The year just passed has been marked by several
occurrences of grave moment to the public and to the
profession. In the first place may be mentioned the
obstinate hold which small-pox has gained on certain
quarters of Sydney, while the seaboard quarantine stations
of South Australia, Victoria, and New Zealand are all visited
by the same disease. Next, we cannot forgeb the great
impurity of the Yan Yean during the last summer, and the
tardy commencement of works which will augment the supply and bring to our houses the water of mountain streams, no longer contaminated by the drainage of Whittlesea, with its alluvial flats and pastoral commons.
The next great medical questions brought before the notice of the public were reform of Lunacy Law and of Hospital Administration, and in each of these departments we trust to see great good result from the discussions and inquiries now in progress.
We have once more the pleasure of congratulating the Medical Society of Victoria on its continued prosperity, as evidenced in the proceedings at the Annual Meetings, a report of which appears elsewhere in our present issue.
Ethical disputes, once so common in the profession and so dangerous to any concerted action, have been frowned down or laughed away ; and where differences have existed between individuals or Societies there has been manifest a spirit of conciliation and a tendency to rapprochement Which we trust will become more and more pronounced.
As to the Journal itself, we have every reason to thank both the subscribers and the contributors for their unabated support. The papers published have been very interesting, and have come to us from all parts of Victoria, from New South Wales, South Australia, Tasmania, and New Zealand.
The extracts from other Journals have grown in number and
in
value through the kind co-operation of Dr. Walsh and Dr. Bennie ; and further assistance in this department would be most welcome. We would again urge upon the medical staff of the various Hospitals the wisdom and expediency of reporting as regularly as possible the cases of interest which present themselves for observation. The habit of reporting has a most important reflex influence over the character of Ward work; it tends to bring the scattered members of the profession more into sympathy one with another, it prevents litany valuable facts from escaping notice, and these fragmentary records may hereafter furnish the material for Wide deductions, or the illustrations of important truths.
However short a report may be, if it display a fact of interest
c2
36 Australian Medical Journal. JAN. 15, 1882
to the writer it is bound to be acceptable to many of our readers, and we trust that no contributor will hang back on account of the brevity of his communication, for short articles are often read carefully when longer and more pretentious ones are passed over. Once more thanking our constituents in every colony for their continued support, we wish them all A Happy New Year.
THE CORONER AND THE MELBOURNE HOSPITAL.
Sweeping as were the charges preferred by Dr. Youl against the Melbourne Hospital, he had undoubtedly some evidence on which to base them. Several inquests had occurred within a short period on persons who had been admitted into the Hospital with more or less severe injuries, and had there contracted some fatal form of blood-poisoning.
For instance, two patients suffering from gunshot wounds died on the one day, one from spreading gangrene, the other from pleurisy and pericarditis apparently due to septic infection. Such a concurrence of cases was bound to attract Dr. Yours attention, and when other cases followed of fatal erysipelas and allied affections, it was not surprising that he spoke out clearly and sharply concerning the apparent state of affairs.
The report furnished to the Committee by the Senior Resident is not altogether satisfactory. Since August 1, 1881, twenty patients contracted erysipelas in the Hospital, of whom three died. We are not informed how many cases occurred of diffuse suppuration, phlebitis, pymmia and allied disorders, but we learn that during the same period four deaths occurred from pyzemia.
The site of the Hospital is rather too small; the buildings are crowded too much together ; the new pavilions have closets opening directly into them; the old block is badly lighted and badly ventilated ; and the ward for females suffering from erysipelas and other infectious diseases is miserably small, and is situated almost in the centre of the building. There is no distinct officer told off to attend to
erysipelas cases. The out-patient department is apt, we fear, to prove a focus of contagion, or, as Dr. Youl has termed it, "A Disease Exchange." If we seek to obtain exact statistics concerning the prevalence of septic fevers in the Hospital the greatest difficulties are met with. Those . published in the annual reports are worthless. The bed tickets, the death certificates, and even the ward books, it is said, may be examined without reaching absolute certainty.
Without further and more precise information it is impossible to estimate the number of cases of septic poisoning in one form or another which occur in the Melbourne Hospital.
Undoubtedly, erysipelas has recently been very prevalent throughout the city, as most medical men must be aware.
Dr. Miller's report alone is satisfactory proof of this; hence it would be wrong to assume that the charges against the Hospital are proved. It may be that it is as free from erysipelas and its congeners as is possible when all the worst cases of blood-poisoning in Melbourne are continually being sent into it. But, most assuredly, there are grave defects in construction, in ventilation, in management, and we trust that the coming inquiry will be made as searching and as exhaustive as possible.
gebithoi,
Rheumatism : its Nature, its Pathology, and its Successful Treat- ment. By T. J. MACLAGAN, M.D. Octavo, pp. 333.
London : Pickering and Co., 1881.
(Second Notice.)
