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beneficial effect on the bowels has doubtless been the chiefcause of the lozenge having become so much liked, so con-tinuously persevered in, and so extensively used. 6. Sulphurin small doses is sometimes useful in aflections of the pul-monary mucous membranes. 7. Sulphur has long had areputation, and doubtless is of much value, in many diseasesof the skin and its appendages. 8. Some arthritic diseases,especially chronic forms of rheumatoid arthritis and gout,and also many cases of muscular rheumatism, are muchbenefited by the continued use of small doses of sulphur.In conclusion, it may be mentioned that the use of the

compound sulphur lozenge, since first employed (not fiveyears ago), has spread most widely; and I have beeninformed that one maker of medicinal lozenges has, duringthe last six months, sent out three hundredweight, which is;at the rate of about two hundred and twenty thousandlozenges a year. Without wishing to lay too much stresson the value of the treatment I have been speaking of inthe present communication, or of being thought to considersulphur applicable as a therapeutic agent in more than alimited number of diseases, still of one fact I feel confident,that there are many hundreds at the present time who areindebted for much health and great comfort to the use ofthis simple and harmless remedy.

ABSTRACT OF

The Milroy LecturesON

OCCUPATIONS AND TRADES IN RELATIONTO PUBLIC HEALTH.

Delivered before the Royal College of Physicians of London.

BY JOHN T. ARLIDGE, M.D., B.A. LOND.,FELLOW OF THE COLLEGE ; PHYSICIAN TO THE NORTH

STAFFORDSHIRE INFIRMARY, &C.

LECTURE III.

IN the last lecture Dr. Arlidge concluded the examinationof the woollen manufacture in its health aspects. Anotheranimal product used for textile and other purposes is horse-hair. Its application in the technical arts is limited, and.gives employment to but a small number of persons. In a,clean condition horsehair is chargeable with no direct ill’consequences to health, but, like wool, foreign importations- of it occur in a filthy state, and are productive of severe.disease. The lecturer quoted from a report drawn up byDr. James Russell, medical officer of health for Glasgow’(1878-79), detailing instances of deaths occurring in a hairfactory near Glasgow, of which no intelligible explana-tion could be given; and contemporaneously some female- operatives suffered severe illness with symptoms resemblingthose noted in the fatal cases. In one case the diseaseshowed itself by a large swelling on one side of the neck,which confirmed the conclusion that it was anthrax thathad to be dealt with. Death in the other fatal cases

’occurred by collapse after constitutional symptoms only.In the eighteenth century the occurrence of the diseaseamong persons who handled skins, bristles, horns, and hoofs"of infected cattle (fellmongers, furriers, fur dyers, mattressmakers, coarse hat makers, tallow melters) had been reco-gnised by French and Italian physicians. The other varietiesof animal dust did not require dealing with extensively.The dust arising from the manufacture of horn had butlittle injurious effect, but that from bone and ivorv wasmore noxious, and might produce respiratory trouble. In’cleaning and dressing feathers a dust was given off which- caused a sense of suffocation and cough; the workers.generally wore a piece of some textile material across themouth to protect them. The dust given off in the manu-facture of mother-of-pearl resembled that given off fromlimestone, both chemically and in its effects. The artisansengaged in the pearl button trade were anxious to maintaina monopoly, and their association had adopted a bye-lawforbidding the introduction of improved processes; theypreferred a short life with high wages. The earliest

symptom observed in mother-of-pearl workers was dyspncea;later on cough commenced. The lesions found after deathwere pronounced. The lung lesions are on record in a con-tribution to the Pathological Societyl made by Dr. Greenhowin 1870.The lecturer next turned his attention to the examination

