COMMUNICATIONS RECEIVED Mr. W. W. JONES, London; THE REGISTRAR OF THE UNIVERSITY BOOKS RECEIVED The Leamington Waters, by F. W. Smith, M.D.-Clinical Observations of the Use of Jequirity in Trachoma, by H. Knapp-Diseases of Women, by H. Macnaughton Jones, M.D., &c.-On the Unity of Poison, &c., by Dr. G. de Gorrequer Griffith-The Non-Bacillar Nature of Abrus-Poison, by C. J. H. Warden, and L. A. Waddell, M.B.-Diseases of the Ear, by Thomas Barr, M.D.-Pathology and Morbid Anatomy, by Dr, Green-Report on the London Water Supply for the month ending April 30, 1884-Report on the Health of the Borough of Birmingham, for the year 1883-Report on the Health of the Borough of Birmingham, for the quarter ending March 29, 1884-Discussion on Albuminuria-Sessional Proceedings of the National Association for the Promotion of Social ScienceReport of the Delancey Fever Hospital for the year 1883-Annual Report on the Birmingham Borough Asylums for 1883-Aneurism of the Femoral Artery, &c., by W. O. Roberts, M.D.-The Periodic Law, by J. A. R. Newlands, F. I. C., F.C.S.-Surgical Emergencies, by Dr. L. Von Lesser-Diseases of the Hip, by V. P. Gibney, A.M., M.D.-Medical Jurisprudence, by A. M. Hamilton, M.D.-Excessive Venery, &c., by Joseph W. Howe, M.D.-Herschell's Urethral Charts-Public Health, by T. W. Hime, B.A., M.B. Monday, May 26. Operations at the Metropolitan Free, 2 p.m.; St. Mark's Hospital for Diseases of the Rectum, 2 p.m.; Royal London Ophthalmic, 11 a.m.; Royal Westminster Ophthalmic, 14 p.m.; Central London Ophthalmic, 2 p.m.; Hospital for Women, 2 p.m.; Royal Orthopædic, 2 p.m. Tuesday, May 27. Operations at Guy's 13 p.m.; Westminster, 2 p.m.; West London, 2 p.m.; Royal London Ophthalmic, 11 a.m.; Royal Westminster Ophthalmic, 13 p.m.; Central London Ophthalmic 2 p.m.; Royal South London Ophthalmic 3 p.m.; St. Mark's Hospital, 9 a.m. ANTHROPOLOGICAL INSTITUTE OF GREAT BRITAIN AND IRELAND, 8 p.m.-Mr. Theodore Bent, "Notes on Remains from Cemeteries in the Island of Antiparos;" Mr. H. O. Forbes, "The Koeboes of Sumatra;" Mr. J. G. Garson, "On the Osteology of the Koeboes of Sumatra." ROYAL INSTITUTION, 3 p.m.-Prof. Gamgee, "Nerve and Muscle." ROYAL MEDICAL AND CHIRURGICAL SOCIETY, 8.30 p.m.-Dr. G. E. Herman, "An Average or Composite' Temperature Chart of Small-pox; Dr. G. W. Cayley and Mr. A. Pearce Gould, "Gangrene of the Lung treated by Drainage-Recovery;" Dr. Cecil Y. Biss, "On the Treatment of Pus-secreting Basic Cavities of the Lung by the Method of Paracentesis and Free Drainage." Wednesday, May 28. Operations at Middlesex, 1 p.m.; St. Mary's, 11 p.m.; St. Thomas's, 1 p.m.; St. Bartholomew's, 14 p.m.; University College, 2 p.m.; London, 2 p.m.; Great Northern, 2 p.m.; King's College (ophthal mic operations), 1 p.m.; Samaritan, 24 p.m.; Royal London Ophthalmic, 11 a.m.; Royal Westminster Ophthalmic, 1 p.m.; Central London Ophthalmic, 2 p.m.; St. Peter's Hospital for Stone, 2 p.m.; National Orthopedic, Great Portland Street, 10 a.m. Thursday, May 29. Operations at St. George's, 1 p.m.; Central London Ophthalmic' 2 p.m:; University College, 2 p.m.; Royal London Ophthalmic' 11 a.m.; Royal Westminster Ophthalmic, 14 p.m.; Hospital for Diseases of the Throat, 2 p.m.; Hospital for Women, 2 p.m.; Charing Cross, 2 p.m.; London, 2 p.m.; North West London, 2 p.m. ROYAL INSTITUTION, 3 p.m.-Prof. Dewar, "Flame," &c. Friday, May 30. ROYAL INSTITUTION, 8 p.m.-M. E. Mascart," Sur les Couleurs." PERIODICALS AND NEWSPAPERS RECEIVEDLancet-British Medical Journal - Medical Press and CircularCentralblatt für Chirurgie -Gazette des Hôpitaux Gazette Médicale-Revista de Medicina - Bulletin de l'Académie de Médecine - Pharmaceutical Journal Wiener Medicinische Wochenschrift Révue Médicale Gazette Hebdomadaire Nature-Boston Medical and Surgical Journal-Louisville Medical News Centralblatt für Gynäkologie · -Le Concours Médical — Centralblatt für Klinische Medicin-Philadelphia Medical News TERMS OF SUBSCRIPTION FROM JANUARY 5, 1884. -Le Progrès Médical New York Medical Journal - Students' Journal and Hospital Gazette- New York Medical Record-The Edinburgh Clinical and Pathological Journal-The Philadelphia Medical Times-Centralblatt für die Medicinischen Wissenschaften -Berliner Klinische Wochenschrift-Maryland Medical JournalThe National Review-The Journal of the Vigilance AssociationWeekblad-Revue de Chirurgie-The Journal of the British Dental Association-Archives de Neurologie-Correspondenz-Blatt-The American Journal of Obstetrics-The Dublin Journal of Medical Science-Revue d'Hygiène-Société Médicale-Revue de Médicine. APPOINTMENTS FOR THE WEEK. Friday, May 23 (this day). Saturday, May 