In our last number we reviewed the evidence on which Maclagan argues that lactic acid is a product of the rheumatic process, and not its cause. With this conclusion we were disposed to agree ; but now we are asked to make a bold leap and conclude that "in rejecting the lactic acid theory we therefore reject in its entirety the view which regards the poison of rheumatism as being something which is generated within the system. We are thus thrown back on the only alternative view that the rheumatic poison enters the system from without." Rheumatism is not a con-
38 Australian Medical Journal. JAN. 15, 1882
tagious disease ; hence, as a last resort, we are driven to compare it with the malarial fevers. It agrees with them in prevalence, for it is especially apt to occur in damp low-lying localities, in certain climates, and at certain seasons of the year. Some people are more liable to be attacked than others. It has no definite period of duration, and is not communicable from the sick to the healthy.
A further analogy may be traced as regards symptoms ; rheumatic fever is irregular in its type, and characterised by variations in its course, being sometimes remittent, sometimes intermittent. One attack is said to render the system more liable to its recurrence, or to the return of some of the symptoms from slight causes ; unless arrested by treatment it may have a protracted and uncertain course. In all these respects it resembles the malarious fevers ; its course is speedily arrested by large doses of the salicyl compounds, while ague similarly yields to quinine. " The symptoms, course, and pathological lesions of rheumatic fever do not differ from those of intermittent and remittent fever more than do the symptoms, course, and pathological lesions of typhoid fever from those of small-pox and of relapsing fever."
" The balance of evidence and of authority favours the view that malarious poisons are minute organisms," the growth and multiplication of which in the system induces the febrile symptoms. " The poison which produces the symptoms of to-day, has to-morrow ceased to be active, but has given rise to an offspring with the same morbific properties." " The poisons of the malarial fevers . . . are not eliminated in an active form.
They must therefore be destroyed and disintegrated. The only alternative view is that they remain permanently in the system, and that is an untenable position." This destruction and elimination may partly account for the unusually copious urinary deposits. Hence it follows that ague and remittents are not communicable from the sick to the healthy. In relapsing fever the spirilla is present in the blood only during the febrile period, and not in the intermissions ; and successive paroxysms occur as often as the second factor, the necessary food of the germ, is reproduced.
It is in the highest degree probable that the second factor of the malarious process exists in the blood itself and never very abundantly ; that it is quickly used up during the active propagation of the poison and quickly reproduced. " A time comes when the renewal of the second factor is so retarded that
the poison is all got rid of before that event takes place. The advent of this time marks the onset of convalescence." But the blood is ever changing, and hence there is a constant tendency to the fresh development of the second factor ; therefore, we have not in malarious disease the same immunity from subsequent attacks which characterises the continued fevers, whose second factor is found in the solid organs on which a lasting impression is more readily made, and often, too, in parts whose activity is limited to certain stages of life, such as the tonsils, Peyer's patches, Jrc.
Such is our author's exposition of the action of malaria, and he contends that the rheumatic process admits of a similar explanation.
The living germs of the disease enter the body of an individual predisposed to it by the existence of the hypothetical second factor in his fibrous tissues : meeting their proper pabulum the minute organisms multiply, and in so doing produce the local inflammations and the general fever. " The second factor may be widely distributed over all the serous and fibrous tissues of the motor apparatus ; or it may exist only in those of one or two joints.
In each case the severity of the attack will be directly as the amount of the second factor." As with Peyer's patches in typhoid and the tonsils in scarlatina, so rheumatism attacks the joints during the period of life when their function is most energetic, and those, too, among them which are most subject to strain or active movement. The tendency to the development of the second factor is capable of being handed down from generation to generation. The excessive transformation of the muscular tissues leads, on the one hand, to the presence of excess of fibrin and urea ; on the other, to abundant production of lactic acid, which in its turn induces the copious sweats. The shifting character of the joint affections agrees with the irregular disposition of the second factor, and relapses, whether affecting the same joints or others, are always due to fresh developments of the specific pabulum.
So far we have followed Dr. Maclagan's argument, which is well worked out, learned and interesting ; but we cannot accept his premises. Excess of lactic acid may be, and probably is, only a phenomenon attending the rheumatic process ; yet it does not necessarily follow that some antecedent of lactic acid may not be the proximate cause of the disease. But we are disposed rather to trust to the analogy of rheumatism to gout, and look to some occult lesions of the nervous system as the fins et origo mall. We
40 Australian Medical Journal. JAN. 15, 1882 know the great control of the nervous system, probably of some distinct thermic centre, over temperature; equally recognised is its influence over the transformations of tissue, the metabolic processes of the body, as manifested in the history of glycogen, itself the grand-parent of lactic acid. Nay more, the history of loco- motorataxy may illustrate the connexion between nervous lesions and affections of the joints.
Maclagan is driven to the nervous system to explain the chorea, the hyperpyrexia, &c., which may complicate the rheumatic process.
