PART IV.

M E D I C A L MISCELLANY.

Reports, Transactions, and Scientific Intelligence.

TRANSACTIONS OF T H E M E D I C A L SOCIETY OF T H E COLLEGE OF PI IYSICIANS.

SESSIOX 1881-82.

GEORGE JOHNSTON, ]~.D., ])resident.

ALEXA~*DER ~'IXON HONTGOMERY, M.K.Q.C.P., IIonorary Secretm'y.

Wednesday, January 4, 1382.

J. W. MOORE, M.D., Vice-President, in the Chair.

T ~ late Dr. Reuben ,7. Ilarveij.

DR. A. •IxoN MO~'TC~O.~IE~r165 Honorary Secretary, read the following Resolution, ~hich had been unanimously adopted at a meeting of ttm Council held on the 29th December : -

Proposed by Dm C. J. NlXO~, seconded by ])m }IAwTner BENSON : " T h a t the Council of the Medical Society of the King and Queen's College of Physicians, Ireland, desire to place on record their profound regret at the death of Dr. Reuben ttarvey, a Member of Council, and their sense of the loss which the Dublin School of ~Medicine has sus- tained by his demise ; and that a copy of this Resolution be submitted by the Honorary Secretary at the next meeting of the Society."

Dm iN'IxoN-, in moving the adoption of a resolution similar to the foregoing, said he hardly thought it necessary to dwell at length on the demise of Dr. Harvey. The suddenness of the event had to himself, and he helieved to most of the members of the Society, given a most painful shock, and one that would not readily pass away. That might explain the unusual course which had been taken by the Council in adopting a resolution, and then submitting it to the members of the Society. No member of their profession had passed away evoking a more heartfelt and genuine feeling of regret than their lamented friend.

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They all admired his industry, ability, and or iginal i ty; his great force of character, his strict integrity, and his unobtrusive spiri t of inde- pendence enforced their respect, while his bright, cheery manner and genial disposition endeared him to all who knew him. I t was not too much to say that great as was the toss which the Dublin scientific School of Medicine had sustained by the death of one of its most pro- mising members, still greater was the loss sustained by those who had been brought into close contact with him through the absence of the br ight and sterling example which he had set of earnestness and devo- tion in fulfilling his short r6le here below. Death had had many spoils of late amongst us. 1Nelther the young nor those laden with years and honours had been spared--roots omnibus communis but no one had left a name more honoured or beloved than Reuben Harvey.

Dm F1TZGEnALO, in seconding the resolution, said he had hut little to add to the obserwttions ah'cady made. They all felt that they had lost an able and accomplished colleague, and a sincere and loving friend.

The CItAn~)~AN, in put t ing the resolution, said he could not trust him- self to add anything to the words of Dr. .Nixon and Dr. Fi tzgerald.

The resolution was passed in silence. DR..NIx()N m o v e d - - " That out of respect to the memory of the late

Dr. Reuben l la rvey , this meeting be adjourned until this night week, the l l t h instant."

DR. HENRY KENNEDY seconded the resolution, which was unanimously agreed to.

"The Society then adjourned to the l l t h instant.

Adjourned Meeting, Wednesday, January 1 lth, 185'2.

J. W. MOOPE, M.D., Vice-President, in the Chair.

BRIGADE-SURGEON JACKSON, C.B., having taken the Chair,

The VICF-I)RESIDENT read the following paper : -

An Outbreak of' Dis'ease traceable to the drinlcing of Impure I~rater. By J. W. MOOICE, M.D., Dubl. ; Vicc-1)resident and Fellow, K.Q.C.P. ; Physician to the Mcath Hospital and to Cork-street Fever tIospital .

