that antipyrin was found, in quantities of 4 to 6 
grammes ( 3 i to 3 i ss X to have a constant and usually a consid- 
erable antipyretic action which lasted at least five hours, often 
much longer. The above quantity is best given in two or 
three doses of two grammes each, at intervals of an hour, 
either in the form of powder in wafers, or dissolved in water 
with some flavouring agent. 

The manner in which the temperature falls, under the 
influence of suitable doses of antipyrin, is as follows : — the 
temperature sinks continuously and gradually, to the extent 
usually of half a degree (Centigrade) even within an hour after 
the first dose ; in the second hour, after a second dose of two 
grammes, it falls still further ; and in the third and fourth 
hours, especially if a third dose of two grammes or even one 
gramme, has been given, it reaches its lowest point. The fall 
in temperature which thus takes place after 5 to <i grammes 
of antipyrin, amounted at least to one and a-half degrees, 
more often to two or three degrees Centigrade. This Lowering 
also was usually complete within the third or fourth hour ; 
rarely was it postponed to the fifth. The duration of this 



308 Medical Items. 

antipyretic action, that is, the interval which elapsed from the 
time that the temperature touched its lowest point till it had 
returned to its former height, varied considerably ; at the least 
it was five to six hours, often 12 hours, and occasionally even 
eighteen. This relatively long duration of the action of anti- 
pyrin is due to the fact that the influence of the drug passes 
off gradually ; the temperature therefore rises gradually, after 
remaining a short time, usually one to two hours, at its lowest 
level. 

The above doses and mode of administration were found to 
be the most suitable in order to obtain a decided and prolonged 
antipyretic action. A similar result may be brought about by 
giving a single large dose of 4 grammes ; or by smaller doses 
(1 gramme) repeated hourly till five doses have been given. 
Half -gramme doses, even when given six times and at one-hour 
intervals, have very little effect, and only for a few hours ; still 
smaller doses have no action at all ; and sometimes no result 
follows the administration of a single dose of even two 
grammes. 

Simultaneously with the reduction in temperature the pulse 
diminishes in frequency; and when the fall in temperature is 
very marked there is often also profuse perspiration. Anti- 
pyrin has no unpleasant effects on the system ; in a few cases 
only it caused vomiting, but in all the others it was well borne, 
even by patients who took, in 4-gramme doses, 94 grammes 
within one day, and also by children, who repeatedly took doses 
of a half and one gramme. The gradual return of the tempera- 
ture to its former height, which occurs as the influence of the 
antipyrin passes off, takes place invariably tuithout rigor. 
This gives to the drug a very important advantage over kairin, 
the well marked antipyretic action of which continues only a 
short time and terminates in a sudden and rapid rise in tem- 
perature accompanied by rigor. 

Dr. Guttmann points out the perfect analogy which subsists 
between the above described action of antipyrin and that of 
quinine, in regard especially of the gradual fall in temperature 
and the subsequent gradual rise ; they differ principally in 
this, that the requisite dose of antipyrin is at least twice that 
of quinine, of which a dose of two grammes acts as a powerful 
antipyretic. Antipyrin, however, has the counterbalancing 
advantage of being much cheaper than quinine. 

Professor Marigliano, of Genoa, describes, in the Italia 
MedAca of 5th June, 1884 (as quoted in the Bull. Gen. de 
The'rapeutique, loth August, 1884), the chemical reactions of 



Medical Items. 309 

antipyrin, its elimination in the urine, and its influence on 
arterial pressure, fever, &c. The drug occurs in the form of 
prismatic crystals, very soluble in water and in alcohol, but 
less soluble in ether. The solutions are neutral in reaction. 

With sulphuric acid the drug forms a salt soluble in water 
and in alcohol, but insoluble in ether. 

The crystals of antipyrin, heated with concentrated nitric 
acid, detonate violently. Heated gently with caustic potash 
they assume a reddish colour. 

With oxidising agents, and in presence of water and with 
heat, it breaks up into various substances, among which the 
derivatives of phenol and of acetone seem to predominate. 
Its aqueous solution, and that of its salts, present the follow- 
ing reactions : — 

A. With chromic acid a yellowish-orange precipitate, which 
when heated assumes the liquid form. 

B. With hypobromite of soda a white precipitate, which on 
heating becomes yellowish and separates in drops, having an 
empyreumatic odour. 

C With Millon's reagent a yellow precipitate. 

D. With perchloride of iron an intense red colouration. 
The liquid is decolorised by impure hydrochloric acid. 

E. With solution of iodide of potassium and iodine, an 
obscure red precipitate. 

f. With potassio-mercuric iodide a white precipitate. 

G. With iodide of potassium and bismuth, a yellow precipi- 
tate tending to orange. 

H. With tannic acid, a white precipitate. 

i. With picric acid, a yellow precipitate. 

Chlorine water gives no colouration ; but if a current of 
chlorine is passed into a watery solution of antipyrin, a solid 
white substance separates. 

The most sensitive of all the reactions is that with iodide 
of potassium and iodine, which revealed the presence of anti- 
pyrin in solutions as weak as 1 in 100,000. 

Antipyrin in the Urine. — To detect the drug in the urine 
the latter must first be acidified with sulphuric acid in the 
proportion of about 5 drops to G cubic centimetres of urine, 
and more if the urine is alkaline. If the mixture becomes 
cloudy it must be filtered. If then 10 drops of the iodine re- 
agent be added, the presence of antipyrin is indicated by a 
reddish -brown precipitate. This reaction is more or less 
marked according to the time at which the urine is passed. 
Three hours after the administration of the drug the precipi- 
tate is noticeable but slight ; in urine passed 4 hours after a 



310 Medical Items. 

dose, the reaction is very marked ; in 24 hours, it is still well 
marked ; in 36 hours, it is still evident. Occasionally 4 hours 
after a dose the reaction is wanting, but is marked at a later 
period. 

General Action and Influence on Arterial Pressure and 
Calibre of the Vessels. — The drug was given to apyretic indi- 
viduals, and to others suffering from fever, in doses of 4 to 6 
grammes in 1 to 3 hours. 

1. It gave rise to no appreciable general phenomena. Some- 
times, with excitable persons, and especially with females, it 
produced vomiting. 

2. Frequency of respiratory movements was not modified. 

3. The pulse-rate always fell. 

4. The arterial pressure, measured with Baasch's apparatus, 
remains the same, or is a little increased. 

5. The normal temperature is not affected. 

6. In apyretic persons it causes a slight dilatation of the 
cutaneous vessels. In persons with a febrile affection this 
dilatation is more marked. It precedes the fall in tempera- 
ture. These observations were made with Mosso's plessimo- 
graph. 

Action on Fever.-. — 1. A single dose of half a gramme gives 
usually a fall of temperature of three or four-tenths of a degree 
two hours after, but this fall does not last. 

2. A dose of 1 gramme produces in most cases a fall which 
begins one hour after, continues for five or six hours, and 
amounts to three degrees (Centigrade). 

3. With a single dose of 1J grammes, there is a still more 
marked fall, which, after seven hours, amounts to two or three 
degrees. 

4. After a 2 gramme dose there is in an hour a lowering of 
temperature to the extent of 0*8 — 1*3 degrees (Centigrade), 
which goes on for several hours, and lasts longer than after a 
smaller dose, for a time entirely abolishing the fever, so to speak. 

5. After repeated doses the action of the drug is still mani- 
fest for 6 to 18 hours, and may continue for 36 or 48 hours, 
or even longer. With phthisical patients who take the anti- 
pyrin in this fashion, the fever is suppressed not only for the 
day on which the medicine is taken, but also for next day 
or even the day following that, so that from being quotidian 
their fever may become tertian or even quartan. 

Internal Use of Chrysophanic Acid. — Dr. Stocquart 
reports sixty-one cases treated by internal administration of 
chrysophanic acid (Annales de Derm, et de Syph., Jan. 1884). 



Medical Items. 311 

No form of local treatment was employed. Of the sixty-one 
cases, fifty-six were entirely cured, and only one was unaffected 
by the treatment. The cases of acne, ecthyma, and impetigo, all 
yielded rapidly to the treatment, except one case of papulous 
acne. One case of pityriasis and three of urticaria were also 
quickly cured. In four cases of lichen and four of prurigo, the 
irritation was rapidly diminished, in lichen disappearing before 
the complete cessation of the eruption. Of thirty-two cases of 
eczema, thirty were cured. The author was much struck with 
the rapid and complete cure of acute eczema and of impetiginous 
eczema in children. Out of five cases of psoriasis, three were 
cured. The acid was generally administered in water, the 
bottle being well shaken before use. In ordinary doses no 
patient objected to it ; it was also prescribed in pills. The 
medium dose is one centigramme a day for children, and three 
centigrammes for adults. In these doses it is generally well 
tolerated ; in larger doses it may cause loss of appetite, nausea, 
palpitation, with precordial distress and constriction of epigas- 
trium, giddiness, vomiting, and cold shivers. This is an occa- 
sional occurrence only, and often much larger doses are well 
borne. Children tolerate the medicine well ; at four weeks, he 
has given one, two, and in one case five centigrammes without 
provoking gastric irritation. Where the eruption is limited to 
parts ordinarily covered, and when the skin is not very thin 
or delicate, the external use of chrysophanic acid as ointment 
is indicated. Where a great extent of surface is involved, the 
internal use is better. Phenomena of local irritation, or erysi- 
pelas, or gastro-enteric symptoms, or nephritis, may be caused 
by the too free external use of the acid. Its internal use is 
also indicated when the eruption affects the hands or face. 
Where the stomach will not bear the remedy, it may be given 
hypodermically, but is then apt to cause pain and abscess. Its 
action is more rapid than when given by the mouth. — London 
Medical Record, June 1884. 

Children's Tonic. — The most pleasant and palatable dis- 
guise for quinine may be extemporised as follows : — 

R — Quinine sulph., - gr. xl. 

Acidi tannic. - - - - gr. xx. 

Tinct. opii camph., ... ~~ ss. 

Tinct. cinchona 1 , ... ^ ss. 

Spts. lavancl. co., ... 3 iij . 

Syrupi simp., ad 5 iv. — M. 

Shake well before using. The dose will be usually one tea- 



312 Medical Items. 

spoonful three times a day, but the amount of quinia desired 
to be administered should govern the size of the dose. It will 
make a beautifully creamy mixture, if the quinia and tannin 
are rubbed together on a pill tile or a sheet of paper with a 
spatula until all lumps disappear, then put in a suitable bottle 
and first add the paragoric, shaking at once, then the cinchona 
and lavender, followed by the syrup. — Canada Lancet. 

Glycerine-Jelly as a Constituent of Dermatological 
Remedies (Gelatinse Glycerinatae Medicatse). — Glycerine- 
jelly (Leimglycerin) is made by boiling together one part of 
gelatin and three or four of glycerine, until they form a 
translucent mass. Of this as much is taken at a time as may 
be called for by any prescription, and is dissolved by steaming. 
The medicinal ingredient, having meantime been finely rubbed 
up when requisite, with water or glycerine, is then added to 
the liquefied jelly, and the resulting compound well shaken 
until it becomes a tenacious fluid, which may be either 
moulded into tablets, or poured into a vessel, the former mode 
of preservation being suitable for the soft, the latter for the 
hard jellies. 

The remedies best adapted to be used in this manner are 
divided into the two following classes : — 

1. All volatile agents (tar, carbolic acid, acetic acid, mercurial 
sublimate, iodine, iodoform, camphor, camphor-chloral, chry- 
sarobin, ichthyol, the balsams, certain narcotic extracts). 

2. Those solid substances whose superficial action is only 
desired (oxide of zinc, lithargyrum, alumina, acetate of 
alumina, acetate and carbonate of lead, iodide of lead, 
salicylic acid, sulphur, arsenic, pyrogallic acid). 

Jellies with which medicines of the latter classes are com- 
bined, possess the decided advantage of exerting a less degree 
of pressure on the skin than is produced by collodion, so that 
they never give rise to erosions, intertrigo, &c, and permit the 
complete and easy passage of the perspiration. This pressure 
has also a beneficial exsanguinating and absorbent action in 
many cases. Glycerine-jellies are soon found to be superior to 
the fatty ointments in two other respects — they cause but 
little soiling of the patient's linen, and they cover the affected 
surface with a smooth artificial cuticle, which is desirable in 
all pruriginous complaints, in lichen ruber, &c, as reducing 
the friction of the clothing to a minimum. 

With regard to the precise constitution of these medicated 
jellies, it is evident that the combining proportions of their 
several ingredients must fluctuate considerably, according to 



Medical Items. 313 

the condition of the remedial agent when thus incorporated, 
and according to the amount of alteration which it produces 
in the remainder of the compound. These variations are too 
numerous to be retained in the physician's memory, since, 
even if the percentage of the active ingredient be taken as the 
same in all cases, the three remaining quantities will vary 
considerably among themselves, the formation of a jelly being 
impossible if these arbitrary relations are not exactly pre- 
served. Thus, a small addition of gelatine will cause a decided 
hardening of the mixture, which may be again softened to a 
certain extent by the addition either of a little glycerine of a 
large amount of water. An excess of glycerine will completely 
prevent the formation of a "jelly," but the same effect will 
not be caused by even a large surplus of water. Consequently, 
we can only say, in general, that, if a fixed percentage of any 
medicine be united with two., three, four, or five per cent of 
gelatine, there will be an ascending and descending, but still 
constant relation between the proportions of water and 
glycerine belonging to that particular "jelly." That is, if 
the proportion of the active ingredient remains the same, it 
may be combined with either two, three, four, or five per cent 
of gelatine, making four series of the jelly ; and for every 
other percentage of the medicine, another quadruple series 
will be formed in like manner. 

The question now arises, whether it is absolutely necessary 
to employ only such glycerine jellies as will harden rapidly after 
being applied in solution to the skin. As a matter of fact, 
it has been ascertained by repeated experiments that when a 
jelly had to be used which could not be manufactured in 
strict accordance with the prescription, the persistently moist 
artificial surface it produced could be promptly dried by 
simply covering it with a bandage, which could then be re- 
moved at any moment with the aid of a wet sponge. By 
this method it was found that the patient's clothing was still 
better protected, and the patient himself more effectually 
prevented from scratching. It will in many cases be advan- 
tageous to resort to it, even when a well made jelly is 
employed, if we do not wish to wait for the drying of the 
latter. 

Not content, however, with recommending this substitute, 
the authors have endeavoured, by accurate experimentation, 
to facilitate the task of finding practically correct proportions 
to be employed in all these cases. The results of their labours 
are presented in the following tables. The jellies prescribed 
in Table A, are of the consistency of a gelatine bougie ; before 



314 



Medical Items. 



being used they are changed into the form of a liniment by 
placing them in hot water, and being then applied to the skin 
soon harden into a pellicle. They are denominated gelatince 
glycerinatce molles. 

Table B comprises those medicines to which a 10 per cent 
addition of gelatine is advised, and which are therefore entitled 
gelatince glycerinatce clurce. These are used in the same way 
as those of Table A ; but their much greater solidity admits of 
another mode of applying them. A few drops of boiling 
water may be poured upon the mass and the skin painted 
over with a camel's hair pencil dipped in the rapidly drying 
solution thus obtained. This method is exceedingly economical, 
and perhaps more convenient than the other. It is recom- 
mended to be used in policlinics generally, and especially 
when it is more important for the physician to keep the case 
in his own hands than to maintain the exact strength of the 
remedy. 

Lastly, Table C exhibits a shorter list of jellies containing 
20 per cent of gelatine. Like those of Table B they can be 
employed as either hard or soft compounds. 

TABLE A. GELATINE GLYCERINAT.E MOLLES. 



Medicine, Pr. Ct. 



Gelatine, 
Pr. Ct. 



Glycerine, 
Pr. Ct. 



Water, 
Pr. Ct. 



Used in 



5 iodoform, 

10 „ 

10 sulphur, 

5 camphor, 

10 sulphur, 

2 camphor, 

1 calc. carb., 

10 sulphur, 

1 calc. carb., ... . 

10 ox. of zinc 

10 ox. of zinc 

1 calc. carb., 

10 alumina, 

10 alum, acet., .... 

10 lithargyr., 

10 plumb, acet., .. 
10 ,, carb.,.. 
10 ,, iod., ... 
10 ox. of zinc...... 

10 alum. acet...... 

5 naphthol, 

5 arsenic, 

5 „ 

01 mere. sub.,.. 

5 chrysarobin. , . 
10 

5 pyrogallic ac. , , 



20 
20 
20 
25 

25 

25 
20 
20 



30 

25 
25 

25 

90 

85 
80 



70 I 
65 J 
65 
65 



57 

59 
70 
64 



Ulcers, bubo. 



Acne. 



30 


55 


30 


55 


20 


65 


20 


65 


20 


65 


25 


60 



45 

65 
65 

65 



Erythema, eczema, 
erysipelas. 



Bubo, Epididymitis. 
Erysipelas. 
Psoriasis, scabies. 

Tumours. 



Psoriasis, mycoses, 

haemorrhoids. 



Medical Items. 



315 



TABLE B. GELATINE GLYCERINAT/E DUR^. 



Medicine, Pr. Ct. 



O'l mere, sub., . 

1 mere. sub.,. 
5 "0 carbol. ac. , . 
10 '0 ox. of zinc. 
10 chloral-hyd. , 

5 cbloral, 

5 camphor, 

5 chloral, 

5 camphor, 

5 carb. ac. , 

5 carb. ac. , 

10 carb. ac, 

5 acet. ac. , 

5 salic. ac., 



10 
10 



5 extr. narcot. fluida, 
10 extr. narcot. fluida, 

5 extr. narcot. fixa... 
10 extr. narcot. fixa... 

5 pix. liq., 

5 bals. peruv., 

5 styrax., 



Gelatine, 
Pr. Ct. 



5 ichthyol. , 
10 pix. liq. , . 
10 ichthyol,. 
20 adeps. , . . . . 



5 pyrogall. ac. , , 
10 pyrogall. ac., 



10 

10 

10 
10 

10 

10 
10 
10 
10 

10 

10 
10 
10 
10 
10 
10 
10 
10 

10 
10 
10 
10 

10 
10 



Glycerine, 
Pr. Ct. 