Why not have resort to it in the first instance The pain of gout and of rheumatism is quite out of proportion to the amount of local lesion, and seems truly neuralgic. The broken, or even explosive history of these disorders, is not without analogy to that of epilepsy and of neuralgia; and we must say that the invention of a hypothetic germ and an equally hypothetic pabulum is not to be tolerated until the whole list of possible causes has been exhausted. The argument by exclusion, though admirable when
used amid a finite group of known causes, leads us woefully astray if we trust it in dealing with the unknown or the impalpable. How can we ever say that every possible cause but one has been eliminated? and yet, reasoning like this is at the foundation of Maclagan's theory. An inverted pyramid standing on its point cannot be made more stable by the most solid additions to its base.
H. B. A.
extracts front tke thiral (o male.
LONDON MEDICAL RECORD.
OCTOBER, 1881.
Dr. W. Wagner, of Konigshutte, writing on the treatment of empyema, lays down the rule that puncture should not be tried more than once, and that if the first attempt do not succeed, recourse should be had without delay to incision. He operates with anesthesia, and under antiseptic conditions. If thought necessary for thorough evacuation he does not hesitate to resect a portion of the rib. If the discharge is fcetid, but not otherwise, he washes out the cavity with a seven per cent. solution of boracic acid. He recommends leaving in a thick short drainage tube till there has been no secretion for about eight days, with a normal temperature during the whole of that time.
Dr. Ringer, from experiments on the frog's heart, has demon- strated a mutual antagonism between chloroform and ammonia.
Hence we may conclude that the intravenous injection of ammonia in paralysis of the heart from chloroform is likely to be beneficial.
Dr. Leuf, New York, on Fractures of the Humerus at the Elbow.—
In fractures involving the elbow joint, place the patient's arm on a pillow fully extended and midway between supination and pronation if the external condyle is the one fractured ; if it is the internal condyle then complete supination of the forearm in addition to full extension (avoiding over extension of carpus) should be made. If both are involved the treatment should be the same as if it were fracture of only the internal condyle, with counter- extension added. He gives very good anatomical reasons for this treatment.
Professor Botkin (St. Petersburg) believes that convallaria majalis, the alcoholic tincture, may be substituted for digitalis wherever the latter is indicated, and is quite harmless even in over doses.
The observations and experiments of Prof. Klebs strengthen the conclusions that the bacillus typhosus is the essential cause of the typhoid process in enteric fever. If this conclusion be correct the treatment should be antimycotics. Klebs recommends benzoate of magnesia, 5 drams daily, with inhalations of a 5 per cent.
solution of benzoate of soda, with cold abdominal compresses and occasional cold baths.
The records of successful cases of nerve stretching in tabes and other diseases of the spinal cord are increasing Dr. Carl Langenbach has published his further experiences of this treatment, He shows that nerve stretching has an influence upon the whole nervous system, and remarks that in these diseases nerve stretching is a method of treatment from which under antiseptic management nothing is to be feared, and everything may be gained.
Prof. Bruns of Tubingen has been experimenting on bone marrow. He completely separated it from its connection with bone and transplanted it under the skin of the same animal, and found that_ in 12 out of 19 experiments he succeeded in giving rise to the formation of true osseous structure.
Tappeiner, on the Artificial Production of Tuberculosis in Dogs by Inhalation, concludes that the inhalation of the sputa of tuber-
42
Australian Medical Journal. JAN. 15, 1882cular phthisis never fails to produce tuberculosis. It is probable that the same effect would be produced on man, although the functions of his skin and lungs differ greatly from the dog's. A knowledge of this should forewarn examiners of phthisical cases.
Aubert gives the following as a sure diagnostic point of favus.
The hairshaft becomes infiltrated with air, and is opaque when seen by transmitted light, but shines and shows a brilliant striation under reflected light.
According to Chaudelux, Rebatel, Friedlander, Koster, and others, lupus is tuberculosis of the cutis.
Clark, on the date of Small-pox Contagion (New York Medical Record). Up to the time of the umbilication of the variolous pustule there are no emanations from the body that will convey small-pox to another person.
A case is reported (the first on record) by Dr. Forrest, of cancer of the mamma in the male, preceded by so-called eczema of the mammary gland.
Rockey, on Rossbach's Delicate Tests for Poisons.—Dr. Rockey found by experiments that to produce the change in the characteristic movements of the infusoria, followed by swelling of the body and death, required solutions of one grain of strychnine to the ounce, and then death took place but slowly.
Carbolic acid produces more decided results. He believes that in America the infusoria have much more stamina than they have on the other side of the water.
Dr. A. S. Hudson, California, reports the case of a woman who died of cancer of the breast never requiring more than 31s grain of morphia to relieve the severest pain. After continued use this small dose was just as efficacious as before. He mentions a case of recovery from a dose of 75 grains, and another from 2 drachms of the drug. P. B. B.
ERYSIPELAS IN THE MELBOURNE HOSPITAL.
A man named Anthony Burke was struck on the head by a stone on Christmas Eve. The temporal artery was divided and profuse haemorrhage occurred. He was taken to the Melbourne Hospital and the bleeding was stopped by acupressure. The patient was placed in one of the accident pavilion wards, in which a case of erysipelas had occurred thirteen days before. On the second day after his admissson, Burke and two other patients in the ward were attacked with erysipelas, and were at once removed