THE accepted w.tiology of typhoid or enteric fever places this form of specific cohtinued fever in intimate relation to certain forms of gastro- enteric catarrh on the one hand and to a specific variety of inflammation of the hmgs- -py thogen ic pneumonia--on the other. And here I would at once avow myself an advocate of the theory of the dual nature of the excit ing cause of typhoid fever. The disease is no doubt in many instances due to contagion, o r - - i n the more cautious words of Murch i son- -" is com- municable in a limited degree," but there is every rc~son to believe with the

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same great writer that it may arise de novo from the decomposition of sewage matter. For more than thirty years Prof. F. yon Gietl, of Munich, taught that the poison of typhoid fever, although contained in sewage, is always derived from the excreta of an individual already suffering from the disease, a drain being nlerely the vehicle for its propagation, or, in fact, " a direct continuation of the diseased intestine. ''a This view was adopted and promulgated by Dr. William Budd, of BristolP But surely it is more philosophical, with Murchison, not to admit as a necessary sequence that because the disease may be sometilnes communicated by the sick, in every case where it is traceable to bad drainage the poison in the drain has of necessity been derived from a person previously infected with the disease, e

If, in a given instance, not only true typhoid fever, but other diseases are so clearly traced to sewage-poisoning as to establish the relation of cause and effect~ are we not justified in arguing that the specific virus of typhoid fever has been generated de novo either outside or within the bodies of those who have developed the symptoms of this disease, rather than that the said specific virus is capable of producing true typhoid fever in one individual, and-- le t us say - -a form of pneumonia in another ?

The outbreak of disease which I am about to describe is a case in point.

From a large educational training institution in Dublin two cases of typhoid fever were admitted in the " fa l l " or autumn of 1880 to the wards of the Meath Hospital. ~'o special attention was unfortunately drawn at the time to this precursor of an epidemic. During the fol- lowing winter and spring there were no other attacks, but on the 1st of October, 1881, a young man aged nineteen, a pupil-teacher in the same institution, was admitted to the Meath Hospital under my care on the recommendation of Sir George B. Owens, who had carefully attended him for some days in the earlier part of his illness. Messrs. F. T. P. ~ewell and Travers Smith took charge of the patient, and the following is an abstract of the clinical notes taken by these gentlemen : - -

C~sE I . - - Jona than C., aged nineteen, unmarried, a pupil-teacher, admitted October 1, 1881. Eight days previously he complained of cold, or a chilliness, and headache with nausea and a dry retching. He lost his appetite, and spent most of his time in bcd. l I is temperature on the morning of his admission (eighth or ninth day) was 101 ~ his pulse was 93, and the respirations were 24. In the evening the tem- peraturc rose to 102 ~ the pulse ~o 96, and the respirations to 27. On

a ~Y[urchisom The Continued Fevers of Great Britain. Second Edition. 1873. P. 483. b Typhoid Fever: its Nature, mode of Spreading, and Prevention. London:

Longmans, Green, and Co. 1873. Loc. clt. r . 483.

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the evening of October 2 the temperature reached the highest point attained during his i l lness--namely, 103-2~ during the subsequent (lays i t ranged generally between 101 ~ and 102"5 ~ On October 5th rose spots were observed on his abdomen. They continued to appear in successive crops unti l October 16, when they ceased to come out. There were never more than four or five visible at the same time. On October 10 the patient pronounced himself to be much more comfortable than at any time since his admission. The headache and all other unpleasant sensations had left him, and his general aspect was not such ~ndeed as would indicate serious disease; his face was br ight and rosy, and his tongue was Mmost perfectly clean; his [)rain was quite clear, and he was Mways ready to enter into conversation with those who attended him even after having been suddenly wakened in the middle of the night. Towards the end of the third week, however, his face became pale and his tongue furred, but no aggravat ing symptoms accompanied this apparent deviation from the uniform mild course of the fever; neither the temperature nor the pulse rose, and his appetite, which at this stage was remarkably good~ remained unaltered. A few days later his tongue cleaned again, but his face remained pale. t i e continued to improve until October 23, when he was allowed to sit up for the first time, and he left hospkal on October" 30. The fever ran a mild course of about four weeks, and was uncomplicated. A t no time had he diarrhoea to any great ex t en t - - tha t is, exceeding three motions daily, but the discharges had the characteristic ochrey colour of typhoid stools.