50 

50 

40 
40 

40 

45 
40 
50 
40 

45 

50 
40 
40 
50 
50 
60 
60 
60 

60 
50 
50 
40 

85 
80 



Water, 
Pr. Ct. 



Used in 



Mycoses, acne, syphil- 
ides. 

Lichen ruber, mycoses. 



35 V Antipruriginosa. 



Condyl. acum. , verrucse, 
Mollusc, contag., calli, 
clavi. 



Herpes zoster, neuralgia? 



25 

25 



Eczema, psoriasis. 
Scabies. 

"\ acne, acne 
Eczema, I rosacea, 
psoriasis, j chilblains, 

J ulcers. 

Psoriasis, tumours, ulcers 



TABLE C. GELATINE, GLYCERINATiE DUR.E. 



Medicine, Pr. Ct. 



10 ol. cadini. , .... 

10 ol. rusci., 

20 ol. cadini., 

20 ol. rusci. , 

20 pix. liq. , 

20 ichthyol., 

10 ichthyol., 

10 pix. liq., 

10 ichthyol., 

10 ol. cadini...... 

30 adeps., 

5 tannin., 

5 pyrogall. ac. , 
10 „ 
20 „ 



Gelatine, 


Glycerine, 


Pr. Ct. 


Pr. Ct. 


20 


70 \ 


20 


70 


20 


60 


20 


60 


20 


60 . 


20 


60 j 


20 


60 I 


20 


60 J 


20 


50 


30 


75 


20 


75 ^ 


20 


70 \ 


20 


60 J 



Used in 



Eczema, psoriasis, &c. 



Psoriasis, tumours, mycoses, ulcers, 



316 Medical Items. 

The durability of both the hard and soft jellies admits of 
their being kept constantly in stock by druggists, and since so 
large a number of dermatological remedies can be compounded 
in this way, they can undoubtedly be used in conjunction with 
other approved modes of application. It will be an interesting 
study to determine the nature of the cases in which they are 
practically of most service. Certain agents — as chrysarobin 
— and certain very mobile bodily parts — as the elbow and the 
palm of the hand, already seem excellently adapted to this 
kind of treatment. On the other hand, it is obvious that 
glycerine-jellies will never come to be so speedily incorporated 
as the fatty ointments, or so powerful in their effects as the 
rubber plaster, or so handy of application to less accessible 
regions as the ether spray. Yet, equally with the fatty oint- 
ments, they are superior to the other two methods, in exten- 
sive or universal skin affections. — (Unna and Beiersdorf, 
Monatsh. f. Prakt. Dermatologie, Vol. II, No. 2.) Journal of 
Gutan. and Vener. Bis. 

Treatment of severe forms of Lupus. — In the treatment 
of lupus, none of the milder remedies hitherto proposed, each 
of which has in turn enjoyed its share of popularity, has been 
able to supersede the " rough and ready " methods of operative 
surgery. On the contrary, linear scarification, multiple punc- 
turing, and the use of the curette have been the measures 
almost exclusively resorted to ever since their advocacy by 
Volkmann, for the cure of this formidable and obdurate 
complaint. The reasons for this preference are not far to seek. 
Besides being more expeditious, the last-named procedures are 
apparently recommended by their superior results, and also by 
the fact that they actually produce less pain than the caustic 
applications formerly in vogue — whence many old lupus 
patients, after running the gauntlet of a ten years' treatment, 
with all its successive changes and improvements, are decidedly 
in favour of them. It is true that the operative measures may 
themselves be of a more or less energetic kind, according to the 
form and extent of the disease and the constitutional peculiari- 
ties of the patient ; and that it is therefore quite unnecessary 
to attack each and every case of lupus with the same unsparing 
severity as has been the recent practice of certain French and 
English surgeons. Alibert, C. Fox, and Malcolm Morris recom- 
mend deep scarification, with extensive destruction of the 
diseased tissues, to be effected in the fewest sittings possible. 
Besnier prefers the thermo- and galvano-cautery in their 
various modifications, with which he employs an imposing 



Medical Items. 317 

array of knives and needles. These processes being very 
painful, and requiring to be frequently repeated, some of the 
above authorities recommend local anaesthesia, sometimes aided 
by subcutaneous injections of morphine and atropine solutions. 
For my own part, having in the course of several years' 
practice thoroughly tested all the known methods on some 
hundreds of lupus patients, I have found none which, when 
employed singly, can be pronounced suited to every case. I 
have often obtained better results from simple than from 
energetic measures ; nay, more, I have frequently witnessed, 
in consequence of the latter, an extension of the disease into 
neighbouring parts previously exempt ; so that I am compelled 
to regard severe local procedures as capable, in certain cases, 
of doing much more harm than good. Many other dermatolo- 
gists can testify to a similar experience ; in short, it is always 
impossible to foresee precisely when and where the treatment 
of lupus is certain to be permanently successful. This much, 
however, is established — that favourable hygienic surroundings, 
a strong constitution, and a healthy condition of the organs 
not involved in the disease, furnish no absolute security for its 
radical removal. That many lupus patients exhibit not a 
sign of tuberculous or strumous tendencies, and yet are difficult 
of cure, is no less true than that such as are poorly nourished, 
scrofulous, or cachectic, are still less promising subjects for the 
exercise of our skill. The best chances for success are generally 
met with in those cases where the lupus patches are of small 
dimensions. Here favourable results are not unfrequently 
obtained, whatever method may have been resorted to ; yet 
even here, the return of the complaint, after a longer or 
shorter interval, should cause us no surprise. It may be 
imagined, therefore, how perplexing and almost hopeless our 
situation must oftentimes appear when the disease occupies 
large surfaces, and goes on extending itself for years, and 
when we must endeavour not only to effect a restoration of 
deeply altered or destroyed cutaneous tissues, but to check the 
further advance of the devouring evil, especially in those 
mismanaged or neglected cases so frequently met with in our 
hospitals. The remedies applicable to the more circumscribed 
forms of lupus have their value also in these almost desperate 
cases, but here it is necessary to proceed step by step, and 
with frequent changes of agencies and methods. Among the 
remedies we must reckon pyrogallic acid, an acquisition of 
decided importance within a limited sphere. It is useful in 
many ways, and sometimes effects quite a speedy destruction 
of the infiltrated cells in particular localities. Applied in the 



318 Medical Items. 

form of a ten to fifteen per cent ointment, three or four times 
daily, it transforms the morbid growth into a pulpy, dirty, 
gray substance. The removal of this renders difficult the 
further employment of the acid, on account of the great 
sensitiveness of the denuded corium, and the obstacles offered 
by the purulent layers which are speedily deposited. The 
cicatrix, when formed, looks smooth and handsome, but is 
seldom free from tubercles, which in many cases present the 
same appearance as at first. A second and third application 
to the same diseased surface were always followed by a like 
result. In short, I was forced to the conclusion that the total 
destruction of the lupus-infiltration is very rarely possible by 
the sole agency of pyrogallic acid. If, however, we could 
succeed in checking, or in wholly preventing this reproduction 
of tubercles from the destroyed stroma, the problem of how to 
cure lupus without resorting to surgery would be solved at 
once. With this object in view, I made trial of numerous 
remedies without success, until I hit upon the emploj'ment of 
empl. mercuriale, the effects of which, in conjunction with 
pyrogallic acid, have been surprising in some instances, gratify- 
ing in most others, and unsatisfactory in only a few. The 
plan I have adopted is this : When the suppuration produced 
by the pyrogallic acid is at its height, instead of promoting a 
healing action by means of simple cerates or antiseptic oint- 
ments, I employ the mercurial plaster either immediately after 
the removal of the acid or the day following, and thus almost 
always succeed in satisfying the requirement which the latter 
agent leaves unfulfilled. The grey plaster, when used alone, is 
well known to be of no value in the treatment of lupus, since 
it is incompetent to cause absorption of the infiltration. That 
is, it has no such specific influence over the lupus deposit as it 
exerts in the case of syphilis — which fact may help us to 
a correct conclusion as to the difference between the two 
maladies. 

The number of patients affected with the most malignant 
forms of lupvs, who were subjected to the above treatment, 
and who remained under careful observation until its close, 
amounted to twenty. The following was the course pursued 
with all of them : — For several da} T s after admission the 
diseased surfaces were kept completely covered with vaseline 
smeared on cloths, in order to facilitate the removal of all 
secondary morbid products, such as scabs, &c. A ten per cent 
pyrogallic ointment was then applied over the same area, and 
renewed two or three times in the twenty-four hours. This 
dressing was employed from four to six days, or, in cases 



Medical Items. 319 

where the cutaneous tissues were insensitive, for six or seven 
days. On its removal, vaseline was again applied for one day, 
after which the entire suppurating surface was covered with 
mercurial plaster. Healing began in from ten days to a 
fortnight in most localities, but isolated nodes and tubercles 
could still be detected in the cicatrized integument. Pyrogallic 
acid was now once more applied for three or four days, 
causing renewed suppuration of the partly healed infiltrations, 
while those more firmly skinned over remained unaffected. 
When treatment was repeated, so much pain in many cases 
was experienced on the second day that mercurial plaster had 
to be at once substituted for the ointment ; but if this was not 
the case, the latter was left on for two days longer. The gray 
plaster was allowed to remain — being changed once daily, if 
the suppuration was trifling, twice or thrice if it was more 
profuse — until cicatrisation was complete, which sometimes 
required four weeks. When the complaint was peculiarly 
indolent and obstinate, the same process was gone over for a 
third time, but treatment never extended further than this. 

An accurate and unprejudiced comparison of the results 
obtained in this way, with those which have followed other 
methods, has proved decidedly favourable to the former. A 
speedier and much better resolution of the most advanced and 
wide-spreading morbid growths was found to occur under the 
combined pyrogallic and mercurial treatment, than could have 
been brought about by the united agencies of scarification and 
the thermo-cautery. 

To make our estimate more precise, and to obviate any mis- 
conception which might cause the means I have recommended 
to be regarded in the light of a Iwyius-panacea, I present the 
following summary of the objects which they may reasonably 
be expected to accomplish : — 

1. The severest and most extensive forms of lupus — those 
hitherto most difficult and frequently impossible of manage- 
ment — may often be essentially ameliorated by these simple 
and comparatively painless procedures. 

2. The application of mercurial plaster, immediately after 
several days' use of pyrogallic acid, is able to bring about 
complete absorption of the tubercles and infiltrated cells at 
some points, while at others it is remarkably effective in 
arresting the morbid growth and forming complete and smooth 
cicatrices, results which are not attained by the use of either 
remedy alone. The combined treatment may be employed 
two or three times in succession without any inconvenient 
consequences. 



320 Medical Items. 

3. The more circumscribed forms of lupus are less amenable 
to this method than the diffuse, serpiginous, and ulcerated 
varieties — perhaps for the reason that in the latter the corium 
affords a less congenial breeding place for the morbific cells. 
Yet sometimes, in these same cases, better results are obtained 
through a previous deep scarification of the affected parts, 
although scarification alone will prove entirely ineffectual. 

4. The duration of treatment is shorter than under the other 
methods, not exceeding three or four months in the worst cases. 

5. Relapses are to be looked for here no less than after other 
processes, but are least to be apprehended when the treatment 
has been thoroughly carried out, i. e., has terminated in uniform 
and complete cicatrization. 

6. This method is indicated in the most extended forms of 
lupus, whether occurring on the face, the body, or the extremi- 
ties, and is especially suitable in neglected cases which have 
received no previous treatment. 

7. The affected surfaces, after healing, retain their redness 
for a considerable period. The discoloration gradually fades 
however, and its disappearance can sometimes be hastened by 
using an ointment of bismuth or zinc. — (Ernest Schwimmer, 
Wien, Med, Wochenschrift, Nos. 20, 21, 22, 1884.) Journal of 
Cv/tan. and Vener. Die. 

Galvanopuncture in Aneurysm of the Aorta. — Dr. 
Francesco Brancaccio reports the case of a man, get. 64 years, 
of intemperate habits, who complained of pain in the left 
anterior part of the chest, over the base of the heart, which 
radiated to the shoulders. The pain came on suddenly after a 
muscular effort, and was intermittent. Examination revealed 
a tumour, limited above by the upper border of the second rib, 
on the right by the sternum, on the left by the mammary line, 
and below was continuous with the heart. The diagnosis of 
aneurysm of the ascending portion of the aorta having been 
made, it was determined to practise galvanopuncture. A fifteen- 
cell Daniell'a battery was used, two needles being carried into 
the sac through the third interspace to a depth of one inch and 
one-fifth, and an inch and a half apar f , The first sitting lasted 
sixteen minutes. In the afternoon the patient felt better, the 
tumour was smaller, the pulse, which had fallen from 118 to 90, 
was stronger, and the respirations were less frequent. Twenty 
days afterward the battery was again used, with twenty 
elements, for fourteen minutes. Altogether it was used four 
times, and the patient was completelv cured. — (Revish i In ternaz. 
di Med. e Ghir., Feb., 1884.) The Practitioner, August, 1884. 



THE 



GLASGOW MEDICAL JOURNAL. 



No. V. November, 1884. 



ORIGINAL ARTICLES. 



THE ALEXANDER-ADAMS' OPERATION ON THE 
ROUND LIGAMENTS. 

By WILLIAM GARDNER, M.D., CM., Glasgow, 
Surgeon to Adelaide Hospital, South Australia. 

This operation, which was suggested almost simultaneously 
by Dr. Adams of Glasgow and Dr. Alexander of Liverpool, 
was first performed on the living body by the latter on 1st 
December, 1881. The first account of Dr. Alexander's opera- 
tions appeared in the Liverpool Medico-Chirurgical Journal 
for January, 1883, and I was so struck with the originality 
and feasibility of the operation that I determined to practise it 
whenever any opportunity offered. My first operation was per- 
formed on 14th February, 1883, and since then I have operated 
on eight other cases, the particulars of which are as follows : — 

Hospital Cases. 

Case I. — Mrs. P., set. 30 ; married. Was admitted to the 
Adelaide Hospital, 5th January, 1883. Complains of " falling of 
the womb," which first occurred when she was 19 or 20 years 
of age, and increased considerably during her first pregnancy. 
Has borne three children, now 8, 5, and 3 years of age respec- 
tively ; miscarried once between the last two confinements. 
She enjoys fairly good health, menstruates regularly, and has 
worn a pessary for a short time recently without success or 
relief. The womb protrudes whenever she stands up, and 
sometimes when recumbent. There is dysuria at times. The 
bowels are regular, and there is no pain in defecation. On 

No. 5. V Vol. XXII. 



322 Dr. Gardner — The Alexander-Adams' Operation 

examination prolapse of about three inches ; the cervix tripar- 
tite ; uterus admits over three inches of the sound. Trache- 
lorraphy was performed, two operations being required owing 
to imperfect approximation of one division after the first 
operation. On 14th February I cut down on the round 
ligaments in each inguinal region, and drew them down about 
an inch and sutured them with catgut in their new position. 
Antiseptic precautions were taken. The patient was placed 
under the influence of opium f gr. every four hours. Urine 
drawn off by catheter. 

loth March. — Micturates easily ; little if any pain. 

17th March. — Began to menstruate last night ; gauze dress- 
ing left off, and carbolic oiled lint substituted. 

Note. — This case remains absolutely unrelieved, owing to im- 
perfect carrying out of the operation and unsuitability for this 
mode of relief. I eventually restored the perinaeum, and 
partially closed the vagina. A watch-spring pessary then 
enabled the uterus to be kept in position. 

Case II. — A. U., aet. 44, married; admitted 10th February, 
1883. Has suffered from " falling of the womb " for 24 years ; 
the first occasion being about six weeks after confinement, 
whilst working in the hayfield. Until fifteen months ago was 
able to work well ; but during this latter period has been 
quite unable to exert herself. Has had. six children ; no 
miscarriage ; menstruation regular. A stout, apparently 
healthy woman, but suffers from haemorrhoids. 

28th February. — Under ether, and using the carbolic spray, 
I cut down on both round ligaments. The right one alone drew 
on the uterus, which was pulled well up, but the cervix tilted 
to the left, and the transverse os became oblique in position. 
Pil opii gr. i every four hours. 

Ji><! March. — Dressed ; able to lift herself up in bed. 

6th Ma rch. — Dressed ; aseptic ; some pain in inguinal regions. 
Pill continued. 

9th March. — Dressed ; still pain and tenderness in groins. 

15ih March. — Ring pessary ; to get up. 

19th March. — Discharged, wearing the pessary; slight 
dysuria and some trouble from the haemorrhoids. 

Note. — I saw this patient a week ago, and she was in per- 
fect health and able to follow the laborious occupation of a 
monthly nurse without any return of the trouble. 

Case III.— Mrs. A. consulted me on the 29th August, 1883, 
complaining of a burning pain in the abdomen, giddiness in 



On the Round Ligaments. 323 

the head, a vaginal discharge, pain on passing water and when 
the bowels act. Six weeks ago was confined ; married seven 
years to first husband ; five living children. Married four 
years to second husband ; first child born alive prematurely — 
died two hours after. Second child born dead. Third child 
born dead at seven months. Fourth child born dead at seven 
months. On examination uterus found retroflexed ; perinseum 
gone. On 26th September, under ether, and using the carbolic 
spray, I cut down on the round ligaments and drew them 
well up, restoring the uterus to its proper position. Kangaroo 
tendon was used to retain the ligaments, which were pulled so 
far out as to allow of their being tied together over the mons 
veneris. 

29th October. — I restored the perinseum under ether. 

4th November. — Sutures removed. 

10th November. — Discharged, wearing a ring pessary. 

On loth January, 1884, I passed the sound, and found 
uterus normal in every way, no pessary having been worn for 
a month. 

Private Cases. 

Case I. — Mrs. H. consulted me on 12th March, 1883, and 
I found lacerations of the cervix uteri, complete retroflexion 
with procidentia and enlargement of uterus, with absence of 
perinseal body and laceration of recto - vaginal septum to 
extent of 1| inches. She was a perfect invalid, and could 
walk no distance without severe pain, and had incontinence of 
faeces. On 19th March, 1883, I sewed up the rent in the 
cervix, and pulled in the slack of the round ligaments until 
the fundus could be felt through the parietes. I then fixed 
them there. On 21st March I restored the perinaeal body, 
and closed the rent in the recto-vaginal septum. She can now 
walk any reasonable distance without pain, and has complete 
control over the sphincter ; has also been pregnant once and 
miscarried. Yesterday I saw Mrs. H., who is now pregnant 
and in perfectly good health. 