24. Operations at King's College, 1 p.m.; St. Bartholomew's, 1 p.m.; (Free by post.) £ s. d. £ s. d. British Islands 12 Months 0 19 6; in advance 0 17 6 6 099 1 2 0 The Continent [12 and the Colonies 6 India(viâ Brindisi)12 090 100 0 10 6 1 4 0 120 0 11 6 0 12 0 See below. AFTER a few introductory remarks Dr. Yeo said that no one would doubt that the keen and searching spirit of positive experimental inquiry which animated the pathology of our day was destined to greatly modify our conceptions as to the nature of disease, in many of its forms; bidding fair to make our present era one of the most remarkable and one of the most illustrious in the history of medicine. The mistaken attempt to base a rational pathology exclusively on morbid anatomy, upon the anatomical analysis of morbid changes, had been pushed, perhaps, to its extreme limits; yet pulmonary pathology must ever remain deeply indebted to these anatomical studies, and, in particular, for having enabled us to differentiate between many forms of pulmonary consolidation and infiltration, which we could not otherwise have accurately distin 1 Abstract of an Address delivered at Birmingham before the Birmingham and Midland Counties Branch of the British Medical Association, on April 24th, 1884. VOL. I. 1884. No. 1770. guished; but it was with the results of experimental inquiries in connection with pneumonia that they were now especially concerned. With the application of that method to the study of pneumonia we had entered upon a new phase in the pathological history of that malady, and it became necessary that we should ask ourselves whether the conceptions that had hitherto prevailed as to the nature of that disease were correct or erroneous. It was a subject of the widest and most general interest, and one which had, he thought, been wisely selected by the British Medical Association for the purpose of Collective Investigation, and by that important branch for immediate discussion. The subject they proposed to examine was acute lobar pneumonia, the so-called croupous pneumonia of German authors, and he intended to limit his observations exclusively to its pathological nature, its ætiology, and its treatment. It had recently been asserted that acute croupous pneumonia was a parasitic disease, and that it was caused by the entrance into the body of a peculiar and characteristic micro-organism. In order to establish the fact that a given disease was due to the presence of microorganism of definite form and characteristics should organisms, it was held to be necessary :-(1) That an always be found in the blood, or in the diseased organs. (2) That the blood, or the diseased tissue, when introduced into another animal of the same species, should produce the same disease. (3) That when the blood or diseased tissue was inoculated on a suitable soil out side the body, the micro-organisms contained therein should grow and be propagated indefinitely on similar soil. (4) That the organism thus separated from the remains of the material in which it was imbedded, thus isolated, when inoculated into a healthy animal, should reproduce the same disease, and the same organisms should reappear in the diseased parts. It was maintained that in pneumonia, as in anthrax, in septicemia of the mouse, in erysipelas, in tuberculosis, and in glanders, all the conditions required to establish the fact that a given disease was due to the presence of a micro-organism had been fulfilled. permitting the periodical ejection of large quantities of pus, the pus in the pleural cavity remained perfectly sweet and quite free from putrefactive organisms; which was no doubt due to this protective office of the bronchial ciliated epithelium. It has, no doubt, been a difficulty with many in the way of accepting the view that diseases like phthisis and pneumonia are dependent on the inhalation from the air of special pathogenic organisms, that so many escape infection who must, it would seem, occasionally inhale these bodies. But apart from the consideration that the causes of these diseases are complex, and cannot consist So long ago as 1875, Klebs asserted that pneumonia of a single factor, we must give due weight to the very was a parasitic disease, and both he, and subsequently obvious reflection I have just stated, viz.