The second case is also one of undoubted typhoid fever, as will appear from the clinical history, which is as follows : ~

CASE ] I . - - O n Friday, October 28, 1881, Frances O., teacher, was admitted under my care from the same institution, )~r. P. M. Skipworth taking charge of the case. She stated that on Thursday~ October 20, she was obliged to leave her class owing to a severe headache, which became worse in the evening; she went to bed early~ but was hot and restless throughout the night. On gett ing up next morning she felt poorly~ and did not go out that day~ but stayed indoors reading, and went to bed early in the evening also. On Fr iday she attended her class. She now lost her appetite. Next day she again attended classes, but stayed indoors all day. A t this time her bowels were confined, for which she took a pill. On Sunday morning she got up with a sore throat, and for this her neck was poulticed. ~No appetite at all. Tha t night she felt very feverish. On Monday Sir George Owens saw her~ and gave her a diaphoretic mixture. On Tuesday spots appeared on the face and neck, which became wsicular where the poultice had been applied. At this period a slight diarrhoea set in (but this did not recur). She had menstruated a fortnight or three weeks before admission. Her

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throat gradually got better, but she still felt sick and feverish. She was admitted on the seventh day of her illness, the temperature being 103 ~ pulse 104, and respirations 30. She was put on arseniate of iron and sulphate of iron in pills. The diagnosis of typhoid fever w,~ made from the history of the case, and from the fact that there was some gastro-intestinal disturbanc% with splenic enlargement. '1"he tongue was thickly furred, and the papillm were enlarged. Since her admission her temperature was a s high as 103 ~ on only two occasions ; the pulse ranged from 90 to 120, and the respirations from 24 to 32 in the nfinute. The sequel of this case is a very sad one. A t the beginning of the fourth week the evening exacerbations of fever became decided~ the patient wasted gradually, until at last she was reduced to mere skin and bone; her voice failed~ a~ld her strength ebbed away. Wi th the view of giving her change of ~ir~ she was moved one day to another ward~ but the exertion proved too much for her, and she passed into a state of insensibiHty~ with choreiform movements of the limbs and dilatation of the pupils. There was apparently ccdema of the brain 'and effusion into the ventricles. After forty-eight hours of anxious watching, her senses returned~ but a gradually extending hypostatic congestion of the lungs, aggravated by the cold weather then prevalent, at last caused her death on Tuesday, December 21, on the sixty-fourth day of her illness. No post mortem examination was made.

The next two cases are part icular ly interesting and instructiv% because both patients were sent into hospital~ from the Training School~ under the impression that they also were suffering from typhoid fever. But the event proved otherwise : ~

C~tsE IIL----Mary Jane M., student teacher~ aged eighteen, was admitted to the Meath Hospital on M0nday~ 7th ~ o v , 1881, suffering from what was at first thought to be,tuphoid fever. For the notes of this case I am indebted to Ma'. A. J. Boyd.

Her illness commenced on Friday, Nov. 4th~ w i t h a headache and a feeling of chilliness. On the following day she lost her appetite, but did not feel sick. There was no diarrhoea, but the bowels were free. On Sunday she complained of a pain in the pit of the stomach, and of a nasty taste in her mouth.

She had menstruated a few days before her illness commenced. On Monday, ~Nov. 7th, the evening observations were i'ulse~ 92;

respirations, 2'2; temperature~ 99"6 ~ On Tuesday the observations were - - in the morning--Pulse , 96 ; respi-

rations, '26; motions~ 0; temperature~ 99"8~ in the evening--Pulse~ 88; respirations, 2"~; temperature, 99"2 ~ On physical examination slight splenic enlargement was observed.

~Nov. 9 th .~Morning~l~ulse~ 82; rcspirations~ 24; motions~ 1; tcm-

of the College of Pl~ysieians. 135

perature, 98"4 ~ Evening--I)uls% 80; respirations, 24; temperature, 97"6 ~ From this on the temperatures, &c, were normal or slightly below 98"4 ~ On ~ov. 12th the bowels, being constipated, were freed by 60 grains of compound liquorice powder.

Nov. 17th.--Tongue was furred~ with enlarged papillm. ~'ov. 18th.---She appeared quite wetl~ so that she was sent to the

Convalescent Home next day.

CASE I V . - - ( F r o m notes taken by Mr. I Iawthorne) . - -Jane C , aged eighteen, by occupation a student-teacher, was admitted ~ov. 15th, 1881, on the seventh day of her illness.

TIisto~w.--On Hallow Eve night she caught cold coming out of a hot room into the open air. About a week after this she had a severe rigor, and felt very feverish. This was followed by violent vomiting, which commenced oll Thursday, 11th ~Nov., and lasted up to the day of her admission, when it ceased. She had sore throat and cough, for which she had been poulticed over the chest before admission. About six years ago she had diphtheria~ and was always subject to colds. Menses regu- lar; was "unwel l " on the day she had the rigor. She was admitted into hospital for supposed typhoid fever.