Case II.— Mrs. P. consulted me on 30th March, 1883, for 
pain in the left groin, across the loins, and down the thighs, 
straining on passing water, pain on defecation and locomotion. 
< )n examination I found a tumour of left labium, complete 
retroflexion and procidentia of uterus, with laceration of 
perinaeum and recto-vaginal septum. 

At the first operation I removed a solid tumour from the 
left labium about the size of a pigeon's egg, and at a second 



324 Dr. Gardner — The Alexander-Adams' Operation 

operation I pulled up the slack of the round ligaments for 
about three inches. I have since restored the perinaeum. On 
examination two weeks after, I found the uterus in the normal 
position, and complete absence of pain. On 18th March, 1884, 
I found the uterus normal, and the sound passed forwards and 
for the normal distance. 

Case III. — Mrs. S. consulted me on 10th August, 1883, for 
certain uterine symptoms. On examination I found retro- 
flexion, with prolapse of both ovaries. Pessaries (ring) were 
tried, but could not be borne on account of the exquisite 
tenderness caused by the pressure of the ring on the prolapsed 
ovaries. On 26th October I operated, and she obtained per- 
fect relief from all her troublesome symptoms. On 3rd June, 
1884, I had an opportunity of examining this patient, and 
found the uterus perfectly normal. She has not suffered from 
any pain since the operation. Since the above date, and when 
on a visit to Melbourne, she suffered from pelvic cellulitis, 
probably due to gonorrhoea. She sought admission to the 
Lying-in Hospital there, and under the care of Dr. Balls- 
Headley soon recovered. She is now enjoying her usual 
health. 

Case IV.— Mrs. M. consulted me on 12th March, 1883. 
She complained, in addition to her uterine symptoms, that for 
the last eighteen months she had suffered from hemicrania, 
with tenderness of the scalp, and also shooting pains in the 
eye and temple. Married twelve years ; five children and two 
living. I found a retroflexion of the uterus, with a large dis- 
placed ovary lying under the uterus. I reduced the uterus 
and inserted a watch-spring pessary, gave her a mixture of 
iod. pot., and she returned to N. S. W. to be again under the 
care of her own medical man. He took out my ring pessary, 
said it was the wrong kind, and inserted a Hodge, which, 
pressing on the prolapsed ovary, set up such violent pain that 
she went to Melbourne for advice. She was there told that 
she had a cervical rent, which must be sewn up. She declined 
operation, and returned to Adelaide, when I examined again, 
and found the uterus retroflexed and very tender to touch, 
with a prolapsed ovary pressed on by the upper limb of a 
Hodge. 

There was now a large node on the right clavicle. After 
preparation I operated on 17th January, 1884, with perfect 
relief to all the symptoms. The other day I passed the 
uterine sound, and found the direction normal. 



On the Round Ligaments. 325 

Case V. — Mrs. P. consulted me on 17th January, 1884, with 
certain uterine symptoms of very marked character. I found 
retroflexion with prolapse of one ovary. I operated on 29th 
April, and she went home in three weeks wearing a watch- 
spring pessary for safety. 

This patient was last seen in the end of June, and I found 
the uterus in the normal position. She was then perfectly 
free from any uterine symptoms. 

Case VI. — Mrs. de V. consulted me first on 14th November, 
1883, complaining of pain in the lower part of the abdomen 
and left groin of several years' duration. Pain is worse at the 
periods, and when pregnant has pains at the date of each 
monthly period. Married six years ; one child, born living at 
eight months, and died in a few hours. Second born living at 
eight and a half months, and died in a few hours. Third 
pregnancy only went two months. On examination uterus 
found retroflexed with malposition of both ovaries, and well 
marked signs of cellulitis. The ordinary routine treatment 
was continued for some months, but no pessary could be borne 
for any length of time on account of the displacement down- 
wards of the ovaries. On the 15th July, 1884, I pulled up the 
round ligaments under antiseptic precautions until the fundus 
could be distinctly felt by bi-manual palpation in its normal 
position. The temperature did not once rise above 100° F., 
and the first dressing was not changed until the sixth day, and 
the drainage tubes removed. So far everything promises well. 

The class of cases to which I would restrict the operation 
is the large one of chronic retroflexion with malposition of one 
or both ovaries, and if one, probably the left (as Lawson Tait 
has pointed out) owing to the absence of a valve in the left 
ovarian vein. In simple prolapse the removal of triangles 
from both anterior and posterior vaginal walls with restoration 
of the perinseal body would, in most cases, enable the uterus 
to be kept in position by a pessary, and if this failed I should 
then be disposed to pull up the round ligaments. My method 
of performing the operation is as follows : — 

After shaving the mons veneris and groins, I push the 
finger into the external abdominal ring, and mark the in- 
vaginated skin with the nail of my forefinger on each side. 
This marks the centre of my first incision, which may be pro- 
longed either upwards or downwards if difficulties occur. 
The first incision I make two inches long, in the direction of 
Poupart s ligament, and parallel to it, dividing, at one stroke 
of the knife, skin, superficial fascia, and fat. Generally one 



326 Dr. Gardner — The Alexander-Adams' Operation. 

or two small vessels require torsion, or the application of 
pressure forceps for a short time. I then define the ring 
thoroughly, and after finding the fibres of the round ligament, 
I follow them up until it becomes a strong round cord, upon 
which I fix pressure forceps. 

The operation is then repeated on the opposite side till the 
same stage is reached. An assistant now passes his finger into 
the vagina, and presses the os uteri backwards, whilst I 
gently but firmly pull up both ligaments until the fundus can 
be distinctly felt in its normal position through the parietes. 
The os will then be found directed slightly backwards. In 
most cases I pull out each ligament from 2 \ to 4 inches, and 
then tie them together, passing a folded pad of gauze under 
them to keep them on the stretch. I then pass sutures of 
kangaroo tendon through the skin and ligament, and also 
round the latter, and bring the edges of the incision closely 
together. A drainage tube is passed under the ligament and 
brought out at the lower end of the incision. Listerian 
dressing is then applied in the usual way, and the operation 
may be done either with spray or without, according to the 
inclination of the operator. In either case the hands of the 
operator should be well washed, or soaked in carbolic lotion, 
and all instruments should be kept in carbolic lotion. For 
the first two or three days after the operation I keep the 
patient under the influence of opium sufficiently to abolish 
acute pain. The urine may be drawn off by catheter every 
four hours if necessary. The uterus ought never to be lifted 
with the sound at the operation, but should in all cases be 
drawn up by the ligaments alone, on account of the danger 
(probably remote) of setting up perimetric inflammation. It 
must always be remembered that, previous to undertaking 
the operation, the uterus must be ascertained to be freely 
movable and capable of being replaced by the sound. It 
is not necessary to insert any pessary until the patient is 
allowed to get up. This may generally be allowed at the 
end of three weeks, and a well-fitting watch-spring pessary 
is then the best support. After six weeks or two months 
this may be dispensed with. 

The results of this operation, so far, have been excellent, 
and several of the patients have been transformed from a state 
of chronic invalidism to perfect health. Case I, of the private 
cases, had been a chronic invalid for five years, and since the 
operation she has been able to walk a distance of two or three 
miles at a time without inconvenience, and has been twice 
pregnant. This case also shows that when there is prolapse of 



Dk. Finlayson — Congenital Unilateral Hypertrophy. 327 

both ovaries into Douglas' pouch with consequent sterility 
(owing to the impossibility of the fimbriated extremity of the 
Fallopian tube applying itself to the ovary), this may be 
remedied by the operation, and pregnancy follow. Another 
advantage gained by this operation is that it prevents the 
necessity for Tait's operation of removal of the " uterine appen- 
dages " when the ovaries are prolapsed with retroversion or 
retroflexion of the uterine body. The same result is thereby 
attained without the obvious disadvantage of the other opera- 
tion — viz., that of preventing pregnancy in the future. All the 
difficulties of the operation can be surmounted by a course 
of operations on the dead body, and any inability to find and 
pull up the round ligaments is probably due to imperfect per- 
formance, as in my second hospital case, where I was only able 
to find one ligament. I can also imagine another difficult)', 
although I have never had the misfortune to have to meet it. 
It is that owing to previous recurrent attacks of pelvic 
peritonitis the ligaments may become so adherent to their 
peritoneal investments that they may not run when pulled 
upon. In such cases there would still be left to the operator 
(if symptoms were sufficiently urgent) the dernier resort of 
removing the uterine appendages from their prolapsed, and, 
probably, adherent position by Tait's radical operation. 



ON THE CASE OF A CHILD AFFECTED WITH CON- 
GENITAL UNILATERAL HYPERTROPHY AND 
PATCHES OF CUTANEOUS CONGESTION. 

By JAMES FINLAYSON, M.D., 

Physician and Lecturer on Clinical Medicine, Glasgow Western Infirmary ; 
Physician to the Glasgow Hospital for Sick Children, &c, &c. 

Isabella M'H , 18 months, was brought to the Glasgow 

Western Infirmary, as an out patient, on loth January, 1884. 
She is the ninth child in the family. Three are dead — one 
from scarlet fever, one from diphtheria ; the third only lived a 
few minutes, and seems to have been in some way deformed 
in the lower limbs. The one with the deformed limbs was 
the fifth child. During that pregnancy the mother had small- 
pox and pneumonia. All the other children are healthy, and 



328 Dr. Finlayson — Case of a Child Affected tvith 

no history of malformations can be traced in the connection. 
The parents are both natives of Morayshire, but are not 
related. During this ninth pregnancy the mother had the 
idea that the child lay somewhat differently in the womb from 
usual, alwa}-s lying, she said, in the right side for the last 
three months without any change in position, but not without 
the usual movements being felt. The child was born at the full 
term, the head presenting, and no difficulty being experienced. 
When born the skin was found to be more sodden than usual, 
and there was apparently an unusual tendency to blueness of 
the skin and coldness of the surface. The woman who washed 
the child, and the mother also, noticed immediately after birth 
a difference between the two sides, not only in the face, but 
also in the arm, hand, leg, and toes — the right being larger, 
and as if swelled, as compared with the left. This observa- 
tion is the more likely to be reliable, as owing to the deformity 
in the lower limbs of her fifth child the mother looked at the 
subsequent ones very critically immediately after birth. The 
mother thinks the relative difference between the two sides 
was as great at birth as it is now ; and she noticed from the 
beginning that anything which excited the child, or over- 
heated her, as crying, &c, made the swollen parts appear more 
swollen ; and she also noticed, from the time of birth, that 
such disturbances caused the skin of the belly, both above and 
below the umbilicus, to become much discoloured, just as at 
present, the tint being deep purple, or almost blue ; but this 
discoloration never was unilateral. 

Another peculiarity was as regards sucking — there seemed 
to be some difficulty in doing so, and the usual idea of the 
child beino- " tongue tied " was entertained, and even some 
little snip seems to have been made at the frsenum, which still 
appears a little more prominent than usual. But the child was 
found to suck easily at the right breast, but not at the left, unless, 
indeed, when the mother held her in the very awkward position 
of having the child's feet and body directed away from 
her own bod}-, and in this way she found she could nurse her 
at both breasts. In this way, during sucking, the child's right 
cheek — the large one — would always be uppermost, and so this 
curious fact may have resulted from the child's deformity. 
The mother stated that the child had a curvature of the spine 
when born ; but this seems to have been rather a general 
buluinir backwards of the whole column than a true curvature, 
and no such curvature can now be traced. 

The teething of the child was peculiar, and as it was the 
subject of comment at the time, by the doctor and others, it 



Congenital Unilateral Hypertrophy. 329 

seems beyond dispute. She cut the first tooth when three 
months old, the right lateral incisor in the lower jaw ; and 
she had eight teeth on the right side when absolutely none had 
appeared on the left. At present there are four on each side 
on lower jaw, and in upper, five on right and four on left. 

She had otorrhoea on the left side when nine months old, 
but this soon stopped ; when it did so the right ear began to 
suppurate, and there have been repeated attacks of this kind 
in this ear since then, the last six weeks ago ; the pus was 
said to have an offensive smell. The mother referred the 
otorrhoea to attacks of sore throat, to which this child and 
other members of the family seem somewhat predisposed. On 
examination of the ears, by Dr. Barr, the case seemed clearly 
to have been one of " otitis media acuta ;" the membranes were 
normal, and showed no cicatrices ; the external auditory canals 
were equal in size and normal in appearance. The right 
tonsil, however, was found notably larger than the left. 

The child is said to have some prolapse of the rectum, and 
the mother says it protrudes chiefly on the right side. When 
brought for examination the child was just beginning to be 
able to stand, with some little support, but could not walk. 
The examination was made on three separate occasions, when 
most of the following points were observed and verified more 
than once. A water-colour drawing was made by an artist, 
but it was not so successful as to be reproduced here. 
Attempts to take casts or obtain photographs likewise failed, 
owing to the restlessness of the child. 

Discoloration of Skin. — This varies to a most extraordinary 
extent, being at times barely recognisable, and other times of 
the most pronounced character. The cause of this difference 
is clearly the influence of excitement, particularly of crying, as 
seen by us ; but the mother says that anything causing her to 
be excited or overheated brings out the deep discoloration — 
even laughing will do it — and she has noticed that washing 
the part of the skin of the abdomen which is affected with 
tepid water, may make it appear very dark, as if filled with 
blood, even apart from any crying during the process. In 
such a case the discoloration passes away in two or three 
minutes after the skin is dried. The most striking discolora- 
tion is on the belly, just about the umbilicus, extending above 
and below it, and not limited by any means to the right Bide. 
It extends to the right leg in particular, and specially to its 
inner aspect and to the back of the leg. There are, however, 
patches on the back, chiefly to the right of the spine, with 
islets of perfectly white or natural skin, and some discolora- 



330 Dr. Finlayson — Case of a Child Affected with 

tion on the left arm and left leg, of a less pronounced kind, are 
also seen. When crying, these patches become very red, or at 
times purple, and even little parts are almost blue — they get 
more and more pronounced the longer the child cries or 
struggles. They suggest the idea of a cutaneous naevus, from 
their general appearance when highly developed. There is 
no elevation of the skin, the skin feels soft and natural, and 
after a time the redness disappears from the belly, so that 
when quiescent their locality cannot be defined. In parts of 
the right leg, however, on its inner aspect, the red parts do not 
regain their pure white colour like the rest of the skin, and 
arborescent streaks or indentations of white, like the fronds 
of a fern, can be traced into this part. A few spots about 
the left breast, and about left elbow, likewise remain dis- 
coloured, so as at least to look a little darker. The rapidity 
and completeness with which the great red or livid blotches 
disappear, when the child becomes quiet, are most striking ; 
the slight remaining differences in colour, with the white 
arborescent streaks, require somewhat close observation to be 
detected. 

The Hypertrophy. — This is essentially unilateral from the 
head to the toes inclusive ; it affects the right side. The only 
exception to this is that the left forefinger and middle finger 
are markedly, and the left ring finger slightly, hypertrophied. 

The difference between the two sides is at once apparent to 
any one whose attention is called to it : from the size of the 
fingers and toes, and of the right cheek, it is likewise at once 
evident, and beyond doubt, that the difference is due to a 
hypertrophy of the right side, and not to an atrophy of the 
left. The hypertrophy clearly involves the bones, in some 
places at least, as well as the soft parts. Thus, on the right 
side, the parietal protuberance is excessive, and also the malar 
bone. Casts both of the ujyper and lower jaws were taken by 
Mr. Oswald Fergus, L.D.S., and they showed a slight but dis- 
tinct difference of the two halves. The bones of some of the 
fingers and toes could likewise be felt to be distinctly larger 
on the right side. The skin, as already stated, seems quite 
natural in its texture without any hypertrophy or induration. 

The measurements of parts in such a young child are difficult, 
but advantage was taken of her sleeping to cany out some of 
these observations. They were taken in various ways ; those 
given were made by means of compasses. Two pairs were 
used, one larger, with the points tipped with wax, the other 
smaller, with very fine points. Many were checked by a 
separate observer taking the measurement. 



Congenital Unilateral Hypertrophy. 

Eight. 
Ear. 
From extreme top to bottom of auricle, . 5 - 3 centim. 

Hand. 

Measured across from root of the fore- 
finger to that of the little finger on 
dorsal asjsect, . . . . . . 5'4 centim. 

Thickness, from before backwards, at 
proximal phalanges, .... 

Foot. 
Measured across in front of malleolus, 

Forearm. 
From olecranon to carpal extremity of 
ulna, ....... 



1'6 centim. 
5 "3 centim. 



331 

Left. 
4"9 centim. 

5 - 2 centim. 
1'4 centim. 

4'9 centim. 



A difference, but not easy to 
state it definitely, in favour 
of the right. 

The Fingers of both hands were so far implicated. The 
middle finger of right hand is the most excessive in size, 
but they are all very distinctly enlarged on this side, except 
the forefinger and the thumb, which are only slightly enlarged. 
On the left hand the middle and forefingers are markedly 
enlarged, and the ring finger slightly, so that the left fore- 
finger is even larger than the forefinger of right side, which, 
as just stated, was only veiy slightly affected. The joints of 
the thumb on the left side are unduly loose, and all the fingers 
can be separated rather widely as if the articulations there 
were a little loose. 

The Tongue shows no difference on the two sides as regards 
the papillae, but the right half seems a little broader than the 
left. 

The Nails were pared as evenly as possible and examined 
after a fortnight's growth — no difference was seen, and none 
had been noticed by the mother. Nothing could be made out 
as to any difference in the hair on the two sides. 

Fauces. — The right tonsil was larger than left. No notable 
difference existed in the palate or in the position of the 
uvula. 

The Eyes seemed normal in appearance, and also as re- 
gards the pupils. An ophthalmoscopic examination was not 
attempted. 

The Arteries were examined as carefully as possible, with 
regard to their pulsation as judged by the finger, but no 
difference could be made out on the two sides. 

The Veins presented no obvious enlargement. A little 
fulness was noticed in some parts during crying. 