—that in the Eberth and Koch, had found a micro-organism in cases respiration of most healthy persons, whatever solid of pneumonia. But Friedlander had the credit of first particles floating in the air, pass into the lung in accurately differentiating this organism, and describing inspiration, pass out of it in expiration; that the air its specific form and characteristics. He found these ordinarily exchanged in respiration is the tidal air, not typical micrococci in the alveolar infiltration, amongst the air of the air cells, and that whatever organisms the leucocytes and red blood corpuscles, in eight cases may penetrate beyond the limits of the tidal air, into of croupous pneumonia, which he examined after the air passages, are arrested and driven back by the death. Günther found the characteristic organisms action of healthy bronchial ciliated epithelium. Now in some fluid he withdrew from the chest of a it is possible that one of the factors in the causation of moribund patient, and Leyden found them in a few these diseases may be, for instance, a temporary or drops of blood withdrawn from the lung of a pneu-permanent paralysis of the ciliated epithelium, or a monia patient, thirty-six hours before death. denudation of this protection from a portion of the air passages. Or some abnormal condition of the mucous secretion may either, on the one hand, paralyse these cilia, or on the other, stimulate these germs to overwhelming multiplication. When we consider that the bacillus which causes septicemia in the housemouse is unable to produce any deleterious effect in the field-mouse, we must be struck with the very special nature of the conditions which determine the growth and activity of these organisms." These organisms, as described by Friedlander, were micrococci of elliptical form, one micro-millimetre in length, and one-third less in breadth. They occurred connected together in pairs, as diplococci, and frequently they formed longer chains; but these chains were distinctly seen to be made up of a series of pairs, a series of diplococci. They were characterised and differentiated from other micro-organisms found in the body by being surrounded by a capsule, which was thought by Friedlander to consist of mucin. The capsules, however, were not always present, and were not easily demonstrated. They were thought to be a product of the life of the micrococcus. After dealing with the objections that had been made, especially by Parjesz, of Klausenberg, to Friedlander's view with regard to the organism he had named the pneumonia micrococcus, Dr. Yeo referred to the researches of Dr. Rudolf Emmerich, of Munich (Fortschritte der Medecin, March, 1884), who had proved that the material found stuffing the space between the floor and ceiling of the dormitories of a prison at Amberg, where epidemic pneumonia had long been, as it were, domiciled, was crowded with enormous masses of the peculiar organism which had been stated to be pathogenic of pneumonia. The pure organism obtained by Friedlander and others by cultivation, had been introduced into the bodies of animals, usually mixed with distilled water and injected into the pleural cavity. On 9 rabbits it produced no effect, but it proved fatal to 32 mice, in from 18 to 20 hours. The organism was found in enormous numbers in the engorged and hepatised lung, in the blood, in the spleen, and in the fluid of the pleura. In the latter situation the diplococci were These observations naturally lent great weight to a encapsulated. When the same fluid was heated so as view of the pathological nature of certain forms of to destroy the organism, its injection produced no pneumonia, which was by no means new; for many effect. Cultivations from these mice produced the same writers in this and in other countries had expressed effect on other mice. An attempt was also made to a suspicion that pneumonia sometimes occurred as an introduce the organism into the lungs of mice by infective and contagious malady, and numerous ininhalation; the fluid containing the micrococci being stances of its epidemic occurrence were on record; diffused by a hand spray into their cage. In this while many, who would be unwilling to admit its experiment some mice were affected, some were not. infectious or contagious nature, were convinced of its In the case of the latter, it was suggested that but occasional occurrence in what was called a "pythogenic" little of the fluid entered the lungs, as they turned form. One of the most instructive instances on record their backs to the spray. of the supposed epidemic occurrence of pneumonia, and its supposed propagation by contagion, was described by Stokes, of Dublin, who wrote as follows :-"The occurrence of this disease, as affecting great numbers in a particular locality, was observed in this city some years since. The persons attacked were young and healthy men, privates in the constabulary force, who were