On admission she was feverish, with a furred tongue and quick pulse (116). The temperature in the morning was 102"6 ~ rising in the evening to 103"4~ pulse 120, and respirations 42.

In the evening she Was seen by the clinical clerk, when she com- plained of cough, slight sore throat, and pain in the left side. IIe suspected pneumonia, and ordered the nurse to poultice her over the chest.

Nov. 16th.---Dr. Moore examined her this morning, but failed to detect any typhoid symptoms, and confirmed the suspicion of the clinical clerk as to the presence of pneumonia. On physical examination there was no tenderness on pressure in tim right iliac fossa, nor was there any splenic enlargement. There was dulness on percussion over the base of the left lung. On auscultation there was tubular breathing in the same locality, with puerile breathing over the front of the chest. Broncho- phony well marked. Tongue furred~ white, with a little herpes on its left side. There was also an herpetic eruption on the upper lip. Sputum slightly rusty. The temperature fell this morning to 98"4~ pulse r 104, and hard; respirations, 48. She was ordered the following mix- ture : ~

l~. Quinim sulphat., gr. 24. Acid. hydrobromici, 3 iii. Spt. chloroforln., 5ii. Aqum camphorec, ad ~ viii.

One ounce to be taken three times a day.

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I t wa~ arranged that the poultices were to be continued, and that she was to be dry-cupped over the base of the left lung.

In the evening the temperature was 98"6 ~ ; pulse, 104 ; respirations, 52. She complained of slight headache, and pain at the top of the left hmg.

Nov. 17 th . - -The temperature fell to 97"2~ the breathing was still fast and irreguIar; tubular breathing well marked. She was again dry- cupped.

Nov. 18th . - -Morning temperature normal, but in the evening the thermometer rose to 100"2~ pulse, 104; respirations, 40. She was feverish, and complained of sore throat. This rise of temperature may be accounted for by the fact that another patient was received into the ward in the course of the day, and that she felt very nervous in consequence.

xNov. 19th . - -Temperature normal. There is still tubular breathing. Nov. 21st . - -Feels better to-day, but complains of pain over the region

of the heart. A poultice was ordered to be applied. l~'ov. 23rd . - -Dr . Moore detected slight "crepl tus redux." Nov. 25th. - -Bronchophony very s l ight ; percussion note clearer. Still

feels sl ight pain in le~t side when she takes a deep breath. Nov. 27th . - -She was allowed up to-day.

tIere, then, we have a series of four cases of illness occurring in the same institution within a few weeks, and in every instance the nature of the attack was eminently suggestive of defective sanitary arrangements. Two of the four patients suffered from true typhoid fever; a third suffered from an attack of acute gastro-intestinal catarrh, o r - - a s some may th ink- - f rom an abortive typhoid ; and a fourth from a croupous pneumonia, which, in its origin and course, closely resembled that variety of inflammation of the lung which was called by Laennec "epidemic pneumonia~" and in recent times has received the names of "sewer-gas pneumonia" and pythogenic pneumonia, a

Let us now see what was the condition of t he sanitary arrangements in the Training School. When the outbreak of disease, which I have described, occurred, Dr. Charles A. Cameron, Superintendent Medical Officer of Health for Dublin, was asked to inspect the premises, with the object of discovering the origin of the sickness. Wi th his usual kindness Dr. Cameron has written for me the following report, which I will quote in his own words : ~

" Condition of the Training School.~The house drains were in a very bad state. When originally laid down the pipe-drains were not brought into proper union by means of cement ; many of them were improperly levelled, and in some cases there was an actual open space between pairs

a Pythogenle Pneumonia~ By Drs. GrimRhaw and J. W. ~oore. Dublin J0urnaI of Medical Science. 1875. Vol. LIX. Page 399.

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of pipes. In the area next the street the drain was choked with foul matter. The pipe leading from the scullery into the area drain was not properly trapped, neither was a pipe which carried water and slops from a sink situated within the house to a drain in the yard, which commu- nicated--without being t rapped--with the street sewer.