332 Dr. Finlayson — Case of a Child Affected ivith 

Temperature on the two sides. — This was ascertained by- 
means of a pair of Hawkesley's Surface Thermometers, 
held carefully on corresponding parts of the two sides. The 
instruments were sometimes reversed, so as to check the 
observation, and the results thus obtained were in essential 
agreement. The difference was very striking, particularly 
for the first feiv minutes of the application, the difference 
becoming less, but not disappearing, after a considerable time 
was allowed to elapse. In the case of the hands, however, the 
difference was trifling, as might be expected from the hyper- 
trophy existing in both. The following are samples : — 

Right Cheek (readings every minute). Left Cheek. 

93° F. - - - ' - - 86° F. 

96-5° .--.- 90° 

98° ----- 92° 

98-4° ----- 94° 

98-8° ----- 95° 

98-8° ----- 96° 

98-8° : 96-4° 

98-8° ----- 96-4° 

98-8° ----- 96-4° 



Right Leg below knee 


(every minute). 


Left Leg. 


87-4° F. - 


. 


86-4° F, 


88-8° 


. 


88° 


89-8° 


. 


89-4° 


92-4° 


. 


92-2° 


93-6° 


. 


93-2° 


94-2° 


- 


93-6° 


94-6° 


. 


93-8° 


95° 


. 


94° 


95-2° 


. 


94° 


95-2° 


. 


94-2° 



Right Hand dorsum (every 1| minute). Left Hand. 
87-4° F. - - - - - 86° F. 
90° ----- 88-8° 

91° ----- 90-4° 

926° ----- 92-6° 
93-6° ----- 93-4° 

27th July, 188Jf. (six months later). — The child remains in 
essentially the same condition. The appearance of deformity 
in the face is, if anything, less striking. The child has grown 
considerably, and can now walk. There is a tendency for the 
risfht knee to be turned in. 



1-5 „ 1-4 

20 „ 19J 

14| „ l4 

5-4 „ b 

4-2 „ 4-5 

on left 'side.) 

57 „ 5-2 

4-6 „ 4-4 

37 „ 34 

1-5 „ 1-4 

5 3 „ 4-9 



Congenital Unilateral Hypertrophy. 333 

Measurements again made to-day with compasses and 
tape : — 

Right. Left. 

Circumference of middle of thigh,. . . . 24J cent. 22j cent. 
Circumference of calf of leg at greatest part, . 20 „ 18| 

Breadth of foot at root of toes, 
Thickness of great toe, .... 
From olecranon to tip of little finger, . 
Circumference of middle of forearm, 
Breadth of hand at root of fingers, 
Length of forefinger from cleft to tip, . 

(This finger much affected 
Length of middle finger from cleft to tip, 
Length of ring finger from cleft to tip, 
Length of little finger from cleft to tip, 
Thickness of middle finger, . 
Ears measured vertically, 

The occurrence of hypertrophy is fortunately not very 
common, but anything like a complete affection of one lateral 
half of the body is evidently very rare. The present case 
comes very near to a perfect illustration of this condition; 
but a slight implication of some of the fingers on the other 
side exists also. In some of the recorded cases one half of the 
head is affected without the limbs being involved, while in 
others the head escapes ; in this case the head is very dis- 
tinctly implicated, as well as the limbs. A very interesting 
point, and one indicating an excessive activity in the nutrition 
of the affected parts, is the rapidity with which the teeth 
appeared on the right side. There is conclusive evidence in 
this child's case of the difference being present from the time 
of birth — a point left in doubt in some of the other cases. 
The occurrence of otorrhoea has been recorded in some of the 
histories, and it was present in this case on both sides, but 
apparently without its having any special connection with 
the deformity. In this child, as in several of the other cases, 
a very marked cutaneous congestion exists, and it very readily 
becomes developed to an extreme extent when the child cries. 
The notable difference on the two sides, indicated by the sur- 
face thermometer, no doubt depends on the fuller supply of 
blood on the right side. This is not associated, however, 
with the presence of distinct naevi, as in some of the other 
records. 

This congestion of the small veins has been supposed to be 
concerned in the excessive nutrition of the hypertrophied 
parts; but in this case the congestion is by no means uni- 
lateral, and in some of the other cases recorded a similar 
discrepancy existed. The hypertrophy exists in this child 



334 Dr. Fixlaysox — Case of a Child Affected with 

on the right side, which is the one usually affected in such 
cases. 

I have made a short summary of what seemed to me, after 
a study of the literature of the subject, to be the most impor- 
tant points in the records of this curious affection, the patho- 
logy of which is still very obscure. 



Notes on the Literature of the Subject. 

(1.) De 1'hypertrophie unilaterale partielle ou totale clu corps. Par 
U. Trelat et A. Monod. Archives generales de medecine, Mai 
1869-Juin 1869. 

This essay is one of the most important in the series, discussing 
the subject in its various aspects, and giving references to the litera- 
ture, and also a summary, in abstract, of the various cases known to 
them. The following are the headings they give : — 

Beck : Medicinische Annalen, von Puchelt, Cbelius et Naegele, 1836, t. ii, 
No. 1. Hypertrophie congenitale d'un membre ; grosseur anormale du 
pouce et de l'indicateur de la main droite, avec augmentation de volume de 
toute l'extremite superieure du meme cote. 

Fouclier : Bulletin de la societe anatomique 1850, p. 108. Hypertrophie 
congenitale du membre thoracique gauche et peutetre du membre abdo- 
minal du meme cote - ; developpement anormal de l'index et du medius de 
la main gauche. 

Devouges : Bull, de la Soc. anatom., 1856, 2e Serie. T. 1. Predomin- 
ance de developpement du cote droit sur le cote gauche ; developpement 
hypertrophique des trois premiere doigts de la main et du pied droit. 

Adams: Lancet, Aout 1858, p. 140. Cas singulier d'hypertrophie du 
membre inferieur droit avec taches vasculaires, noevi, du meme cote. [See 
under (9)]. 

Ckassaignac : Bulletin de la Societe de chirurgie, le Serie. T. viii, p. 
452. Hypertrophie congenitale des deux membres droits ; taches san- 
guines multiples, varices, &c. 

Ckassaignac : Bulletin de la Societe de Chirurgie, 1859. T. x, p. 52, p. 
103. Chez tous, les taches, siegeaient sur le membre hypertrophie ; tandis 
que chez cette jeune fille elles occupent le membre qui a conserve son 
volume normal. 

linrht : Service de M. Oilier, Gazette medicale de Lyon, Juillet, 1862, 
p. 309. Inegalite congenitale des deux moities du corps ; hypertrophie 
considerable du cote droit. 

Friedreich: Virchow's Archiv. T. xxviii, p. 474, 1863. Hypertrophie 
congdnitale et unilaterale de la tete (cote droit) autopsie. [See further 
account of this case under (3).] 

Passauer: Virchow's Archiv. T. xxxvii. Hyperplasie de la moitie" 
gauche de la face. [See under (4).] 

Trelat: Observation imVlite. Hypertrophie de la moitie droite du 
corps, portant surteut sur le membre inferieur. 

Broca: Journal Physiol. Brown-Sequard. T. ii, p. 70, 1859. Inegalite" 
congenitale des deux parties du corps. Singulieres consequences physio- 
logiques. 

Friedberg : Virchow's Archiv. T. xl, p. 353, 1867. Developpement 



Congenital Unilateral Hypertrophy. 335 

gigantesque congenital et progressif du membre inferieur droit. Inclinai- 
son consecutive du bassin et scoliose de la colonne vertebrale. Elephanti- 
asis des Arabes congenital du bras gauche. Lijjomes dans le dos. Dilata- 
tions veineuses cutanees, pemphigus chronique, &c. [See full title (17).] 

(2.) Ueber angeborenen Riesenwuchs der oberen und unteren Ex- 

tremitaten. Von Dr. Richard Wittelshofer. Archiv fiir klin- 

ische Chirurgie. Bd. 21. Berlin, 1879. 

This paper is of special value, inasmuch as it collects 46 cases, 

and in a large plate gives illustrations of the deformities copied from 

the original sources, to the extent of 15 figures. In connection with 

our present subject of unilateral hypertrophy, the first case from 

Billroth's Klinik, 1873, is illustrated by a remarkable drawing, 

showing the great difference of the two sides. In the 46 patients 

summarised there were 53 monstrosities in the extremities — 31 

upper, 22 lower, 23 on right side, 18 on left side, and 12 not stated. 

(3.) Ueber congenitale Kopf hypertrophic. Yon Prof. Dr. N. Fried- 
reich. Virchow's Archiv. Bd. 28. Berlin, 1863. 
This case is interesting as presenting a deformity of the head 
somewhat similar to that found in the child described in my paper. 
There is an illustration of the face and of the tongue showing hyper- 
trophy on right side. The right tonsil is described as enlarged. 
The case subsequently came to a sectio, and the bones were found to 
participate in the difference. This case is included in Trelat and 
Monod's paper. In Friedreich's paper allusion is made to a case of 
Dr. Heumann's — a boy 5 years old with great hypertrophy of the 
left side of the face. 

(4.) Angeborne Hyperplasie der linken Gesichtshalfte. Von Dr. 
0. Passauer. Virchow's Archiv. Bd. 37. Berlin, 1866. 
In this paper there are illustrations of the appearance of the boy's 
face and tongue. 

(5.) Hypertrophy of the lower parts of the face. By R. Barwell. 
Transactions of the Clinical Society. Vol. 8. London. 1875. 
In this case there was great vascularity, and the facial arteries on 
both sides were tied with some little benefit. 

(6.) Congenital Hypertrophy. By William Anderson. St. Thomas' 
Hospital Reports. Vol. xi. London. 1882. 
In this paper a case is narrated of hypertrophy of the left lower 
extremity, and a very interesting summary of the whole subject is 
given, with numerous references to cases recorded. 

{7.) Case of Congenital and Progressive Hypertrophy of the right 
upper extremity. By William Osier, Montreal. Journal of 
Anatomy and Physiology. Vol. xiv. London. 1879. 
The child referred to was 8 years and 10 months old. Various 
measurements are given, showing the difference of the two sides. 



:}36 Dr. Fixlaysox — Congenital Unilateral Hypertrophy. 

(8.) Hypertrophic congenitale de la rnoitie droite du corps. Par 

le Dr. Langlet. Union medicale et scientitique du Nord-Est. 

Sept. Reims. 1882. 

This ease was communicated to the Medical Society of Reims on 

7th June. The man was a labourer 36 years old. The hypertrophy 

was general on the right side, but the face was not involved. 

Measurements are given of the thorax, abdomen, arms, legs, fingers, 

A-c. The skin seemed normal, but the subcutaneous tissue on the 

chest and abdomen appeared thicker on the right side. The bones 

seemed normal. 

(9.) Singular case of Hypertrophy of the right lower extremity, with 
superficial cutaneous nsevus of the same side. By John Adams. 
Lancet, August 1858, p. 140. 

10.) Case of remarkable Hypertrophy of the fingers in a girl. By 
T. ]1. Cwrlvng. Medico-Chirurgical Transactions, vol. 28. 1845. 

(11.) The Malformations, Diseases, and Injuries of the Fingers and 
Toes, and their surgical treatment. By Thomas Annandale. 
Edinburgh. 1865. 

(12.) Congenital Hypertrophy of the foot and leg, especially of the 
skin and subcutaneous tissue of the sole [left side]. 
Congenital Hypertrophy of the hand and forearm. By Frederic S. 
Eve. Pathological Transactions. Vol. 34. London. 1883. 
p. 298. 

In the first case there was lateral asymmetry of the head and face, 
the left being the larger, and the same asymmetrical enlargement 
affected all parts of the left side of the brain. In the second there 
was dilatation of the lymphatics of the skin in the part affected. 

(13.) Case of Unilateral Hypertrophy of the head and face, involving 

the bones and soft parts. By Richard Barwell. Transactions 

of the Pathological Society of London. Vol. 32. London. 

1881. 

In this case the tongue was also hypertrophied on one side. The 

common carotid artery was tied. The patient died of secondary 

haemorrhage. 

(14.) In St. Bartholomew's Hospital Reports, vol. 14, Dr. Norman 
Moore mentions a case of a girl, seventeen months old, with a 
large right ear and a small left ear. Her right leg and arm 
were a little large also. 

(15.) In Billroth wnd Pifha's Deutsche Chirurgie, Lieferung 64, 
there are references to the literature of congenital malformations, 
and, amongst others, to congenital hypertrophy. 

(16.) Heath. Unilateral Hypertrophy of the ramus of the mandible. 
Lancet, 1883. Vol. 1, p. 409. 



Mr. Maylard — Death from Chloroform. 337 

(17.) Hermann Friedberg : Virchow's Archiv. Bel. 40. 1867. 

Riesenwuchs cles rechten Beines: Angeborener und fortschreitender 
Riesenwuchs des rechten Beines : consecutive Verschiebung des 
Beckens und Skoliose der Wirbelsaule : angeborene Elephantiasis 
Arabum des linken Arrnes : Lipome an dem Riicken : venosen Tele- 
angiectasie der Haut, chronischer Pemphigus, <fcc. 

In this case the patient was a girl 10 years old when seen. The 
paper is illustrated by three remarkable plates ; these are reproducer! 
in Wittelshcifer's paper already referred to. (2). 

In addition to the above I find a reference, which I have been 
unable to look up. Hofmokl Ueber angeborene und erworbene 
ungleichmassige Entwickelung der unteren Extremitaten bei Kinderu. 
Wien. Klinik. 1879, p. 286-294. 



DEATH FROM CHLOROFORM, ACCOMPANIED WITH 
UNUSUAL SYMPTOMS. 

By A. ERXEST MAYLARD, B.S.Loxd. 
Extra-Dispensary Surgeon to the Western Infirmary, Glasgow. 

D. M., aged 26, was admitted into the Western Infirmary, under 
the charge of Dr. Patterson, on 24th June, 1884, suffering from 
injuries to his legs, produced by the fall of a metal plate. On 
examination he was found to have a simple comminuted 
fracture of the left femur a little below the centre of the 
bone, and a similar comminuted fracture near the right knee 
joint, involving both femur and tibia, with considerable dis- 
placement of parts. The patient, who was a strong, well- 
made man, presented no marked collapsed condition, notwith- 
standing the extensive injury received. The limbs were placed 
in position, and on the following morning chloroform was 
administered to allow of certain re-adjustments of the parts. 
The anaesthetic was given in the usual way, with a folded 
towel, and the patient went quietly under its influence with 
nothing abnormal to attract attention. On removal of the 
splints about the middle of August the fractures were found 
firmly united, and at the end of the month the patient was 
allowed to get up daily for a short time. He continued in 
the same way during the month of September, being unable 
to walk or use his limbs from stiffness of the joints. 

Being in charge of the wards, in the absence of Dr. Patter- 
No. 5. Z Vol. XXII. 



338 Mr Maylard — Death from Chloroform, 

son, I arranged that on 1st October we would give the man 
chloroform, and forcibly move his stiffened joints. At the 
appointed time the house surgeon and myself proceeded to 
give the anaesthetic. The patient showed not the least sign 
of nervousness, actively put himself into position for adminis- 
tration, and commenced inhaling by several rapid shallow 
inspirations, as if determined to get quickly under the in- 
fluence of the drug. Following immediately upon the shallow 
movements were three or four very deep inspirations. Feeling 
that this method of inhaling must have entailed a large and 
rapid consumption of chloroform, I told the house surgeon to 
remove the cloth, when the patient, though still breathing, 
was seen to have his eyes wide open, pupils extremely dilated, 
or rather rapidly dilating, and conjunctiva insensible. The 
face was neither livid nor pale ; the»lips, indeed, were of their 
normal pink hue, and the cheeks slightly flushed; in fact, 
besides the condition of the eyes, there was nothing in the 
facial aspect to excite alarm. Up to this point the time from 
commencement of inhalation could not have exceeded one to 
two minutes. On feeling the right radial no pulse could be 
detected ; this was confirmed by a student on the opposite side, 
who had hold of the left wrist. The pillow beneath the 
patient's head was at once removed and the head lowered. 
Respiration then ceased, not, however, until three or four 
breaths had been drawn after the recognised cessation of the 
pulse. The tongue was immediately withdrawn by the artery 
forceps and artificial respiration commenced. The case being 
one of undoubted primary cardiac failure, measures were 
taken to stimulate the heart. The bed was raised to a con- 
siderable height at the foot: a subcutaneous injection of 
ether given (20 min.) and galvanism applied. This latter, 
not being on the spot, some ten or fifteen minutes must have 
elapsed before it was brought into use. After artificial 
respiration (Sylvester's method) had been continued for, I 
should judge, about a minute or two, the patient took a deep 
inspiration. This, with varying intervals, was followed by 
three or four more, but the acts were much more suggestive of 
the final " gasps " of a dying man than of the gradual return of 
normal respiration. The pupil slightly contracted, but again 
dilated, to remain permanently so. Although there was this 
indication of some activity in the respiratory system, there 
was no indication of any return of cardiac contraction. After 
the final " gasp " the face began to assume the appearance of 
post-mortem lividity, the cornea lost its lustre, and all signs of 
life seemed extinct. Artificial respiration was, however, kept 



Accompanied with Unusual Symptoms. 339 

up for half-an-hour, but no indication whatever of returning 
life manifested itself, and there seems little doubt that our 
patient must have been dead from the moment the heart 
definitely ceased, and that only about two minutes after the 
commencement of administration of the anaesthetic. 

Remarks. — Reviewing the case as the symptoms presented 
themselves, the rapidity of respiration with which the patient 
commenced inhaling is by no means an uncommon method of 
taking the anaesthetic. The patient is told to " breathe away," 
when he at once begins — to use a rather vulgar though 
apt simile — pumping like a steam engine, and as a result 
passes into a condition of apnoea manifested by cessation 
of respiratory efforts. The blood being then hyperoxydized, 
there is no need to respire, and the patient accordingly holds 
his breath. So frequently is this seen, that when our patient 
commenced breathing in this way, I casually remarked to the 
house surgeon that the man would soon hold his breath, 
having induced a condition of apnoea. Instead, however, of 
doing this, he commenced quite suddenly taking deep and 
rapid inspirations, and standing in such a position as to be 
able to see beneath the towel I noticed his eyes wide open. 
These two abnormal sequences — open eyes and deep inspira- 
tions following upon the rapid shallow breaths — induced me 
at once to tell the house surgeon to remove the towel. I 
would here parenthetically state, so as to be perfectly ex- 
plicit, that the respiratory movements were not merely 
thoracic or abdominal upheavings, but air rushing— as best 
expresses it — audibly through the larynx and mouth. The 
face presented the appearance already stated. There was 
neither the lividity of obstructed respiration nor the pallor of 
cardiac failure. The condition of the eyes alone suggested 
some radical derangement, and induced me to examine the 
pulse, which I had not previously watched, nor directed any- 
one else to watch. 