of industrial diseases attributable to the inhalation of dustof vegetable origin. Such dust arises from cotton, linen,jute, cocoa-nut fibre, espartero and other grasses used inpaper making, from flour and gutta-percha, and from wood.To this list may also be added dust arising from rags usedin paper making and for other purposes. The larger portionof the labour in cotton mills is carried out by females; itinvolves long standing, but otherwise no strong physicalexertion. Scutching and carding are very dusty operations,but the evils therefrom are obviated by the use of enclosedmachines. This simple expedient has greatly lessened theamount of disease formerly existing among carders. Ex-cepting some kinds of spinning and the business of weaving,the processes concerned in making cotton, after the prepara-tory stages are past, present few features of an unhealthycharacter, other than long hours, long standing, and con-finement in the close and often heated air of rooms. In thespinning rooms, however, where "high numbers" are spun,there is both dust and an elevated, unhealthy, moistatmosphere. In the weaving sheds matters are very muchworse, for there the operatives have to contend with a largequantity of dust and with excessive heat and moisture.The dust is derived from the so-called sizing, which consistsof China clay mixed with an adhesive flour or starch pasteand certain salts-viz., chloride of zinc, magnesium, andcalcium, with a certain proportion of sulphate of magnesia.Inquiries conducted by Dr. George Buchanan, Dr. Bridges,Mr. Timothy Holmes, and Mr. Osborn, resulted in a con-currence of opinion on the part of those gentlemen as to themischievous consequences to health. The inferior cottonsrequire the most sizing, and as much as from 100 to 200 percent. of the clay size is added to the cotton before weaving,and to secure the necessary heat and moisture no externalair is admitted, while jets of steam are let into the weavingsheds, saturating with moisture the walls, ceiling, floors, aswell as the clothes of the workpeople. Consequently theycomplain of debilitating sweating, of great prostration,faintness, vertigo, loss of appetite, and impaired digestion,leaving them prone to take colds, and to get pneumonia,rheumatism, and consumption. Their outer clothing, whenhung within the weaving sheds, becomes wetted with thesteam, the deliquescent chlorides in the size contributing tothe result. Consequently on leaving the mill, the dampclothes cling to the workers, aggravating the chillsfollowing exposure in the cold outside air. As this stateof things has gone on unremedied, or, in fact, grown worseby greater weight of sizing, we hear again, naturallyenough, of renewed agitation to induce Parliament tointervene by some restrictive legislation, so that the healthof the artisans be not sacrificed to the avarice of themanufacturers.

Dr. Arlidge next gave the result of his analysis of theforms of sickness prevailing among 1725 cotton operatives,apart from all other artisans. These figures were kindlysupplied by Dr. R. C. Brown, of Preston, who copied themfrom the returns of the infirmary and dispensary of thattown. Taking in-door and out-door patients together,phthisis stands at 13’45 per cent. of the whole numbertreated, bronchitis (acute and chronic) at 15’10, uterinemaladies and displacements at 8’38, rheumatism at 8’50,anaemia and debility, heart disease, and stomach disorderseach at about 6’50, pneumonia and albuminuria at about2’50 for each, struma at 3’03, and cancer at above 5 percent. By thus taking in- and out-patients together, afairer view of prevalent diseases is obtained than byexamining each class of patient by itself. Stomach ailmentsappear six times greater among out- than among in-patients.The like happens with regard to bronchitis and catarrh,which counts above four times greater. On the other hand,heart diseases amount to three and a half times moreamong in-patients, and rheumatism to twice the number.The lecturer next proceeded to touch upon flax manu-

factures, the chief centre of which is Belfast and someneighbouring towns. The best account of the health aspectsof the flax industry is to be found in some scattered papersby the late Dr. C. D. Purdon. As in the preceding textile

1 Trans., vol. xxi., p. 66.

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trades reviewed, it is in the early or preparatory processesthat the evils of linen manufacture are chiefly found, andtheir most energetic cause resides in the dust evolved. Thelecturer described the various processes of " retting,"" scutching," " roughing," "heckling," and "spinning."The name under which the flax dust is known among theworkers is "pouce," and those suffering from its effects aresaid to be "poucey," a word coming directly from theFrench. It appears to be the property of the dust of theflax more than that of cotton and wool to set up a severe Idyspnoea. This does not prevail in proportion to lunglesion present, but seems to have a nervous basis. Flax ’,dust is more difficult to get rid of by expectoration thanthe other two mentioned. In advanced cases the coughand dyspnaea are very urgent, and it is characteristic ofthem that they are paroxysmal. The seizures are worseon first rising in the morning and after quitting the millThey will often by their violence cause the sufferers to staggerand to catch hold of any near object for support. Chronicityis the character of the chest affection, and its victims maybe known by their haggard wasted looks, their roundedshoulders, and tottering weakness. Women are the chiefsufferers, because they form the majority of the mill hands.Dr. Purdon states that a female who starts at carding atseventeen or eighteen years old begins to break up at thirty,and that the average duration of life of caiders is aboutforty-five years. He also calculates the death-rate of thoseoccupied in the preparing processes at 31 per 1000, and thatof hecklers at 11 per 1000. Hence, few of those classesreach sixty years of age. A high temperature prevails inthe rooms where dressing of the linen web is carried on. Itis the occupation of a very few, and those adult men ; butits mischievous effects on health are so fully recognised thatnone are taken on until they are eighteen years of age, andfree from chest affections. The heat varies from 90° to

120°, and those exposed to it are so subject to pulmonarydiseases that their average duration of employment is littlemore than sixteen years.Besides pulmonary affections and rheumatism, there are

slighter ill consequences associated with the linen manu-facture. One such is the disturbance of health called"mill fever," which attacks young hands within a few daysof their entering upon work, and is regarded by the opera-tives as a sort of seasoning to the occupation. It is usheredin by chills, nausea, and vomiting, quickly followed byheadache, thirst, and heat of skin, and is a true febriledisturbance. After from two to eight days it spontaneouslydisappears, leaving the patients weak and languid. No

special medical treatment is commonly adopted for it, as itnaturally disappears when left alone.