" T h e water used for drinking purposes was chiefly taken from a tank situated iu the front area, but in a confined place, having a stone roof. The overflow-pipe from this cistern did not pass directly into the drain, but delivered its contents over a grating which communicated with the drain. The latter, however, was in a very bad state, broken and choked with foul matters. I t is evident that sewer gases, &c., came up abundantly through the fissures in the area floor, and were dissolved by the water stored in the uncovered cistern. The area was dirty, to(), and contained various kinds of refuse which had been blown into it from the street. On examining the water microscopically i t was found to contain, in decidedly large numbers, algae and various kinds of infusoria~ especially of monads and rotifers, and several varieties of paramecium. An imperial gallon of the water yielded 0"014 grain of albuminoid ammonia and 0"008 ~rain of saline ammonia--proportions largely in excess of those found in pure Vartry water, which this water originally was. I t is difficult to decide whether the water or the sewer gas was the direct cause of the outbreak, but I am inclined to think that it was the water."

With this report on the condition of the water used for drinking purposes in the Tra ining School before us, we can have no hesitation in agreeing with Dr. Cameron that it was most likely the foul state of the drinking water which gave rise to the sickness--at least in the first three c'~ses. In conclusion, I have only again to direct attention to what, in my opinion, is the most interesting feature connected with the outbreak--namely, that the using of water impregnated with sewer gas probably gave rise to three varieties of disease--true typhoid or pytho- genic fever, gastro-enteric catarrh, and pythogenic pneumonia.

The CRAm)JAN said there was every reason to believe that impure water was a most fertile source of disease. A few years ago, when he was serving in the Transvaal, a body of the troops with which he was connected were stationed at a place called Fort Weber, which was supplied from two rather deep wells, in which there was probably a sulphurous impregnation. Although there were a number of individuals l iving in a filthy state, and a number of cattle, Ire was informed by the medical officer in charge of that body that there was no case of sickness. He was in another place supplied with water which came down from a village. A quantity of sewage from an Indian corn field ran into this stream, and natives washed their clothes in it at a point above the

138 Transaetio~s of tlte Medical Socidty

village. In a short time there were nine or ten cases of sickness amo~.g the troops supplied with this water.

Dt~. FrNNY said it was important to record every case in which it was possible to trace the origin of enteric fever. Two views as to its origin chiefly prevailed. One was the pythogenic theory of Murchison, advo- cated by Dr. Moore, which was that the infection proceeded from decomposed animal and vegetable matter, introduccd by means of drinking water. The other view was that the source of the disease was septic matter which had proceeded from a typhoid patient, and infected air, water~ or food. .Many persons thought that there must be a state of receptivity before t he contagion could be ~'cceived into the body. The late Dr. Stokcs pointed out that every person was not equally liable to fever. There was, he (Dr. Finny) believed, a certain period of receptivity with l'egard to typhoid fever. A person might be a long time exposed to the same exciting causes, but there were only particular conditions of body in which he would take the poison which would produce enteric fever. IIe believed Dr . Moore was right in tracing the cases of fever to which his paper referred to the foul water and the imperfect sewerage. ~o doubt gastro-intestinal catarrh or pneumonia might have occurred in a young female going out of a heated room into a cold atmosphere without calling in as a cause~insanitation, and he did not think they should necessarily..connect the case of pneumonia with the outbreak of typhoid fever ; he asked that some good reason should be given for applying to this case the name " pythogenic pneumonia." I t appeared to him to be a case of pneumonia of an asthenic type~ with a gradual and protractcd first stage. A t the same time he admitted the epidemic nature of pneumonia, and fully appreciated the term "pytho- genie pneumonia," as described some six years ago by Drs. Grimshaw and Moore. On another point he would ask Dr. Moore's ()pinion. All those cases were cxtremcly mild~ and with the exception of the case where there was severe marasmus there was no evidence of great fever- poisoning, considering the tcrribly insanitary condition of the house where these young people resided. Why was the fever of so mild a nature--especially where it was assumed that there was an epidemic of it ? If fever poison be introduced into the body was there any way of telling whether the fever would be of a severe type or not ? Did Dr. Moore consider that the absence of profuse diarrhoea was in any way due to the small amount of the fevcr poison ? He said that in one case the stools were never more than three in a day. Was that an evidence of the small quantity of the poison absorbed, or of the mildness of the type of the fever which had prevailed during the last two or three years ? IIis (Dr. Finny's) experience was that in a great many cases diarrhcea was not the rule, but rather that constipation was the pro- minent symptom.