Although my object in fully reporting this case is not 
specially to exculpate myself from any possible precautions left 
untaken or methods of treatment unapplied, still I frankly 
confess myself reasonably exposed to three accusations. 
First — for not removing the anaesthetic when the patient com- 
menced breathing in a manner which may rightly be des- 
cribed as abnormal respiration ; second — for not watching the 
pupils ; third — for not attending to the pulse. Concerning the 
first 1 must say, that in doing what I did I was pursuing 
a course usually adopted in similar cases. So constantly, 
indeed, have I seen the anaesthetic continuously applied 



340 Mr. Maylard — Death from Chloroform, 

during this condition without untoward symptoms, that one 
has grown to look upon it as a useful adjunct towards 
producing rapid anaesthesia. The ensuing condition of 
apncea is always pi*otective against the otherwise too great 
and concentrated absorption of the anaesthetic ; and not- 
withstanding the often fortunately futile endeavours of the 
administrator to make the patient go on breathing, he 
still resists long enough to allow the drug to diffuse itself 

DO O 

and the blood to regain its comparatively normal con- 
dition before any further introduction of the anaesthetic. 
Had our patient been deprived of the chloroform when first he 
commenced the abnormal respiration, I think it within the 
bounds of extreme probability the fatal result might have 
been averted ; but precedent was in our favour, and, alas ! we 
continued. I know of no case where death has occurred in 
precisely the same way as in the above ; had I, I should have 
acted otherwise — and should this possibly be the first, it has 
taught me a lesson, and I should venture to hope my confession 
may not be without its beneficial effect in the practice of 
others. While I believe it is not unlikely other causes sub- 
sisted which may have materially conduced to the fatal end, 
the amount of the drug which must have been absorbed 
during the rapid inspirations both shallow and deep formed 
by far the most cogent agent in effecting the issue. 

Concerning the other two points — watching the pupil and 
attention to the pulse — much is to be said. I shall, imprimis, 
receive the accord of my compeers, both old and young, in the 
general assertion that lack of experience in our own practice 
should induce us to follow the dictates of those to whom 
opportunities are especially afforded, and whose professional 
position is a sufficient guarantee of reliance. Although I can 
number my personal administrations of chloroform by hundreds, 
I cannot do so by thousands, and what experience may be 
gained by the former is in its effects greatly augmented if in 
accordance with, or materially lessened if adverse to, the ex- 
perience derived from the latter. For the teaching of Sir 
Joseph Lister I have the profoundest respect, and to find in 
his admirable article on anaesthetics, in Holme's System of 
Surgery, facts coinciding with my own comparatively humble 
experience is, I venture to think, a sufficient justification for 
any method of diagnosis or line of treatment. Throughout 
this article the author deprecates any special attention being 
attached either to the pulse or the pupil. The impression one 
derives from reading the subject is that paramount importance 
must be attached to the respiration, while observation of 



Accompanied with Unusual Symptoms. 341 

either pulse or pupil may be almost entirely discarded. This 
my own comparatively short experience had supported, but 
now supports no longer. The very two conditions which in 
this case would have intimated that something was wrong 
were ignored, and what might possibly have indicated at an 
early stage preventive measures, existed later as simply pas- 
sive fatal symptoms. So absolutely manifest here was the 
cessation of the pulse, and the dilatation of the pupil previous 
to the stopping of respiration, that on the strength of only this 
single case one feels fully justified in forcibly refuting the 
drift of Sir Joseph Lister's teaching, and asserting rather that 
attention should be equally distributed upon pulse, pupil, and 
respiration. It must, however, be said that in those cases 
where death occurs at an early period of the administration 
from primary cardiac failure, the heart stops suddenly without 
any premonitory indication of increasing feebleness of the 
pulse, and life from that moment is irrecoverably gone. Still, 
this is not the least argument against the advantage likely to 
accrue from carefully watching the pulse from the outset. To 
ascertain the immediate stoppage of the heart is to allow of 
active measures being at once taken, perhaps at the only period 
when it is possible to recover cardiac contraction. 

The peculiar normal hue of the cheeks and lips, notwith- 
standing the cardiac cessation, must receive their explanation 
from one of two causes — either there was paralysis of the 
sympathetic, whereby the small arteries and capillaries failed 
to empty themselves, or the highly oxydized condition of the 
blood within the veins induced them to ffive the skin the 
ordinary appearance resulting from arterial supply. Although 
one is fully justified in assuming that the blood, after the 
rapid respiratory acts, was in an apnceic condition, it seems 
mure feasible to suppose that the same influence which had 
deranged the cardiac nerve mechanism had also produced a 
like effect upon the nerve mechanism of the blood-vessels. I 
use the more general term " nerve mechanism " because it 
involves too much theoretical reasoning to attempt — in the 
absence of any careful post-mortem examination — to differen- 
tiate between the possible influences invoked through the 
medium of the cerebro-spinal centres on the one hand, or 
directly through the organs themselves on the other. Thus, 
to have found the cardiac cavities either all empty or all con- 
taining an equal quantity of blood, or one side empty and the 
other distended, might have helped toward sonic reasonable 
solution. The rapid pallor which usually ensues in nearly all 
cases of primary cardiac failure, would seem to be due to a 



342 Mr. Maylard — Death from Chloroform, 

spasm of the vasomotor nerves causing the arteries at once to 
empty their contents into the veins. It is not unlikely, too, 
that the cessation of the heart may similarly be produced by 
spasmodic action. So one cannot help feeling that an ex- 
amination of the heart in the present case might have thrown 
some light upon the peculiar pink colour of the lips. To have 
found the heart uniformly distended with blood would have 
supported the theory that both the cardiac and vasomotor 
centres in the medulla had been paralyzed. 

The return of the "gasping" after a short interval of 
artificial respiration is a point of interest. The explanation 
must rest upon the condition of apnoea induced by the rapid 
respiration. The blood being surcharged with oxygen there 
was no need for inspiratory efforts ; but as soon as deoxydiza- 
tion had taken place the respiratory nerve centre was 
stimulated and the "gasps" ensued. If this be the true 
explanation, then it shows how much more deeply and sooner 
the cardiac nerve mechanism was affected than the respiratory. 
With the light thrown upon the subject by the well known 
experiments of Dr. Snow upon animals, where a concentrated 
atmosphere of the anaesthetic produced death by primary 
cardiac failure, and a dilute one by primary cessation of 
respiration, it would seem that our conclusion was a correct 
one, and that death was principally caused by an overdose of 
chloroform concentrated or accumulated in the system in a 
short space of time. 

The gradual, but finally extensive, dilatation of the pupil 
seems a sign more of impending death from any cause than 
indicative of any special one. The last case of death from 
chloroform which I witnessed under the hands of an old and 
experienced surgeon, was one where the respiratory troubles 
gave rise to the most prominent symptoms, and here, also, the 
pupils became rapidly and widely dilated. 

Stress is attached by some surgeons to the importance of 
watching the colour of the lips. There is no doubt that in 
most cases they become at once anaemic on failure of the 
heart's action ; but, as has already been mentioned, the present 
case gave not the least indication of any such event having 
happened. The lips, at first pink, passed gradually into a 
livid condition, presenting at no time any peculiar pallor. 
The ensuing lividity seemed to result from the tilting of the 
body. 

I feel I trench on delicate ground in attempting to raise 
any objection to the conventional towel method of adminis- 
tration — a method which consists in folding an ordinary 






Accompanied with Unusual Symptoms. 343 

towel into a square, and pouring into the centre of it an un- 
measured quantity of chloroform. It has done such good service 
for so many years without, perhaps, more fatal, or more success- 
ful, results than have occurred with other methods that one 
naturally feels some hesitation in venturing to raise any 
objections. Nevertheless, with all due deference to those who 
still use it, and believe it to be the best means of administration, 
I feel forced to the opinion that there is an air of clumsiness 
about it in appearance, and undoubtedly often a carelessness in 
application. It was originally introduced by Mr. Syme, and 
used extensively both by him and Sir Joseph Lister. The 
latter, however, has for many years discarded it, and in its 
stead used the corner of a towel neatly pinched up so as to 
form a hollow receptacle, in size just sufficient to cover the 
nose and mouth. This is an extremely simple method, always 
at hand, readily allows a perfect and constant observation of 
the patient's face and respiration, and permits but the 
application of a very small quantity of the anaesthetic at a 
time. 

The folded towel, when first introduced, was no doubt used 
with many precautions as to quantity of chloroform poured on 
the towel, position on the face, and so on, but time seems to have 
lessened the cogency of these directions, and one now sees the 
anaesthetic poured on to the cloth from a large twenty-ounce 
bottle by a " rule of thumb " process ; the quantity not unfre- 
quently being sufficient to flow off the towel and over the 
administrator's hands. One finds amongst the old directions 
as to the place of the towel on the face that " care should be 
taken that free space is afforded for the access of air beneath 
its edges." Yet how often is this neglected, and the patient's 
face completel}' shut in except at the front part. Again, the 
extent to which the face is covered is another very variable 
factor in the process of administ ration. One man will have a 
well-arched space beneath the towel, while another holds it 
almost flat upon the patient's face; one will hold it low 
enough to expose the eyes and obscure the mouth, while 
another will do the opposite. These are all points possibly of 
little moment to the experienced administrator who, with a 
perfect knowledge of his agent, varies the conditions accord- 
ing to requirements; but to the student, who will probably 
never attain extended experience, any thingwhich fails to convey 
in so important a subject the most complete perspicuity and 
precision is bound to be fraught with more or less dang< r. 
That there is an air of indefinitenesa and carelessness often 
evinced in this method of administration one feels convinced, 



344 Mr. Maylard — Death from Chloroform, 

and for that reason alone it seems justifiable to reject it as a 
method to be taught. 

The simple plan adopted by Sir Joseph Lister does away 
with many of the above difficulties and dangers. The towel 
being held by one hand the other is at liberty to feel the 
pulse (radial, facial, or temporal), examine the eye, or with- 
draw the tongue. Instead of the large chloroform bottle, so 
awkward in every way, the administrator can carry a small 
measured drop-stop bottle, provided with a hook and hung to 
a button -hole. With the free hand the anaesthetic can be easily 
dropped upon the cloth at any time and to any extent. 

The bearing which this question of method of administra- 
tion has upon the case at issue is not without weight. The 
house surgeon, a man of much experience, exercising at all 
times the greatest care, and trained under a most esteemed 
surgeon, commenced administering the anaesthetic as he had 
done scores of times previously. If, now, instead of the usual 
half ounce of chloroform poured upon the square folded towel 
and placed over the patient's face, there had been from one 
to two drachms sprinkled on the towel-end, it is just possible 
our patient might not have succumbed. The quantity would 
likely have been too small to have accumulated within the 
system and paralysed the heart. Whether this be so or no, it 
does not alter what one feels to be the principal consideration, 
that as soon as the patient begins to breathe in that rapid and 
abnormal way seen in our case, the wisest plan is — no matter 
what the method of administration — to remove the anaesthetic 
at once. 

Turning now to other conditions which may be readily 
acceded as having conduced indirectly to a fatal issue, it seems 
not unreasonable to assume that the man's constitution must 
have undergone marked changes during his residence in hos- 
pital. His face, indeed, seemed to indicate this. According 
to the report taken at the time of his admission he is des- 
cribed as " a strong, healthy looking man," while as seen 
recently his face had grown much thinner, his cheeks palish, 
and his whole countenance presenting the appearance of a 
delicate constitution. He was, however, according to his own 
feelings, in good health, taking his food well, being generally 
of a happy and cheerful disposition. Thus, then, we have a 
strong, able-bodied man, actively engaged in labour, suddenly 
put upon his back for about two and a half months, and for a 
month longer capable only of the slightest movements. It is 
impossible to conceive but that all those organs, which in 
a young man were probably augmented in size from functional 



Accompanied with Unusual Symptoms. 345 

activity, must have suffered very materially from this sudden 
change in mode of living, and that very probably fatty 
degeneration and infiltration would be the predominating 
pathological process alike in nerve and muscle tissue. Whether 
any such organic change had actually taken place or not we 
were, unfortunately, unable to determine. Much as we desired 
and endeavoured to obtain a 'post-mortem examination the 
patient's friends remained obdurate, so that whatever may be 
our conclusions as to the possibility of extensive fatty changes 
they can only be conjectural. 

Finally, then, we are reduced to these two alternatives — 
either that the patient died from the effects of an overdose 
of chloroform, pure and simple, or from chloroform acting 
upon a greatly enfeebled heart, brought about possibly by 
fatty degeneration and infiltration of nerve and muscle tissue. 
From cases reported where there has been found most exten- 
sive fatty degeneration of the heart after death from other 
causes, and where chloroform had been administered some 
short time previously with perfect success, one is forced to 
admit, in the absence of any other known lesion, the strong 
probability of the former surmise being the correct one, and 
that had the patient taken the chloroform in the same way 
when formerly administered, he would just as likely have 
succumbed. If this be accepted as the true explanation, we 
have yet still further to allow an unusual susceptibility to the 
drug. For, while other patients inhaling the anaesthetic in 
precisely a similar way have in apparently all cases recovered, 
this one did not. 

Within the comparatively short space of ten years, accident 
has placed me in the position of witnessing four deaths from 
chloroform. With the exception of the one narrated, the 
rest occurred in the hands of experienced hospital surgeons, 
and the general impression which these cases, with my own, 
have produced upon me is, that one's attention should not be 
exclusively directed to the occurrence of a particular symptom, 
nor one's faith pinned to the possible infallibility of a whim in 
method of administration ; but that the administrator should 
always be alive to the possibility of his having a fatal case, 
and look upon every aberration of normal function as an 
indication of grave importance. 

From remarks by Sir Joseph Lister, and from conversation 
with some Glasgow surgeons, it seems a fact that deaths from 
chloroform in both our large Infirmaries have increased in 
recent years; that whereas, some fifteen or twenty years ago, 
the} r were comparatively unknown, they appear at present to 



346 Dr. Finlayson axd Mr. Maylard — 

be becoming unfortunately too familiar. Why this should 
be it is impossible to say, seeing chloroform was as frequently 
given then as now. 

I would conclude this rather long article with the three 
following questions, leaving every thoughtful surgeon to 
endeavour to answer them for himself. 

First, Have our patients, from some cause — possibly fear, 
created through meddlesome interference and prejudicial 
publicity, rendered upon the subject by misguided, though 
often well-meaning, lay members — become more susceptible to 
the influence of the drug ? Second, Is the constitution of 
chloroform the same at the present time as years ago ? Third, 
Is our method of administration free from all possible blame ? 



CASE OF FCETID PYO-PNEUMO-THORAX TREATED 
BY MEANS OF TWO FREE INCISIONS, CONTIN- 
UOUS DRAINAGE, AND FREQUENT ABLUTION 
WITH CONDY'S FLUID. TEMPORARY RELIEF. 
DEATH FROM SUPPURATIVE INFLAMMATION 
IN THE OTHER LUNG. 

Under the Care of Dr. FINLAYSON and Mr. MAYLARD. 
Reported by Dr. FINLAY, Resident Physician, Western Infirmary. 

M. B., set: 49 years, an ironworker, was admitted to the 
Western Infirmary on 30th September, 1884, complaining of 
cough, dyspnoea, and a sense of oppression in the chest, or as he 
described it, " a feeling of choking." For a period of eighteen 
months he had not been in good health, his illness beginning 
apparently with a neglected cold in the first instance ; before 
that he was very robust. He seems to have always used 
whisky freely and often to excess. The very acute symptoms 
dated more particularly from the month of June of the pre- 
sent year, when he suffered from pleurisy, and it was only then 
he discontinued his work. About three weeks after the com- 
mencement of the pleuritic attack he was much troubled, 
especially in the night time, by what he described as a "flow of 
phlegm in the chest," and at the same time he observed that 



Case of Foetid Pyo-Pneumo-Thorax. 347 

if he flexed his body forwards a large quantity of very fcetid 
yellowish fluid would gush from his mouth. This running of 
pus out of the mouth was verified repeatedly after admission. 
He never had haemoptysis ; there was no history of a sudden 
onset of localised pain accompanied by dyspnoea, by which the 
date of the pneumo-thorax could be ascertained. 

On admission his cough was most irritating, and the ex- 
pectoration very profuse, about 12 oz. in the day, purulent in 
character, and having an intensely foetid odour. Indeed, the 
foetor was so extreme that the patient had to be removed from 
the ward and placed in a side room, and carbolic sprays and 
disinfectants used to improve the air. The expired air, during 
coughing, had the same foetid, almost gangrenous, odour. (The 
sputum was examined for lung tissue but none was found.) 
The face was decidedly livid, and this seemed to become more 
marked as the case advanced. Orthopncea was present from 
the time of admission, and the respirations were rapid and 
laborious. 

Physiccd Signs. — On inspection, the right front in the upper 
zone of chest is seen to be a little flatter than the left. 
Respiratory movements are diminished on the right side as 
compared with the left. Myoidema is marked. On percussing 
the right front from above downwards, the sound becomes 
slightly dull, about ^ inch above the horizontal line of 
the nipple, and it becomes absolutely dull about \ inch below 
that line. This dulness extends into the axilla ; and in the 
lateral region there is no clear percussion. The percussion 
note in front cannot be said distinctly to change by altering 
the position of the patient. Measured immediately below the 
nipple, also in the lower zone of the chest, the right side is 
fully an inch less than the left. On auscultation the respira- 
tory murmur on the left front is puerile, and subcrepitant 
rales arc heard on expiration. On the right side the breathing 
is not so loud, and harsh mucous rales are heard both on 
expiration and inspiration, especially in the mamillary region 
above the nipple, and then the breathing is occasionally heard 
to have something of amphoric quality. Metallic tinkling and 
splashing sounds on succussion are most distinctly heard in 
the right mammary region when the patient lies on his back. 
The bell sound has not been clearly made out, and there is no 
marked difference in the vocal resonance on the two sides. 
Posteriorly there is dulness to percussion on the right side, 
particularly in the lower half. The auscultatory signs are 
nearly the same as in front. The urine is free of albumen. 