quartered in the then newly erected barracks in the Phoenix Park; these young men were well fed and clothed, and might be considered as possessing the greatest strength and vigour. It is a remarkable circumstance that at the time of the appearance of this disease, many cases of another and extraordinary affection were observed in the poor-houses and hospitals in and near Dublin. I allude to cerebral-spinal arachnitis, and it is important to mention that several cases of this disease occurred in the force contem "But there is another consideration," said Dr. Yeo, "which has been somewhat overlooked in connection with the inhalation of pathogenic organisms, and to which I may take this opportunity of calling attention. It is, that under normal conditions the suspended solid particles in the atmosphere taken in with the inspired air, are cast out with the expired air. The mucus of the buccal and pharyngeal mucous membrane is crowded with micro-organisms, but these the ciliated epithelium of the air tubes keeps from reaching the air cells; and they, probably, penetrate but a short distance into the air passages with the tidal air. This was well-shown in a case of empyema communicating with the lung, which was under my own and Sir Joseph Lister's care, in King's College Hospital, last year. For though there was an opening in the lung, poraneously with those of pneumonia. The general characters of the pneumonia were suddenness of invasion and great rapidity of progress; the lung rapidly passing into hepatisation." Another interesting account of an epidemic of pneumonia was given by Surgeon-Major Costello, of the Bengal Medical Department. His regiment had lost from this disease between 30 and 40 men out of 550, in a few weeks. It was almost confined to two companies, and when it appeared amongst the married, it spread to different members of the family, and when cases were taken into hospital, it spread to other patients, ill of other diseases, and to the nurses and attendants. There was always a catching pain in the side, the infiltration spread rapidly through the lungs, and was attended with "typhoid" symptoms. Removal from barracks to tents, isolation of affected persons and their attendants, immediately arrested the progress of the disease. 1 older and more generally accepted views as to the A very remarkable series of cases, pointing to direct contagion, had been recorded by Mr. Patchett, of Shaw, near Oldham,' and another, scarcely less remark-long able, by Dr. F. H. Daly, of Hackney Downs.1 Many instances from the time of Courvoisier, Laennec, and even earlier, were also on record of the epidemic occurrence of pneumonia; cases of pneumonia occurring together in groups, larger or smaller, and in which the suspicion of spread by contagion had not been altogether absent. These instances appeared to have occurred independently of any common meteorological conditions, but they had, in many cases, appeared to be in some way connected with local insanitary surroundings. A good example of the latter was the account given by Penkert of an outbreak of croupous pneumonia in a village of 700 inhabitants, 42 of whom were attacked and 2 died, between the 11th of March and 14th of May, 1881. They were doubtless aware that the question had been raised, whether these so-called epidemics of pneumonia might not be, in some instances, cases of typhoid, with early development of lung consolidation. It had also been observed that epidemics of pneumonia succeeded epidemics of typhoid, and epidemics of typhoid succeeded epidemics of pneumonia; and it would seem that the presence of putrescent matter was favourable to the culture of both germs.' In an epidemic observed by Kühn,' at Moringen, in Hanover, the approximation to typhoid in some of the cases was well marked. The cases occurred in an overcrowded prison; 33 cases were observed in one epidemic, and 70 in another. They differed from those of typical pneumonia-there was no initial rigor-and the onset was gradual; the intestinal follicles were sometimes found swollen, and diarrhoea was present in two-thirds of the cases. It was distinctly infectious, and spread to the attendants. "I have here brought before you," Dr. Yeo continued, "but a small fragment of the mass of observations which are on record, and upon which was based the view that pneumonia is an infective disease dependent on the presence of a specific pathogenic organism in the body; and that under certain, somewhat rare circumstances of time, place, or season, it may spread by direct and indirect contagion. "I have thought it best to bring this view of the nature of pneumonia before you, first of all, in order that we may the better be able to compare it with the 1"Stokes, on Diseases of the Chest." New Sydenham Society's Edition, p. 303. 