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Dm WRICRT said that during 1879 and 1880 there was much typhoid fever in Dalkey. I t was confined to a number of single-story cottages on one road, and the cottages had yards, into which refuse matter was thrown, and in which pigs were kept. At the end of 1880 a system of sewerage was introduced into the township and sewers were run up the road, and the inhabitants of these cottages were forced to connect their drains with the main sewer. In 1881 there was not a single case of typhoid fever in that road~ although in 1880 there were twenty cases, some of which were genuine typhoid, but a good many others were what he would call febrile gastro-enteric catarrh, accompanied with diarrhoea, but running a shorter course than typhoid~ and having no characteristic eruption but a very high temperature. When the fever was bad he suspected that the water was the cause of it. The people living there derived water from two sources. One was a Vartry fountain at the end of the road. The other was a pump which was celebrated from time immemorial for the purity of its water. When the people got the fever they sent to the pump for water. He sent a sample of the pump- water to Dr. Cameron, who pronounced it perfectly pure. In 1880 the three worst cases of typhoid occurred in two cottages at the very top of Dalkey Hill. The people who lived in those cottages got water from a well which was a good deal above the level of the sewerage of their houses~ and he was puzzled to find the cause of the fever until he asked where the privy was, and he found that it was close to the houses, and that connected with it was an ashpit from which there was a sickening stench. There was fmcal matter mixed With.water, and a terrible smell. t i e got it roofed in, and, though there were between twelve and fourteen families in those cottages, there was no more fever there from that time. The only case of typhoid fever they had this year in Dalkey was in a cottage which the nmin sewer did not reach, and which lay lower than the level of the road. i Ie could not find whether there was any drainage to the cottage r or how they disposed of the sewerage.

DR. POLLOCK mentioned that about a year and a half ago a young lady, resident in llis neighbourhood, the daughter of an officer in the army~ got the severest attack of typhoid fever that he had ever seen. She was insensible for ten or fifteen days. The drainage of the house was first examined~ and afterwards it turned out that the family had spent the summer in a house at Dalkey. That house was examined, and it was found that the drainage was completely stopped~ and that the closet gave off a tremendous-quantity of sewer gas. Another young lady in the same house got typhoid fever also.

1)n. IIE~Rr KEN~'EDY said it had often struck him that attacks of typtmid fever occurred years after the causes to which they were attributed had been in operation, and were then put down to bad sewerage or bad water, as the case might be. I t was very difficult to

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understand why persons should be attacked after they had been subject for years to the influence of such causes, l I i s own conviction was that both typhoid and typhus arose within the indiv idual People succumbed when they got out of health, but that either form of disease was due to bad water or to bad sewerage, to use a Scotch expression, was not proven. He would be slow to set down pneumonia to either bad water or bad sewerage.

Dir CRA~'Nr said the occurrence of epidemics was the answer to Dr. Kennedy's observations. Dr. Moore's cases went to prove that the water supply was the cause of the typhoid fcver, but more probably the original source was the sewer air from the decomposing matter in the sewers. Professor Tyndall, in his last work on germs, stated that it was not simply tile bad air of drains that caused disease, but that the germs of disease, foa t lng about in the air, found in sewer-gas the most proper nidus in which they could develop, and that it consequently became pestilential.

Dl~. MOOI~E, in reply, said that the individuals whose cases he had brought forward were healthy, well-fed, placed in favourable circum- stances, lived in a healthy part of the city, and had free open air and exercise. Furthermore, the type of typhoid fever in Dublin had recently been singularly mild. He (Dr. Moore) had called the pneumonia "py thogen ie" from the course i t took. I t was true that the girl came out of a hot room into cold air on a IIal low Eve night, but she did not pass into pneumonia at once. 2k week elapsed before she got the r igor ; there was a period of incubation. Again, the atmospheric conditions under whleh the attack of pneumonia developed were eminently suggestive of its pythogenic origin. What those conditions were was pointed out in the paper written some years ago by Dr. Grimshaw and himself, already referred to, in the following words : - - " Our conclusions a r e - - T h a t whereas ordinary pneumonia is especially prevalent dm'ing a continuance of cold, dry weather, with high winds and extreme variations in tempera- turexpythogenic pneumonia reaches its maximum during tolerably warm weather, accompanied by a dry air, deficient rainfall, a hot sun, and rapid evaporation." With the exception of the last-mentioned, those were exactly the atmospheric conditions that prevailed during the whole of November. The weather was singularly mild; there was no cold weather whatever, and it was after two or three nights of summer-like weather that the girl fell ill of pneumonia. Some weight should be attached to the fact that the disease appeared while she was exposed to poisoning by sewer-gas, and was living in an institution where undoubted cases of sewer-gas poisoning had occurred. Put t ing all the facts together, he submitted that they were justified in saying that there was some connexion---he did not press the point very much--between the pneumonia in her case and the condition of affairs in the institution.