During the week before he was operated upon the tempera- . 



348 Dr. Finlayson and Mr. Maylard — 

ture was febrile with the exception of one day. On the night 
of admission, a maximum of 1024° F. was reached ; and in the 
remaining six days the temperature ranged from 99'4° to 10i"6°. 
Occasionally he was inclined to be a little delirious. He did 
not take his food well. Bowels were regular, and the urine 
free from albumen. A little opium was given to relieve the 
cough. He was also allowed some stimulant. 

On 8th October the patient was operated on by Mr. Maylard, 
and the pleural cavity washed out (as described in his remarks). 

Evening. — There has been little cough, and the patient is 
quiet ; but the respirations are getting rapid — about fifty, and 
he is sweating. No great rale on left side. He has been 
taking food and stimulants freely. Opium was stopped last 
night, and to have ammonia mixture now. 

9th October. — When dressing the case last night, Mr. Maylard 
adopted continuous drainage ; the tube discharged into a 
vessel of carbolic solution, and it seems to be acting well. 

Ufth October. — Since the above note, the patient has not 
become any worse, but rather better. His cough is much less 
troublesome, and he has none of the thin purulent expectora- 
tion ; he spits up, however, some distinctly shaped sputa. 
There is no pain, except what might be expected from the 
wounds. The breathing is less rapid, averaging from thirty- 
six to forty-two, and is performed with less difficulty. The 
lividity of his face has disappeared. The foetor of the dis- 
charge has almost entirely gone. He takes his food well and 
sleeps well, although he continues very weak and helpless. 
Since the operation, the temperature has remained much the 
same as before. A maximum of 103° F. was reached on the 
12th, at 4 p.m. The temperature has usually been 2° or 3° 
higher in the evening than the morning. 

loth October. — Last night the patient seemed much worse. He 
complained of no pains, but only of great weakness. Respira- 
tion became more rapid, and occasionally he was delirious. This 
morning he looked somewhat better, but his condition altogether 
was very unfavourable. About 10 a.m. he got rapidly weaker. 
His face assumed a dusky hue, and a cold sweat broke over 
his face and arms. His condition resembled more what it was 
on the morning before the operation was performed. Distinct 
indications of consolidation in the lower part of left lung were 
made out. Stimulants were freely administered, but he died 
at 430 p.m. 

Post-mortem examination. — The heart muscle soft and 
flabby, and the external fat considerably increased on the 
surface of the ventricle. The tricuspid orifice is considerably 



Case of Foetid Pyo-Pneumo-Thorax. 340 

dilated, and readily admits of six fingers, otherwise, it presents 
nothing remarkable. 

The left lung is pretty generally adherent, and upon section 
presents very considerable oedema. Posterior part of lower 
lobe is distinctly consolidated, and presents a red appearance. 
In this consolidated area are several small abscesses filled with 
yellow pus, and lined with a distinct pyogenic membrane. 

The right lung is firmly adherent over its upper lobe. 
In the pleural cavity, over an area corresponding with the 
lower lobe of the lung, there is a considerable quantity of 
purulent material ; and the walls of the space containing the 
pus are lined with soft purulent exudation. On attempting to 
remove the lung, the tissue of its apex is extensively lacerated 
from the excessive degree of adhesion. No communication can 
be made out between the bronchus and the pleural cavity ; but 
owing to the torn condition of the lung no attempt was made 
to discover the aperture by inflation. In the apices of both 
lungs small calcareous concretions are discovered, but nothing 
of the nature of recent tubercular disease can be detected. 

Spleen is enlarged, weighing lOf ounces, and is of very soft 
consistence. 

Kidneys are soft and somewhat pale, without any proper 
line of demarcation between the cortex and the pyramids. 

The liver presents healthy characters. 

Remarks by Dr. Finlayson. — The examination of this case 
was somewhat difficult owing to the serious dyspnoea, the very 
troublesome cough, which was easily aggravated on disturbing 
him, and also owing to the very extreme foetor. Within a 
couple of days, however, after admission, the diagnosis was 
made on the detection of splashing sounds, and on finding 
that thin foetid pus ran out of his mouth on stooping down. 
We had then clearly a foetid pyo-pneumo-thorax, and a free 
communication with the bronchus. The case was reported 
with great care by Dr. Pretsell — one of my former pupils, 
and from his notes this abstract has been compiled. After 
hearing the full report, I at once decided to seek Mr. May- 
lard's assistance, although I feared that the case was essen- 
tially based on phthisical disease. This fear of phthisis was 
in a sense justified by the post-mortem examination, as a few 
old cretaceous masses were found, but really no recent or 
active mischief of this kind existed. 1 was to some extent 
misled by the presence of physical signs in the opposite or 
left side, these, indeed, <mlv indicated bronchial irritation, 
but taken in connection with an illness before the pleurisy, 
and with a pyo-pneumo-thorax, they were strongly suggestive 



350 Dr. Finlayson and Mr. Maylard — 

of phthisis. The livid and prostrate appearance of the patient 
on the morning of the operation seemed to indicate that there 
had been undue delay, and the course of the case after the 
operation confirmed this view. For while the operation 
afforded immediate relief to the paroxysms of coughing, and 
to the extreme foetor, it became evident in a few days that 
the other lung was becoming more affected, and before death 
indications of consolidation in the lower lobe were detected. 
I discussed with Mr. Maylard the cause of the supervention of 
this mischief, which seemed likely to cut short the case, even 
although the results of this operation had been, so far, hope- 
ful. I indicated my belief that the fcetid pus, in gaining 
access during so many weeks to the bronchus and trachea, 
might very readily, during the paroxysms of coughing, or 
during the violent inspirations succeeding a cough, be sucked 
into the other bronchus, and penetrating into the smaller 
tubes, set up there the species of inflammation so well known 
to be determined by foreign bodies ; and this mischief would 
in all probability be more intense owing to the extremely 
foetid character of the matter thus sucked in. I had been 
forced to think of such an accident owing to the remarkable 
mischief I had seen produced in the lungs from a perforating 
ulcer of the oesophagus opening into the trachea, and so allow- 
ing portions of food to be sucked in. (See Glasgow Medical 
Journal, vol. xix, p. 313.) The iDost-mortem examination 
showed the veiy condition likely to be thus produced. This 
mischief in the left lung had no doubt existed for some little 
time before admission, and had produced the physical signs 
construed then erroneously as due to phthisis. The presence 
of this complication, although preventing the success of the 
operation in this case, seems to show the necessity for such 
interference all the more strongly ; and if the operation had 
been performed a few weeks earlier, this patient might very 
likely have been saved. 

Remarks by Mr. Maylard. — The surgical aspect of this 
case contains some points of interest. When first I saw the 
patient, in consultation with Dr. Finlayson, he was in such a 
condition as to admit of the reasonable consideration of 
opening the chest ; and we accordingly arranged to do this on 
the second day from my first seeing the man. On arrival on 
the morning decided upon to operate, we found the patient 
much worse, and, indeed, so bad as to raise the question of 
doing anything at all. He was livid in the face, and delirious, 
and had all the appearances of a man who could not live 
through the day. To administer chloroform seemed quite 



Case of Foetid Pyo-Pnewmo-Thorax. 351 

inadmissible, and if anything was to be done it must be 
without an anaesthetic. Considering it was the only possible 
chance the man had, it was decided to freeze and make a free 
intercostal incision into the pleural cavity. An incision, about 
one and a half inch long, was made in the fourth intercostal 
space, about three and a quarter inches from the median line 
in front, and immediately the cavity was opened a copious 
ejection of putrid gas and sero-purulent material took place. 
A bougie was then inserted, and a counter opening made 
about four inches behind the other and through the sixth 
space. An india-rubber tube was fixed by one end to a No. 8 
gum elastic catheter, and by the other to a funnel. The 
catheter was then inserted into the anterior wound, and a 
solution of Condy's fluid poured through the cavity. This 
was continued until the fluid which flowed from the posterior 
aperture was clear, the total quantity being from one to two 
gallons. Drainage tubes were inserted into each wound, and 
large pads of carbolic gauze and carbolised tow placed over 
them to absorb the discharge. The patient seemed much 
relieved after the operation, his troublesome cough ceasing 
almost entirely. On the day following the operation, I 
arranged the tubes of ingress and exit in such a manner that 
the one coming from the posterior wound passed into a 
solution of carbolic acid placed beside the bed, and thus 
allowed of complete drainage ; and the other sufficiently long, 
and with a stopcock, to permit the Condy's fluid being poured 
in without disturbing our patient. In this way we washed 
out most effectually his pleural cavity twice daily, using on 
each occasion about two quarts, which was sufficient for 
complete purification. Although the discharge never became 
quite sweet, its pungency and offensiveness were greatly 
reduced. The wounds in the chest were dusted with iodoform, 
ami protected as much as possible with slips of lint soaked in 
carbolised oil. 

Had it been possible to administer chloroform, it w T as my 
intention to have removed a piece of rib at the posterior 
orifice. The advantage of doing this was very clearly shown 
in the difficulties, daily increasing, of keeping the tube in 
position. For it was found that, as the pleural cavit} 7, 
contracted, the skin incision altered its relation to the deep 
intercostal orifice, so that the sinus was becoming more and 
more oblique, and the tube consequently easily slipping out 
and readily getting obstructed. 

Reference may be made to an interesting case published 
conjointly by Professors Gairdner and Buchanan, in the 



'A')2 Current Topics — Reviews. 

February (1883) number of the Glasgow Medical Journal. 
The clinical features were different, but the treatment much 
the same. Also, another case by Dr. Russell, in the September 
number of the same Journal for the same year, where he 
likewise ofives references to other cases. 



CURRENT TOPICS. 



Glasgow Southern Medical Society. — Session 1884-85. — 
At the Annual Meeting of this Society, held on the 9th ult., 
in their Rooms, 11 Bridge Street, the following gentlemen 
were elected Office-bearers for the session 1884-85 : — Presi- 
dent, Alex. Napier, M.D. : Vice-President, Wm. Carr, M.B., 
L.RC.S.Ed.; Treasurer, Ed. M'Millan, L.R.C.S.Ed. ; Secretary, 
David Tindal, M.D. ; Editorial Secretory, James Hamilton, 
M.B., CM.; Seed Keeper, Thomas Lapraik, M.D. ; Court Medi- 
cal, Robert Park, M.D. {Convener) ; James Morton, M.D. ; A. 
Pearson, M.D.; James Barms, M.D. ; John White, M.D. ; 
Ordinary Members to complete Council, John Glaister, M.B., 
L.R.C.S.Ed.; Wm. J. Shaw, M.B., CM.; Fred. A. Freer, 
L.F.P.S.G. 



REVIEWS. 



Memoirs of Life ami Work. By Charles J. B. Williams, 
M.D., F.R.S. London: Smith, Elder & Co. 1884. 

Many centuries ago a philosopher, whose name is still a house- 
hold word, wrote, " nor can I regret that I have lived, since I 
have so lived that I may trust I was not born in vain." 
There is something very grand and noble in this confidence 
in the value of his life and work ; something which makes one 
feel, that in spite of all we can claim for this boasted nineteenth 
century, there were giants in those days. Perhaps the average 
of men now are less of dwarfs, possibly even the dwarfs of 
to-day might then have taken rank as giants, hence the Sauls 
among the people seem less heroic. 

Biographies were not so common in the days of Cicero, their 



Reviews. 353 

frequency is a more modern development ; not an undesirable 
development if we can believe Carlyle that " Biography is by 
nature the most universally profitable, universally pleasant of 
all things ; especially biography of distinguished individuals," 
yet not fully reliable, if, as Dr. Clifford Albutt thinks, a course 
of Fowler's Solution might have denied us Mrs. Carlyle's 
Letters, or the Confessions of an English Opium Eater. 

Assigning even the lowest value to such scepticism, we look 
far and wide without finding evidence of confidence in the 
permanency of their work in men of the present day. En- 
thusiasts and discoverers all believe their work to be immortal ; 
but the chilling influence of advancing age and contemporary 
discovery begets fears and doubts which Cicero appears not to 
have known. Sir Henry Holland, old in years, and one would 
think overburdened with honours, prefaces the second edition 
of his Medical Notes and Reflections with an apology for 
presenting general views and suggestions which he considers 
deserve more notice than they have hitherto commonly received. 
Dr. Williams confesses "to a predominant feeling of painful 
surprise in glancing through several subjects" (in Quain's 
Dictionary of Medicine), " with which my name has been 
identified during the last fifty years, at not finding it once 
mentioned." 

There is something of the spirit of Cicero in Dr. Quain's 
reply, " I should as little have expected a reproach from you 
for not mentioning your name in connection with these 
subjects, as from the shade of Harvey for not mentioning his 
name in connection with the disorders of the circulation, or of 
Laennec because no reference is made to his name in connection 
with the stethoscope and auscultation." To feel that one has 
not been born in vain is evidently now more difficult, either 
because it is now more difficult to feel that we have greatly 
surpassed our contemporaries, or because the multiplication of 
the aims, and consequently of the branches of science, makes 
one feel that so much is still left undone. 

With such preface we are led to the points of this memoir. 
We approach them with the knowledge that many notices are 
already in print. We do not regret the fact, for it frees us 
from the necessity of giving prominence to much which is 
historical and important, and permits us to examine the 
biography of a great and successful man from a more human 
and personal standpoint. 

Even Mr. Galton would be satisfied with Dr. Williams' 
genealogy. Born of a stock notable for superior mental attain- 
ment, he was brought up amid the surroundings of a rustic. 

No. 5. 2 A Y,.l. XXII 



354 Reviews. 

Destined for the life of a medical man, the early manifestations 
of an observant power, as controlling taught information, would 
fulfil Dr. Moxon's requirement of five sense philosophy as an 
element of true greatness in the physician. 

This taught information is apt to have a very stagnating 
influence, unless both teacher and taught are continually open 
to a five sense criticism, and have radical tendencies. Teachers 
seldom fail in this respect; pupils often. Dr. Williams was 
not such a pupil. Beginning his adult life in what may be 
termed the infancy of to-day's medicine, he has been spared 
to see the birth of a new era — truly begotten of the past — and 
acknowledging to himself and others a filial duty. Few men 
are permitted to witness so much of two generations of progress; 
but the work of Laennec and of Koch cannot be regarded as 
less than two generations. 

About the year 182G, as a student of Laennec's, Dr. Williams 
wrote, " Clever as he (Laennec) had been in tracing the signs 
empirically, he was not equally successful in explaining them 
rationally, . . . yet it appeared to me that physical signs 
must be amenable to physical laws, and that a knowledge of 
these laws, so far as attainable, would be the best guide to a 
knowledge and understanding of the signs and of the causes 
which produce them." We can make no more fair comment 
upon this quotation than to say that twenty years later, when 
the Pathological Society of London was formed, Dr. Williams 
was elected its first President. It must not, however, be 
assumed that Dr. Williams was exclusively a pathologist. We 
would rather class him as a clinical teacher, who recognised in 
pathology the true basis not only of the physical changes 
which disease works, but of its clinical recognition and demon- 
stration. It was a bold step to become the champion of such 
a statement. The gold-headed cane had bowed to the evidence 
of pathology as regarded the post-mortem appearances of 
disease. But to admit vital signs as evidence of pathological 
changes was to admit the existence of an unmapped territory. 
Yet, Dr. Williams, confident that the benefit of humanity 
weighed heavily in the balance, cast in his self-interest to turn 
the scale. The balance did not turn at once, and as we read 
the story of his life we learn how great is the vitality of 
truth. 

Very different indeed is Dr. Williams' reception of the 
discovery of the tubercle bacillus by Koch in 1882 (page 393). 
He admits, and even claims, the suggestion of a possible 
zymotic agency in phthisis ten years previous to Koch's demon- 
stration. He welcomes Koch's observations, but he does not 



Revieivs. 355 

plant them in a hot-bed, nor force them to produce their fruit. 
Rather, he recognises that the spring of discovery will be 
followed by a summer of growth, an autumn of change, and 
a winter of possible death — only with this reservation, that all 
true things are immortal. 

It is doubtfully possible for us of the present day to estimate 
the magnitude of the arch which links Laennec with Koch. 
The physical signs of disease, and associated rather with 
diseases than with physical conditions, was the subject-matter 
of Laennec's treatise and teaching. Dr. Williams laid the 
next stone by his rational exposition of the physical signs. 
Then followed the long process of building which ended in 
the differentiation of true tubercular consumption from a host 
of allied and non-specific pulmonary inflammatory affections, 
often tending towards the development of the specific disease. 
The more hopeful prognosis which this differentiation spread 
over a large number of cases, resulted in the earnest search 
for a specific cause in the less hopeful. With Koch's discovery 
we again touch ground. Standing upon such ground, which 
seems the hither resting point of a fresh span, we recognise 
that the quotation " Physical signs must be amenable to 
physical laws, and that a knowledge of these laws, so far as 
attainable, would be the best guide to the knowledge and 
understanding of the signs and of the causes which produced 
them," is the true keystone of the completed arch. We can 
find no better rule in projecting the future. 

It is not, we hope, inappropriate that we should have chosen 
the subject of consumption for our disquisition on the work of 
Dr. Williams' life. He was in no way a rigid specialist, and 
though his name will always be associated with the fact that 
his researches in the pathology, clinical history, and treatment 
of chest disease, saved the lives of thousands of his fellow- 
creatures, his other work proves without a doubt that his 
usefulness was bounded only by his humanity. 

Dr. Williams' work was great; but we must take exception 
to his repeated assertion that it was " laborious." It never 
lacked energy, but his whole memoir is a perfect lesson how 
to attain great results without needless labour. Granted a 
fuller period of student life than falls to the lot of most men, 
even in the present day, we find him early attaining that self- 
respect of personal knowledge which insures self-confidence. 
To reach such a level early in life leaves the whole world at 
his feet. He is not unconscious that in many or all directions 
much remains to be done, but he recognises the duty of 
waiting the call of opportunity. Even before this time he lias 



356 Rt vu W8. 

assured himself that to expend energy on the language in 
which his observations shall appear is superfluous labour. 
To avoid misconception we would define " laborious " work as 
that which has a general and distant, rather than a particular 
and near, attainment as its object. It becomes "laborious" 
because the inciting power is less definite and helpful, and 
because the attainment being less definite and more distant 
will probably embody a smaller amount of the energy 
expended. Whether this definition fulfil technicalities or not, 
it expresses the difference between the work of a fully 
qualified physician, and that of a student under instruction. 
Not, we would remark, the qualified physician of a conjoint 
board, but the qualification for practice which only can insure 
self-confidence. 