1 Lancet, January 29th, 1881. 1 Lancet. February 25, 1882. 1 Lancet. November 12, 1881. 1 Berlin. Klin. Wochensch. 1881, 40, 41. "Of these two views, it will be seen that the one is entirely opposed to the theory which regards pneumonia as a parasitic disease, infective, sometimes contagious, and not infrequently epidemic; whereas the other view gains support from and is quite consistent with the belief in the parasitic nature of this disease. But there is yet another view which merits our attention, viz., that pneumonia is sometimes an inflammatory and purely local disease, and at other times an infective, general disease. This view has been advocated by Mr. Wynter Blyth. After alluding to some interesting cases of apparent communication of pneumonia mentioned to him by Dr. Christian Budd, of North Tawton, he says, 'In all probability there are two forms of pneumonia-one probably arising from cold or a like cause, the other zymotic-and these two forms are at the present time confused together, just as typhus and typhoid were. That such an epidemic form exists, infectious, zymotic, self-propagating, I feel in my own mind convinced.' "I must own there appears to me to be much that may be said in favour of this eclectic view. When we consider what diverse conditions are capable of setting up inflammation and consolidation of the lung, when we consider in what various morbid states secondary pneumonias occur, it is surely not inconsistent to believe that primary pneumonia may arise from more than one exciting cause. But even if we admit that pneumonia is caused by exposure to cold, it does not necessarily follow that the chill acts directly on the lung; and it is still open to us to believe that the blood is primarily affected, just as it may be in acute rheumatism. But the prevailing want of symmetry in the lung affection would seem to point to the cooperation of some more strictly local influence. "Those, however, who maintain the unity of pneumonia-and so great an authority as Jurgensen is amongst the number, although, if I understand him aright, he would separate certain so-called typhoid forms as not croupous pneumonia at all, but only secondary lung consolidation dependent on septicemia those advocates of the unity of pneumonia, notwithstanding the very varying degrees of intensity with which it appears in different periods, contend that these differences are due to the different degrees of Alison. Archives. Générales de Médecine. Sept. and Oct., 1883. activity or malignancy of the exciting cause, of the 1 Deutsch. Arch. f. Klin. Medicin. 1878, xxi., 4. Berlin. Klin. Wochenschr. 1879. 73. 1 Lancet, September, 1878, p. 416. morbific germ, at different times and in different places; and they urge in support of this view that great changes in the virulency of various pathogenic organisms have been shown under cultivation; that well-recognised infectious diseases, like scarlet fever, appear at different times with very varying degrees of virulency; that the organism characteristic of pneumonia has been found in mild as well as in severe cases; that an extreme virulency has been observed in cases which post-mortem examinations have shown to be cases of true croupous pneumonia. For instance, Jurgensen reports a case that ended in eight hours from the initial rigor; and Mendelsohn mentions two cases, one that of a vigorous man, 38 years of age, who died in thirty-four hours, and another case, communicated to him by a friend, that died in twenty-four hours." quired careful consideration. These were (1) Excessive dyspnea, from overwhelming pulmonary hyperemia and edema, in addition to the consolidation. This was the only indication he knew of for bleeding in pneumonia, and its occurrence was exceedingly rare. (2) Excessive pyrexia, attended with delirium and danger of rapid cardiac exhaustion. Here the cautious application of cold to the surface might be used with benefit, as advocated by Jurgensen; but we should select our patients very carefully for this mode of treatment. Quinine combined with sulphurous acid merited more frequent use for reducing temperature in low typhoid forms of pneumonia. They should be given from the commencement of the illness. (3) Pain in the side. He was in the habit of giving 5-grain doses of Dover's powder every five or six hours, in the earliest stage of pneumonia, to relieve pain, and he found it had an excellent Dealing with the etiology of pneumonia, Dr. Yeo