of tlte College of Pltjsicia~,s. 141

Dr. Wr igh t had pointed out that the same sanitary defects gave rise to true typhoid fever and to gastro-enteric catarrh. For that he (Dr. Moore) had contended in the third case given in his paper. He also attached importance to Dr. Wright ' s de novo origin of the fever on the top of Dalkey Hill, although of course some person might have deposited typhoid germs in the privy. As to Dr. Kennedy's observations, they could readily understand that persons could become acelimatised to conditions to which others could not be suddenly exposed without very disastrous results. Persons might attend a fever hospital for years, and might at last succumb to typhoid or typhus. As Dr. F inny had said, the receptivi ty of an individuM, no doubt, varied from time to time, according to his state of health. Dr. Cranny seemed to think that there was no connexion between the drinking water and the disease in the t ra ining institution, but it should be remembered that sewer-gas was readily taken up by water. The cistern was in a closely-confined area, and the overttow from the untrapped drain was sufficient to account for the pollution of the water. That i t was polluted was proved by Dr. Cameron's analysis.

DR. IIENlZY KE~NED~ read a paper, entitled " Remarks on Salisbury's Views relating to the Treatment of Phthisis." l i t will be found at p. 87].

The VIC~-PI~ESID~NT said they were indebted to Dr. Kennedy for br inging forward Dr. Salisbury's novel views as to the origin and treat- ment of phthisis. The la te Professor Niemeyer did not l imit the setiology of phthisis to pneumonia. He recognised tubercular phthisis as indepen- dent of pneumonic phthisis, and occurring either as acute mil iary tuber- culosis of the lungs or as a secondary neoplasm or new growth in the lungs. ~Niemeyer desired to expose the fallacy that the caseous masses so often found in the lungs were in every case tubercular. The with- holding of cod-liver oil was quite consistent with Dr. Salisbury's views as t<)the a~tiology of the affection, but it was not easy to follow that wri ter in what he said about "yea~st in the stomach." I Ie probably meant to imply that a fermentative process was set up which led to some morbid condition of the blood, predisposing to destructive lung disease.

BRIGADE-SURG]E0~ JACKSON said he had had many years' experience of pneumonia amongst soldiers; many patients par t ia l ly recovered, but afterwards fell into a low state of heMth. I f from a fresh cold or any other cause fresh action was set up, the temperature would rise again, and consumption would set in. Afterwards, on examination, more or less extensive portions of the hmgs would be found to be tubercular.

])r~. FINNY observed that Dr. Kennedy had on the one hand condemned most of the points of Salisbury's treatment, and yet on the otimr he had alluded to them as "br i l l ian t . " I t e (Dr. Finny) was one of those who did