We recognise that Dr. Williams was right when he waited 
for the necessity of publishing a book on Auscultation, for the 
need of writing lectures for his students at University College, 
or having material for his Gulstonian Lectures to expend 
intense energy upon special subjects. 

We glide from this illustration of the conservation of energy 
into a further one. A necessity having arisen and been met, 
it ought to follow that the greatest possible return is exacted. 
Here again Dr. Williams does not fail. His early works upon 
the physical signs and on diseases of the chest render to himself 
the confidence of the profession and of the public, which 
exacts in turn his splendid work upon consumption. But 
meanwhile, the more general work of his lectures at University 
College and his Gulstonian Lectures find a further sphere of 
usefulness in the publication of his Principles of Medicine. 
This book was the marvel of its age. It is now out of print ; 
but so pregnant was it of suggestions, some of which have 
since come to successful birth, while others have not yet 
reached so full a development, that it defies being brought up 
to date almost as strenuously as the works of John Hunter. 
This volume was published in 1843, and Dr. Milner Fothergill, 
in his Practitioner's Handbook of Treatment, published in 
1876 (page 104), speaks of " that excellent and now little 
known book, ... a work every thinking student should 
procure and peruse carefully." In this age of progress, such 
notice comes little short of the pagan's idea of deification. 

We have given this prominence to the Principles of Medicine 
because it is Dr. Williams' less well known work. Not the 
merest tyro can be ignorant of the value of the work on 
consumption which is now undergoing a new edition by the 
hands of Dr. Theodore Williams. We have endeavoured to 



Revieivs. 357 

indicate an underlying principle in the consecutive direction 
and discretion of Dr. Williams' labour. We have done so 
fully, in the hope of learning and of second hand teaching, in 
no way of detracting, We have attempted to glean that others 
might reap, and so rich and ripe is the harvest that we believe 
even such gleanings may be of value. 

Before quitting our notice of his literary work we must 
refer with regret to the revival of some matters which had 
better have been left entombed. The unhappy misunderstand- 
ing with Dr. Hope, concerning their mutual share in the 
investigation of the causes of the cardiac sounds, robbed both 
investigators of much that was doubtless due to them, and had 
surely already done its full measure of mischief. The author's 
services to the Pall Mall Gazette and to the public, in the trial 
for libel instituted by Hunter, are marred rather than enhanced 
by republication, which savours of what Junius calls a " holy 
zeal to persecute a sinner." The record of the authors action 
after the death of Liston, and of the action against the Duchess 
of Somerset, may perhaps fulfil an honourable duty to the late 
Sir Thomas Watson, but the same might have been done in 
fewer words and with less cause of offence to others. 

Dr. Williams' early and honoured association with many 
philosophical and medical societies is notable evidence of the 
esteem in which his work as a physician was held. But we 
find from his notes that he seldom attended their meetings or 
took any very prominent part in the subjects under discussion. 
This has been somewhat a matter of surprise to us, for as a 
student at Edinburgh (page 12) we find him writing in no 
measured terms of the value of information gathered from the 
clear words of a living speaker. Yet the notes of his attendance 
at the societies record a history of attempted reform in their 
administration rather than a keen interest in their work. 
Notably, at the Royal College of Physicians, his active work 
is to inaugurate new rules for the admission of Fellows and 
Members. At the Royal Society a similar and persistent 
effort is made, but in neither case is his success commensurate 
with his professional standing. Dr. Williams deems it advisal »le 
to recount his proposals in detail, but the verdict of these 
learned societies already pronounced forbids further comment. 

In a notice, which for reasons already stated, deals rather 
with a successful man and his method of work than with 
matters which he has made topics of general history, little 
more remains to be said. There is one point, however, which 
(iiimot be omitted, and in a journal largely read by members 
and students of a great medical school, ought not to be 



358 Revieivs. 

omitted. Dr. Williams suffered from an early age from 
chronic catarrhal deafness. At first sight it seems incredible 
that a master of auscultation should not have been possessed 
of his full hearing — yet the case is not without parallel. 
There is no evidence that his hearing was perverted, or that 
any such assertion can be made of it as has been made con- 
cerning Turner's eyesight with regard to his wonderful 
paintings. He was simply a man who, with less of hearing 
than most men, and more of the brain lobe which receives 
auditory impressions and converts them into motor acts, 
surpassed his fellows. So truly was this the case that while 
his deafness progressively increased until it compelled his 
retirement from practice, up till the last his opinion in cases 
of chest disease was more sought than that of any of his con- 
temporaries. Discounting much for the assistance of his son 
and friends, the fact remains remarkable. It should not 
encourage a partially deaf man to attempt a similar achieve- 
ment, but it should stimulate a man whose hearing is normally 
acute to a greater sense of his responsibility. 

Dr. Williams has reached old age. Not the old age which 
Shakespeare describes as the last scene of all, for the speech 
of Jacques pictured the average man, and Dr. Williams was 
never of average stature as regarded his manhood. Though 
precluded now from usefulness in the sphere which has been 
his life work, he relaxes not the exercise of such faculties as 
have been spared him. He makes no attempt to combat the 
advance of science in the direction in which he had formerly 
aided it, but he meets present investigators on subjects which 
he is still able personally to observe. 

The last chapter of these Memoirs is devoted entirely to 
meditations on the higher life. It must not, however, be 
supposed that such meditations are confined to the last chapter. 
The lives of many great men, and notably that of Newton, 
demonstrate how easy is the transition from the greatest 
discoveries in the scientific world to the grandest thoughts on 
the supernatural. But while all men must be grateful for 
such evidence of an easy transition we must not look for 
demonstration. That religion should be accepted by the 
multitude requires that it should not necessitate any great 
mental attainment. Conversely, it must be granted that those 
who, with great mental attainments, acquire increased firmness 
in their sacred beliefs, attest the truths of the religion they 
maintain, rather than become valuable as expositionists. For 
those who wish to follow Dr. Williams in his meditations on 
the higher life, we have only one suggestion to make, and 



Reviews. 359 

that is, that accepting all his propositions we would add to 
his aids to devotion the study of Thomas a Kempis. No 
accessory so truly indicates that the one divine attribute 
which man can in any perfection imitate is forgiveness. 

Our notice promised to be personal and human — and we 
hope that it has fulfilled its promise. Because we are human 
we shall be better for the study of such a life, and for so much 
as we can make personal we shall give thanks that this man 
" was not born in vain." 



Hints on the Health of the Senses. By H. Macnaughtox 
Jones, M.D., F.R.C.S.I. and Ed. London : Longmans, Green, 
& Co. 1884. 

Probably few men in our profession exert a greater degree of 
literary activity than the author of this volume, in which Dr. 
Jones has made a valuable addition to medical literature in its 
more popular aspect. In the whole region of preventive 
medicine there is probably no question of greater interest and 
importance than how to preserve a healthy condition of " the 
five gateways of knowledge," and, so far as we know, this is 
the first separate work which instructs the public on so im- 
portant a matter. 

In the first chapter the author discusses the propriety of 
instructing the people in physiology and hygiene, and the 
responsibilities of physicians as guardians of the public health. 
He points out, also, in a forcible way, the power for good which 
might be exercised by the pulpit in matters pertaining to the 
preservation of health. " In controlling the habits, tendencies, 
vices, and practices of social life the church has at least an 
equivalent power to the medical profession, and she will exert 
this power best by utilising the vast opportunities she possesses 
of teaching the people the dire influences, both on body and 
mind, that are exerted by the pin-suits and occupations which 
society encourages, and which both religion and morality, were 
the truth fearlessly proclaimed, alike forbid." 

In the volume before us, as might be expected, the preserva- 
tion of sight, and the maintenance of a healthy condition of the 
eye, receive most attention. The author's remarks on the im- 
portance of treating promptly and efficiently discharge a from 
the eyelids, the injurious effects of indiscriminate poulticing, 
and the necessity for giving early attention to deformities of 
the eye, such as squint, are well worthy of careful perusal 
The somewhat difficult subject of disturbances of the refraction 
of the eye, myopia, hypermetropia, and astigmatism, is des- 



360 Revieivs. 

cribed with remarkable clearness, so as to present, even to the 
non-professional reader, little difficulty in apprehension. In 
connection with this, good practical advice is given on the use 
of glasses. " Spectacles we might look on as doing for an eye 
what a splint does for an injured leg ; they give it rest. I can 
hardly exaggerate the importance of the proper and scientific 
adjustment of suitable lenses to the eye, not chosen at hap- 
hazard and at random; not those picked up promiscuously, 
which appear to magnify the letters or work ; not worn when 
there is an irritated and congested retina that requires com- 
plete and total rest, but glasses certainly and critically 
adjusted — remembering that an eye cannot be treated worse 
than the foot or hand, for which we have accurate propor- 
tional measurement taken before a boot or glove is worn. We 
are dealing with an infinitely more delicate organ, with an ex- 
quisitely sensitive mechanism, and a retina on which this 
mechanism acts for good or ill, just as we treat it well or 
badly." 

The chapter on the ear is an especially valuable one. There 
is probably no part of the body regarding which there is 
greater need of diffusing among the people, and even among 
the members of the profession, information as to the causes 
and prevention of disease. Are medical men even yet fully 
awake to the dangers connected with a purulent discharge 
from the ear, or to the serious consequences of impaired hear- 
in-- in childhood ? Are they yet cognisant of the evils which 
may attend the improper syringing or poulticing of the ear, or 
of the mischief that may be done to the ear by immersion of 
the head in cold water, or of the impropriety of treating the 
organ without previous examination ? The experience of the 
special worker in this field still compels him to reiterate, with 
wearisome frequency, that not only have the public a great 
deal to learn in these matters, but also that he to whom they 
naturally look for guidance — the family medical attendant — 
too frequently guides them in the wrong path. This work of 
Dr. Jones must help in dispelling the darkness and ignorance 
which .still unfortunately exist on this subject, and which 
prove so pernicious to the well-being of this organ of sense. 

The work is not wholly taken up with the organs of sense, 
three of the chapters being devoted to the voice, to dress and 
diet, and to education. The injurious modes of dress adopted 
by ladies do not escape attention, and the words of truth and 
warning will, it is to be hoped, help in bringing about the 
abandonment for ever by ladies of tight lacing, and other 
similar eccentricities which tend to the serious injury of vital 



Reviews. 361 

organs. The author's remarks on diet are particularly effec- 
tive, and include a useful list of articles of food which should 
be avoided by dyspeptic persons. In condemning the system 
of late dinners, with their many courses, there is the following 
graphic picture : — " Heavy meals, after long intervals of rest, 
are not easily digested ; neither are late dinners, with their 
many courses — soup, fish, rounds of entrees, joints, several 
kinds of vegetables and sauces, all floating in a liberal potation 
of hock, sherry, and champagne, followed by heavy puddings, 
laden with fat, to be immediately congealed by ices, now 
mingled with apples, pears, raisins, and nuts, to be again set 
floating in quantities of claret or port, and then the entire 
capped with hot coffee, cream, and sugar — finally, the soothing 
and narcotising influence of the tobacco fumes, as an antidote 
for the stimulating wines and coffee which have gone before. 
Little need we wonder if gout, gravel, torpid and fatty livers, 
diseased and fatty kidneys, palpitating hearts, dyspepsia, and 
all sorts of indigestion are prevalent, and that visits to con- 
tinental and English spas are considered indispensable to the 
health of the fashionable man." 

Dr. Jones wisely omits anatomical descriptions of the 
various organs of sense ; but there are introduced a number of 
very clear diagrams, with full explanatory text, which enable 
any reader to form a very fair conception of their structure. 

This is a most readable and instructive book, neatly got up 
and printed in very clear type, and fitted for both pro- 
fessional and non-professional readers. 



A System of Obstetric Medicine and Surgery, Theoretical 
and Clinical, for the Student and Practitioner. By 
Robert Barnes, M.D., and Fancourt Barnes, M.D. Vol. I. 
London: Smith, Elder, & Co. 1884. 

Tins is the first volume of a large work on Midwifery, by 
Dr. Robert and Dr. Fancourt Barnes, the second volume of 
which has not yet appeared. If, however, we are to judge 
of the second from the first, the finished work promises to be 
one of the most complete and perfect treatises in the language. 
At present, however, we can only speak of the first volume, 
and with this we are exceedingly pleased. The scope of the 
book is very great, and the different subjects are fixated of in 
ilir most minute detail, the discussion of the various topics 
being completed as far as the end of gestation. Professor 
Milnes Marshall has been associated with the authors in 



362 Reviews. 

writing that portion dealing with the earlier development of 
the ovum, and the result is that a most complete and well 
written description of the changes involved has been given — 
far more complete, indeed, than is usually given in obstetric 
text books. In this, we think, the authors have been most 
judicious, for, as they point out in their preface, the practising 
obstetrician has but little time to devote to a careful study 
of this very difficult and intricate subject. Speaking of the 
work which has more properly fallen to the lot of the authors 
themselves, we can testify to the completeness and excellence 
with which it has been carried out — an excellence indeed 
which is guaranteed by the well known name and sustained 
reputation of the senior author. This is a book which would 
prove a most useful and comprehensive guide to every 
practitioner extensively engaged in the practice of obstetrics, 
for not only are the views of others given in great detail, and 
references quoted, but Dr. Robert Barnes criticises, and con- 
firms or modifies them according to the results of his own 
large and varied experience, thus giving great additional 
weight to the statements made. In the preface it is said that 
the " obstetrist " is of necessity a surgeon, as well as a physician ; 
but no one can read this volume without at once coming to 
the conclusion that it is necessary for him to be a physiologist 
and a pathologist as well — and that in the very highest sense 
of the terms; and we quite agree with the remarks made in 
the preface on the subject of specialism. The chapter on the 
Diseases of Gestation is quite a little medical and pathological 
treatise in itself, and those who are interested in the subject 
of the pathology of albuminuria and its relations to puerperal 
convulsions will find abundant food for reflection in it. The 
authors largely accept Mahomed's views on albuminuria; but, 
without entering upon the discussion of this very extensive 
subject, we may be permitted to say that we differ from them 
in this. 

The style is on the whole pleasant and attractive, and the 
tedium of the text-book is occasionally relieved by touches of 
humour, as, fur example, when the question is asked, Whether 
man, as compared with woman, is the inferior animal on 
account of his pelvis approaching the type of the lower 
animals? or again in the following — "There is the instance 
cited by Velpeau of the Russian peasant, Wasilew, whose first 
wife had quadruplets four times, triplets three times, and 
twins sixteen times. The second wife had triplets twice and 
twins six times, so that this patriarch had eighty-four living 
children out of eighty-seven which he had begotten. It 



Reviews. 363 

requires a robust faith to accept this marvellous story." In 
other places the style is terse and forcible, for example, when 
the use of the finger in pelvimetry is described — " He traces 
the circumference of a ring — the brim, and weighs in his 
mind the probability of a plastic ball — the child's head — 
resting upon the ring, passing through it, allowing for 
moulding, spontaneous or by the use of forceps. This know- 
ledge, approximate though it be and only to be acquired by 
considerable experience, is what no instrument can give." 
If we have a fault to the style at all, it is that there seems 
to be a tendency to the use of what appear to us at least 
somewhat pedantic words, e. g., " obstetrist," " sexuality," 
" togetherhood," " genesial cycle," &c. ; and here and there 
we find considerable repetitions, e.g., compare p. 205 with 
246. Of course, we admit that the latter in a work of such 
magnitude as the present is perhaps unavoidable. Here and 
there we have noted small printers' errors. At p. 31, second 
last paragraph, " each ovum " should apparently be each 
ovary; the lettering of fig. 15 is not quite right; and the 
drawing of fig. 59 as compared with the description in the 
text seems to us to require modification ; at p. 187 should it 
not be, instead of " O50 less than the true conjugate," 0'50 
more than, &c. ? at p. 250, in the last paragraph, we think 
some confusion exists in the use of the terms " lower " and 
"upper." We have thus drawn attention to a few, what 
appear to us, typographical errors, because in a work of such 
importance as the present it is essential that they should be 
corrected in future editions. 

This is one of the best works on midwifery we have seen, 
and we have great pleasure in bringing it very favourably 
under the notice of our readers. 



A Treatise on the Chemical Constitution of the Brain: based 
throughout upon Original Researches. Ity J. L. W. 
Thudichum, M.D. London: Bailliere, Tindall & Cox. 1884. 

Aids to Physiologic// Chemistry. By the same Author. 

These are two new works by one of our most voluminous and 
well known writers on the subject of medical chemistry, and 
it is difficult to conceive of two books presenting greater 
differences, both as regards scope and aim. The first is a large 
volume of some 260 pages, dealing in minute detail with one 
of the most difficult problems in the whole range of physio- 
logical chemistry. The work was undertaken about twelve 



.S64 Reviews. 

years ago for the then medical department of" the Privy Council, 
and is " a systematic consolidation of all the researches on the 
subject which have been laid before Parliament in the annual 
reports of the medical officer of the Privy Council and Local 
Government Board respectively." The labour involved in 
carrying out the necessary experiments must have been very 
great, and the volume containing their results must prove of 
great interest and service to those engaged in the study of 
this most complicated and difficult subject. After a somewhat 
lengthy introcluctoiy chapter, the method pursued for the 
isolation of the immediate principles is described, and this is 
followed by a most exhaustive and elaborate account of the 
different chemical principles of the cerebral tissue. 

The second work is a very small manual of about 110 pages, 
and in many places is practically little more than an enumera- 
tion of the different compounds of the fluids, tissues, and 
organs of the body : and we must confess that it is somewhat 
difficult to see how, in the present state of medical education, 
such a book is likely to prove of service to the heavily taxed 
and over- wrought student, for whom it has evidently been 
written. 



The Handbook for Midwives. By Henry Fly Smith, B.A., M.B. 
Oxon. Second edition. London : Longmans, Green & Co. 
1884. 