influence, not only directly, in the relief of pain, but said, that most observers agreed that pneumonia some- indirectly, by relieving the distress and anxiety of the times occurred in connection with insanitary conditions; patient and procuring calm sleep, and so really sparing that, in short, there was what has been named a "pytho- his strength and protecting him against exhaustion genic" pneumonia. But what was the real influence later on. By relieving the pain in the side, the patient of exposure, of chill, as a cause of this disease? Was was also enabled to make deeper inspirations, and so it simply a predisposing cause, or was it an exciting to make the best use he could of the breathing surface cause? That it had a causal relation of some sort to that was left free to him for aërating his blood. A many cases of pneumonia, there seemed to him no rea- few leeches applied over the seat of pain was also a son to doubt; but possibly we had been in the habit valuable expedient. (4) The tendency to cardiac exof over-rating its influence as a cause. It was notori-haustion, with sleeplessness and delirium.-The so-called ous that pneumonia often occurred during the prevalence of winds, especially the winds of spring; and not with winds from any particular quarter, for it was found to prevail with south-west winds as frequently, or more so, as with east or north-east winds. Now, in this connection, we had rather overlooked the fact, that winds were carriers of dust as well as conveyers of cold (or rather, abstractors of heat); and that while, | on the one hand, they carried away heat from the surface of the body; on the other hand, they gathered up dust of all kinds, and blew all manner of microorganisms into our air-passages. It had been noticed, again and again, that all depressing agencies might predispose to pneumonia, such as exhaustion from physical fatigue,' and depressing emotions; and it might be that exposure to a cold wind acts both as a predisposing cause, by the depression of the normal resisting power it produced by rapid abstraction of heat, and also as an exciting cause, by means of the micro-organisms it blew into our air-passages, especially if the view he had already suggested be correct, that a paralytic or sub-paralytic condition of the bronchial ciliated epithelium may in this way be induced. A French writer, whom he had already quoted, found in the analysis of eighty cases of pneumonia, that physical fatigue was apparently a predisposing cause in a great proportion of them. And he, the speaker, had heard it said, that pneumonia occasionally occurred in public school boys after fatiguing games of football. It would be interesting to have further information on this point. As regards the treatment of pneumonia, personally he was content to be what, in political language, was called "an opportunist." He believed in no special treatment, but in a rational common-sense management of individual cases. He was entirely opposed to all lowering methods of treatment, which were counterindicated by the tendency to cardiac asthenia, which the concomitant pyrexia induced; and also by the consideration that those cases that supported lowering measures best, were precisely those cases which did extremely well without any active interference. There were, however, certain circumstances, certain accidents of the disease, the treatment of which re 1 Mendelsohn, Zeitschrift für Klinische Medicin. 1883. typhoid symptoms. The free use of alcoholic stimulants was here essential. Many cases of pneumonia required no alcohol; many other cases could only be kept alive by alcohol! One word on the so-called abortive treatment of pneumonia by aconite. He was not ignorant of the excellent effect of aconite in certain ephemeral pyrexiæ, associated with local inflammations; and he believed it to be a valuable remedy in cases of slight pulmonary congestion with pyrexia, a condition which should be more precisely differentiated and described than it had been in our text-books. But he had no belief in an abortive treatment of acute croupous pneumonia by aconite. A consulting physician in London had told him that he had seen recently three fatal cases of pneumonia in which aconite was being "pushed." He hoped, if there was any advocate of that treatment present, he would forgive him for saying, that it was to him inconceivable how it should ever be thought right to "push" such a drug as aconite in such a disease as pneumonia. Dr. Yeo concluded his address with some remarks on the work of the Collective Investigation Committee of the British Medical Association. |