142 Transactions of tl, e 3fedical Socie'ty

not agree with the author of the papcr, or even with the late Dr. Stokes, in believing in a pre-tubercular stage and a deposit stage of tubercle as ~ cause of consumption; but tie did follow the steps of ~'iemeycr as to its most usual inflammatory origin in the smaller bronchi and pulmonary vesicles. Niemeycr, and those wt~o adopted his views, rccogniscd a "pre-consumptive" stage--every physician did. There was a certain lowering of the constitution and system, after which, in a certain time, the consumption was developed. I t was in that early stage, he presumed, that Salisbury noticed those wonderful things in the blood, in addition to spamemia. They should be careful about accepting the obscrvat:ions of a single man, or of a single microscopist, for there wa.~ no person, how- ever clever, who Was not liable to a bias of observations, in some degree, under the influence of a preconceived idea. They should not, he thought, without very great confirmatory evidence, receive this idea of yeast (!) in the blood. If they acknowledged such a state of the blood to exist, and were able, in a given case, to find it, it would be doubtless a great step towards making up their minds that the case was likely to develop into phthisis, but Salisbury's Weak point was that he acknowledged the same state of blood to exist in a uumber of other cases ; and many other cases might be quoted ill this country besides those mentioned in which a similar state of an:emia was found. Niemeyer quite understood that there was a state of body called scrofulous, a low state, in which there Was strumous disease, catarrhal pneumonia, and caseation of the lung, with or without the development of tubercle, l i e (I)r. Finny) considered further that Salisbury's observations on the state of the blood, even if confirmed by others, were of very little practical advantage, for how were they to obtain the blood of a patient who was in this low state of health, in order to examine it and decide what kind of food he was to get, as patients do not generally consult a physician until some definite symptoms develop themselves. If tile tubereuh)sis developed in the pigs fed as Salisbury described, it was only because the animals were in a low state of health, slmilar to that of persons living under bad sanitary conditions. IIe also took exception, as a practical physician, to the pre- tubercular theory, and to the tubercular deposit theory. These were thoroughly unpractical, and led to a most gloomy and disheartening line of treatment. I te did not think they had any evidence before them that tubercle, once widely spread, had ever been recovered from. i n con- clusion, with reference to Salisbury's animal dietary to be exclusive of starchy foods, he begged to call attention to the advantage he had fre- quently derived from a mode of treatment the opposite of Sal isbury 's-- namely, the administration of maltine to phthisical patients. )~any who could not take cod-liver oil had been able to take maltine in combination with a considerable quantity of starchy food, with decided and permanent advantage.

of the College of Physicians. 143

Dm II~z~itY K n ~ n D Y (in reply) remarked that the swine experimented on showed signs of sickness in three weeks, disease appearing first in the bowels, and then in the lungs. The natural history of pneumonia was quite sufficient to establish the fact that i t was not t h e start ing point of phthisis, save in exceptional cases. I f it attacked the upper part of the lungs, as phthisis notoriously did, he could understand the theory; but pneumonia of the upper lobe of she lung was very rare. On the other hand, phthisis commenced in an insidious, slow, and doubtful manner, this state of things lasting for weeks and months before the physical signs of the disease developed. There was something wrong with the patient, but nothing that could be detected. There might be weak respirat ion; but he bad never known ordinary pleuro-pneumonia to be the precursor of tubercular disease. I Ie did not say that he had not seen cases in which pneumonia ran into phthis is ; but the vast major i ty of patients attacked by pneumonia recovered.

The Society then adjourned.

A N ~ W SOLVE*NT Ii'OR D I P I I T I I E R I T I C ME~IBlgANE.

])R. HAT.~ WR~TE, after performing trachcotomy on a child suffering from diphtheria, sprayed the throat with a Siegle's spray, put t ing half an ounce of the glycerin of pepsin into the glass bottle. The spray was repeated every two hours from the cvcning of July 7th until the evening of Ju ly 10th, when, as no membrane ]tad been coughed up for twelve hours, the spray was discontinued. Dr. Whi te states that i t was the ()pinion of all who saw the pieces expelled that they had a very soft and gelatinous character, as compared with the thick, tough pieces of mem- brane usually seen. The case was a bad one, as the child had a tem- perature of 104 ~ and suffered from vomiting and diarrhcca. The child continued to do well unti l i t got broncho-pneumonia, owing to sudden changes in the weather. Af te r death the examination showed that the pepsin had not caused any ill effect upon the lungs, bronchial tubes, or trachea. The pepsin was raised to its active temperature by being immersed in water at 110 ~ F. before i t was used. The vapour coming from the spray apparatus was not hot enough to destroy the activity bf the pepsin, and as the child had a steam bottle attached to the tent, the air in the trachea did not cool it. Dr. White believes that the chief good was done by the pepsin getting thoroughly mixed with the secretions in the small tubes and preventing the formation of membrane there, and not by its action upon the large pieces of membrane lining the trachea and bronchi.--The Lancet, Oct. 22, 1881, and The Practitione73 Jan., 1882.