We rather dissent from the opinion which prevails, at least 
amongst authors of this class, that it is necessary to enter 
pretty fully into anatomical and physiological details in 
teaching midwives and nurses, or that such pathological con- 
ditions as retroflexion and retroversion need be even referred 
to. But setting this aside, we think very highly of the little 
work before us. The author is concise and simple in his style, 
turning every little point to practical account when that is 
possible. Nothing seems to us less common in such works 
than a really good practical description of natural labour, and 
this the author has given us. 

Perhaps he will excuse us referring to what is possibly 
after all a " hobby " of ours, and a very little one — viz., that it 
is a mistake to include the breaking of the membranes as a 
part (i. e., an essential part) of the end of the first stage. We 
remember an old master of the Rotunda who would " pluck " 
forthwith either student or midwife who ventured to include 
this in his or her definition. "What," he would say, " marks 
the end of the first stage ? " " The complete dilatation of the 



Western Infirmary. 365 

os." " Anything else ? " he would sometimes ask in an 
encouraging tone of voice ; but woe betide the misguided 
candidate who added anything else, except a polite negative. 
And we have no doubt he was right, both from a physiological 
and clinical standpoint. 

To be a "thoroughly revised" edition, there are one or 
two typographical errors which might have been observed. 



A Popular Guide to the use of the Bath Waters, with useful 
hints to Visitors; Notes on the Climate of Bath, and its 
advantages as a Health Resort and Place of Residence, &c. 
By J. G. Douglas Kerr, M.B. The Bath Herald Office. 
1884. 

The historic springs of Bath are beginning to re-assert them- 
selves as a health resort in rivalry to the numerous Continental 
spas, although still far from the position they occupied at the 
end of last century. The little work before us is therefore 
opportune in its appearance. It is the highest praise that we 
can accord to it to say that it fully comes up to the pretensions 
stated on the title page, and given above. The diseases for 
which the Bath waters are specially useful are gout, rheuma- 
tism, joint affections, and skin diseases ; but they are also used 
in uterine diseases, and as an adjunct to a mercurial course. 
So far as its literary style is concerned, the book leaves much 
to be desired ; and there are an appalling number of typo- 
graphical errors ; but these matters will be improved in a 
second edition. 



REPORTS OF HOSPITAL AND PRIVATE 
PRACTICE. 



WESTERN INFIRMARY. 

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

From the Pathological Department. 

two oases of bright's disease with contracted kidney, 
presenting some points of comparison and contrast. 
[Reported by John Lindsay Steven, M.D.]— Case I. Wm. W., 
set. 21, a coachman, was admitted to Professor Gairdner's 



oG<J Hospital Practice. 

Wards on 6th October, 1884, suffering from pains all over 
the body, especially in the back and loins, and more severely 
in the legs than the arms ; also complaining of vomiting and 
loss of appetite accompanied by severe headache, the pain 
being sometimes in the occipital and sometimes in the frontal 
region. Up till April last he had always enjoyed good health, 
never having suffered from any illness except measles when 
he was a child. Since April his health has not been so good 
as formerly, but the only thing he felt wrong was a tendency 
to vomiting and occasional headache till about eight weeks 
ago, when he was suddenly seized with dull oppressive pains 
all over the body, present day and night, accompanied by 
vomiting, which came on at any time, before dining, or 
shortly after meals, or just as readily in the intervals between 
meals. There was also complete anorexia. This state of 
matters continued with slight variations for seven weeks, 
when his face began to swell, and, as the result of medical 
advice, he came into hospital. He has not been more than 
usually exposed to cold, nor has he ever had scarlet fever. 
On admission the swelling of the face was considerable, but 
there was none in the feet or legs. The pains noted above 
were also present, the headache being the worst of all. Until 
a week before his admission, his attention had never been 
directed to his urine, but during the past eight days he has 
observed that it is sometimes passed with difficulty. Upon 
examination the following state of the urine is found: — 
Specific gravity, 1,012: reaction, acid; albumen abundant; 
hyaline, granular, and blood casts, and pus corpuscles. 

Lftli. October, 188 %. — No change occurred in the state of 
this patient up to the 12th inst., about 3 - +5 p.m., when all of 
a sudden a convulsive attack occurred with complete un- 
consciousness, the convulsion lasting for a minute and the 
unconsciousness longer ; this was followed by a succession of 
similar attacks up to 7 p.m., when convulsions ceased, but 
restlessness was still observed during the night ; it seems 
certain, however, that consciousness was preserved, as he 
spoke to his mother several times during the night, and on 
the following morning responded to several questions by Dr. 
Gairdner without, however, showing any great amount of 
intelligence. His pulse was good and regular. No appear- 
ance of difficulty of breathing, and, as he was in a hot pack, 
examination was not pursued. It appears, however, that no 
urine was passed for twelve hours or so before the convulsive 
attack, nor was any known to be passed afterwards. A 
degree of irregular twitching or tremor of the mouth was the 



Western Infirmary. 367 

only approach to a convulsive symptom noticed on the 
morning of the 13th, and in the course of the day twitchings 
also of the muscles of the lower jaw were observed, followed 
in the evening by irregular respiratory movements, not 
apparently indicative, however, of extreme dyspnoea. He 
complained of no pain, although the state of his tongue made 
it impossible for him to take anything but liquid food. 

The treatment pursued from the period of the first con- 
vulsion onward was a hot pack, 2 m. croton oil, 3i- spt. setheris 
nitrosi every four hours, and a mixture of salines with 
scoparium every four hours ; copious sweating followed these 
remedies, with very free purgation on the evening of the 
convulsions ; after this the hot pack was repeated several 
times on the 13th ; on the afternoon of the 13th two blood- 
stained motions were passed. Mustard was also applied over 
the loins after leaving the pack and dry cupping applied. He 
died quite suddenly on the evening of the 13th, about 9 P.M. 

A post-mortem examination was made by Dr. Coats on the 
14th October, 1884, of which the following is a report : — 
External Appearances. — The skin is generally very pallid, 
and there is slight oedema of the face, but none of the leo-s. 

Chest. — The pericardium contains about one ounce of slightly 
turbid fluid. The heart presents very marked hypertrophy 
of the left ventricle, whose wall in the middle part averages 
| of an inch in thickness. The organ weighs 16 ounces. The 
valves present nothing remarkable, but the mitral orifice 
admits three fingers readily. The right lung is adherent 
throughout by old but somewhat soft fibrous connections ; the 
left is non-adherent. Both present well marked oedema with 
engorgement posteriorly. 

Abdomen. — The spleen is normal in size, weighing 3^ 
ounces. The left kidney is much reduced in size. On the 
cut surface the bases of the pyramids are seen to be very 
ill defined, and the cortical substance somewhat thinned. 
The capsule is very firmly adherent, and the surface highly 
granular. Both on the surface and on section numerous 
cysts are visible. The organ weighs 2£ ounces. The right 
kidney is smaller than the left, weighing 2 -J- ounces, and its 
capsule is even more firmly adherent, but otherwise it presents 
similar characters. The liver presents nothing remarkable, 
and weighs 3 lbs. 8h ounces. The small intestine is consider- 
ably distended with yellow fluid faeces without any blood, and 
the large contains a deep-brown semifluid faeces, approaching 
to red in colour towards the rectum. Towards the lower end 
of the small intestine the solitary follicles and Peyer's patches 



368 Hospital Practice. 

present a general but not very great enlargement, and the 
mucous membrane is somewhat intensely injected. In the 
large intestine there are patches of injection with an occa- 
sional interstitial haemorrhage. [X.B. — The appearances in the 
intestines were probably due to the croton oil and other pur- 
gatives.] 

Head. — On exposing the brain its surface is found compar- 
atively dry. and there is no considerable amount of fluid in 
the sulci. The whole substance of the brain is unusually pale, 
but no lesion is discovered. In some cerebro-spinal fluid 
which escaped from the ventricles on removing the brain 07 
per cent of urea was present. It should be remarked that 
French's test, applied during life, yielded abundant fumes of 
chloride of ammonium. 

Case II. Mrs. T., aet 42, a dressmaker, was admitted upon 
the 9th of August, 1884, to Dr. Finlayson's wards, suffering 
from a general dropsy which began in June last. The follow- 
ing is a short summary of the clinical history entered by Dr. 
Finlayson in the Pathological Report Book : — Twelve years 
ago she suffered from erysipelas, or more probably eczema; 
and fourteen months ago a little swelling in her feet was 
observed for the first time. Since her admission to the ward 
there has been a gradual increase of the dropsy, and latterly 
the breathing has been very seriously implicated from effusion 
into the large serous cavities. The urine was rather scanty — 
the specific gravity varied from 1013 to 1015 — and it contained 
abundant albumen ami granular tube-casts. The patient died 
at about 7 o'clock on the morning of the loth, and a post- 
mortem examination was held on the 16th of October. 

External appearances. — There is the most pronounced 
anasarca, and the abdominal parieties are greatly distended 
from the presence of fluid in the peritoneal cavity, which 
escapes in very large quantities when the abdomen is opened. 

Chest : The pericardium contains a small quantity of serous 
fluid, and the heart presents the most typical hypertrophy of 
its left ventricle. The wall of this ventricle is fully £ of an 
inch in thickness, the muscular tissue is firm but somewhat 
pale, and beneath the endocardium the yellow mottling 
characteristic of fatty degeneration is slightly present. The 
organ weighs 17 ounces, and is otherwise normal. The aorta 
presents a few patches of atheroma. The pleural cavities con- 
tain abundant serous fluid, and on section both lungs are 
found to present very considerable oedema and hypostatic 
engorgement. 



Western Infirmary. 369 

A bdomen : The spleen presents normal characters, and 
weighs 3 J ounces. The kidneys are much reduced in size, the 
left weighing 3^ ounces. The capsule is slightly adherent, but 
the surface generally is not highly granular, although in a 
few places it is so. The surface presents innumerable pale 
opaque markings from fatty change, and on section the cortex 
in many places is distinctly reduced and ill defined, and pre- 
sents the fatty markings already mentioned. In the cortex 
also a few cysts are visible. The right kidney is smaller, 
weighing only 2f ounces, but is otherwise like the left ; and 
both organs show indications of the division into lobes 
presented by the foetal kidney. The liver weighs 3 lbs. 
6f ounces, and is slightly fatty. 

Remarks by Dr. Steven. — In one sense there is nothing very 
remarkable either in the clinical history or the morbid anatomy 
of these two cases ; but taken together they are interesting as 
illustrating the distinctive features of the two varieties of 
Bright's disease. In the first case the disease was insidious in 
its onset, and a lengthened period elapsed before the kidneys 
were suspected ; in the second, the affection was recognised as 
renal from the first. In the first case, with the exception of 
some swelling of the face, there was no dropsy throughout ; 
in the second, dropsy was from the first a marked feature, and 
continued gradually increasing till death. The differences in 
the morbid anatomy of the affected organs was also striking. 
In Case I, we have the small, dark-red, highly granular organ 
typical of the contracting, cirrhotic, or gouty form of Bright's 
disease ; whereas in Case II, we have the small lobulated, pale, 
fat-speckled, slightly granular kidney characteristic of the 
later stages of parenchymatous nephritis. The cases were 
comparable in that both presented during the later stages a 
somewhat similar condition of the urine, and in that both were 
the subject of typical hypertrophy of the left ventricle. As 
we have said, taken singly, there is nothing, perhaps, very 
striking in cither case, except, perhaps, the very early age at 
which cirrhosis of the kidney has developed in the first ; but 
taking them together it is a striking and suggestive fact that 
with two cases where the kidneys were small and contracted, 
and so similar in appearance that one unaccustomed to patho- 
logical investigation might readily have supposed the changes 
due to the same affection, we have in one only the very 
slightest, in the other the most extreme, dropsy, amounting, 
indeed, to the most perfect anasarca. Another important 
feature, from a pathological point of view, is that in a case of 
essentially parenchymatous nephritis there should have been a 
X.». 5. 2B Vol. XXII. 



370 Meetings of Societies. 

well marked hypertrophy of the left ventricle. We know 
that this condition is generally associated with the cirrhotic 
kidney, and, indeed, there are some who do not believe that it 
ever occurs in parenchymatous nephritis. However, we have 
here a case where there can be no doubt of its presence, and 
this may possibly be associated with the fact that in all cases 
of small kidney, resulting from parenchymatous inflammation, 
there is always more or less interstitial new formation of con- 
nective tissue. 



MEETINGS OF SOCIETIES. 



MEDICO-CHIRURGICAL SOCIETY. 



Session 1884-85. 
Meeting I. — bth October, 1884. 



Dr. W. T. Gairdner, President, in the Chair. 

The following gentlemen were elected Office-bearers for the 
ensuing year : — 

President — Dr. G. H. B. Macleod. 

Vice-Presidents — Dr. Hugh Thomson, and Dr. David,. Taylor (Paisley). 

Council — Dr. D. Maclean, Dr. J. C. Woodburn, Dr. Wm. Whitelaw 

(Kirkintilloch), Dr. W. A. Wilson (Greenock), Dr. E. Cowan, Dr. 

J. A. Lothian, Dr. Wm. Patrick, Dr. M. Thomas. 

Secretaries — Dr. W. L. Reid, Dr. J. W. Anderson. 

Treasurer — Dr. Hugh Thomson. 

Dr. Gairdner said that at the end of last session he had, 
in a short address, endeavoured to give effect to a retrospec- 
tive glance at the work of the Society while he had had the 
honour to occupy the Chair; and the words he then said 
might be regarded as a formal leave-taking of his official 
position. But as the newly elected President was, from some 
cause, unable to attend that evening, he might add one word 
on a point to which he had not referred in that address. 
There was only one incident during his tenure of office which, 
to his mind, slightly marred the satisfaction with which he 



Medico-Chirwrgical Society. 371 

looked back on his presidency of that Society. The incident 
he referred to was the endeavour made, and to some extent 
carried into effect, to implicate the Society in medical politics 
in respect to the matter of the Medical Bill. At the time he 
distinctly intimated that this was contrary to his judgment of 
what the aim and object of a Society of this kind ought to be. 
He very strongly held that whatever might be the view taken 
of the strict letter of the laws and constitution, the procedure 
adopted at that time was against the spirit of the laws of a 
Society desiring to be considered as the organ of the scientific 
aspirations and practical work of the profession in Glasgow 
and the West of Scotland. To drag such a Society into the 
vortex of politics was a thing most dangerous to its usefulness. 
The opinion he then expressed he still strongly held ; and he 
had ascertained, on inquiry, that the practice of the Medico- 
Chirurgical Society of Edinburgh was entirely in harmony 
with his conviction. If, in the future, the question should 
again emerge in a practical form, he would give all the assist- 
ance he could to those who might strive to keep the Society 
within its proper sphere of scientific work. 

Dr. Hugh Thomson, in proposing a vote of thanks to Dr. 
Gairdner for the most efficient manner in which he had dis- 
charged the duties of President, said that he agreed with him 
in opinion on the matter to which he had just adverted. 

Dr. W. L. Reid read a paper ON three cases of the 

ALEXANDER-ADAMS' OPERATION FOR SHORTENING THE ROUND 
ligaments, of which the following is a summary : — 

Case I. set. 33. — Chronic retroflexion, with prolapse of left 
ovary. Symptoms: Backache, leucorrhea, dyspareunia, ina- 
bility to walk, dysmenorrhea, painful defecation. Duration, 
ten years. Operation on 1st November, 1883. Result at 23rd 
July, 1884 : Dysmenorrhea and dyspareunia gone, uterus in 
good position, defecation easier, patient able to walk two miles ; 
has still backache and a muco-purulent discharge from cervical 
canal. 

Case II. ret. 27. — Chronic retroversion, with great hyper- 
trophy. Symptoms : Backache, leucorrhea, frequent micturi- 
tion, diarrhea, delirium at menstrual periods. Duration, 
eight years. Operation 3rd November, 1883. Result, 2nd 
July, 1884: Much less diarrhea, uterus in good position and 
smaller, no delirium, able to walk pretty freely, micturition 
normal ; has still backache, leucorrhea, and now and again 
diarrhea. 

Case III. got. 45. Severe retroversion and hypertrophy. 



372 Meeti rigs of Societies. 

Symptoms : Leucorrhea, backache, painful defecation, bearing 
down and complete inability to walk ; has been confined to 
bed for the past year. Duration, thirteen years. Operation 
on 20th February, 1884. Result, 25th June, 1884: Uterus 
somewhat anteverted, defecation normal ; able to be up all 
day and to walk a mile ; very little headache, and general 
health much improved. 

Conclusions in regard to method of operating. — 1. It is 
better to keep the wound aseptic all through. 2. The end of 
the round ligament is most readily isolated by standing on the 
side operated on. 3. The withdrawal of the ligament from the 
canal is rendered more easy by seizing it with a broad pair of 
dressing forceps rather than with the fingers. 4. The slack of 
the ligament should be cut off, not left in the wound. 5. In 
this region an elastic bandage is of great service in preventing 
air from gaining access to the wound. 

Conclusion o,s regards curative residts. — The operation im- 
proves the position but not directly the condition of the 
uterus. It will be found valuable in rendering other curative 
treatment more effectual. 

Dr. Gairdner said that he had been favourably impressed 
with the candour, and especially with the scientific caution, dis- 
played in the paper. There was no work of the present day 
to his mind more striking than the many kinds of inter- 
ferences — operative or otherwise — in the pelvic organs, more 
especially of the female sex. He said this notwithstanding 
that he had seen not a few meddlesome interferences which 
had had their day, and were now no more heard of. This 
paper, however, cautiously guarded as its statements were, 
bespoke a certain amount of confidence for a new and almost 
untried operation. 

Dr. J. A. Adams thanked Dr. Reid for having given the 
operation a fair trial. His own first difficulty was to get any 
one to perform it, having himself at the outset no oppor- 
tunities for obtaining cases. He had now, however, performed 
the operation in three cases. The first case turned out to be 
wholly unsuital >le, the uterus being bound down with adhesions, 
traction on the ligament producing no alteration in its 
position. The other two cases were different, and had been 
attended with very favourable results. They were both young 
women in the Town's Hospital, and he was allowed to operate 
by the kindness of Dr. Robertson, the medical officer. They 
were cases of prolapse connected probably with poor feeding. 
Acting on the experience he had obtained in Dr. Reid's cases, 
he cut off the slack or loose end of the ligament as this in- 



Medico-Chirurgical Society. 373 

variably s