Hsemorrhoids, also, are common among the women,attributed to long standing. Another minor ailment, calledby Dr. Purdon lichen, breaks out upon exposed parts of theskin of children, especially the weakly ones. It has apapular character, and is attended by prickly heat. It was

assigned to the action of the flax water, but seems to be, infact, due to that of certain oils used in spinning. There isyet another cutaneous eruption seen occasionally, having apustular appearance closely resembling small-pox. Itsoccurrence has been associated with the employment ofcertain kinds of Russian flax; but it is to be regretted thatDr. Purdon gave no account of the general symptomsattending the rash, for its occurrence raises an interestingquestion as to what relations it possibly might have withthe serious septic diseases already noticed as consequentialto the use of Russian products infected by bacilli. Lastly,those who have to handle the yarn, whilst bleaching in anirritating lye, suffer a severe and painful form of eczema,which breaks out about twenty-four hours after they com-mence work, and, if not attended to, grows after a whileunendurable.

Dr. Arlidge next referred to the minor industries, such asthe manufacture of jute, lace making, paper making,cocoanut fibre, wood turning, flour mills, tobacco manufacture, charcoal dust, bronze casting, and chaff cutting,all more or less dust-producing businesses. In regard topaper making, it had. Dr. Arlidge said, been proved thatcertain imported rags caused disease among sorters andcutters. A peculiar outbreak at Ria was investigated bySchulz, Krannhals, Herrganen, and Radecki. The pro-minent symptoms were fever, tremors, dyspnoea, and weakpulse, fatal cases dying in collapse. Alter death, decompo-sition occurred early, and pleural and pericardial effusions,with enlargement of the bronchial glands and spleen, were

found. M. Krannhals, among other micro-organisms, founda small bacillus which he believed to be identical with thebacillus of malignant oedema (Koch) in the pleural effusion.Millers again suffered from cough and shortness of breath-miller’s asthma. Major Beadon, in his factory report, 1884,writes that it is quite exceptional to see a person who hasworked any time in a flour mill who is not more or lessaffected as to the respiratory organs, and he quotes fromthe trade paper called 2’Ae Miller that the average lifeof millers is only forty-three years. With regard to

tobacco, its manufacture gives rise to some dust, chieflyin the operations of cutting and making snuff. Notwith-standing, however, the occupation seems remarkably freefrom ill consequences to health. The newly employedfor a short time manifest slight disorder in the shape ofnausea, giddiness, irritation of the eyes and nose, butthey very soon become used to their work. There is alsoevidence that the pupils of the eye become dilated, butthis seems unaccompanied by injury to sight.

Dr. Arlidge next turned to mineral dusts, and describe(Ithe various classes of workers in coal mines and the diffe-rent classes of pits. Referring to the characters of the dust,,the lecturer said the fineness of much of the dust diffuseCLthrough the mines is indicated by the manner in which it.will take fire, and by the hypothesis of its being, in a greatdegree, the explosive matter of mines. This dust must beperpetually inhaled by the men during their hours of work,and it is therefore not astonishing that their bronchialtubes get irritated by it, and that, as time goes on, it,slowly but surely works its way into the smaller bronchi,and even the alveoli themselves, choking them to a greateror less extent, interfering with the normal circulation in andaround them, and setting up a low form of inflammation,inducing a state of fibrosis of a concretionary character, as.described in a previous lecture. Thanks to wonderfullyimproved ventilation, the conditions of coalpit labour have inthe course of the last twenty or thirty years been wellnightransformed. In fact, colliers have complained that in somepits the ventilating currents are so powerful as to give themchills and produce colds and rheumatism. Amongst othercauses which operate injuriously on miners may be enurne-rated the darkness, which is always unfavourable to vitality;.the dripping water, rendering the labour of the colliers wetwork; the presence of several hundred men and aconsiderablenumber of horses underground, and the consequent foulingof the air by respiration, and a growing unwholesomenessfrom excreta; and another tax upon the health and vigourof the coal-getters, which operates largely and severely-viz., the very constrained and, to those unaccustomed,actually painful positions obligatory on the men in carry-ing on their work. The dust of coal mines, operating doubt-less in combination with other incidents of pit life, iscausative of pulmonary disease, especially in the case of theholers or coal hewers, who are most exposed to it. Chronicbronchitis, asthmatic breathing, black expectoration, con-solidation of lung tissue, and vicarious emphysema still

prevail, according to the lecturer’s experience, among miners,.And to pulmonary lesions must be added diminished vigour,pallor, dyspepsia, misshapen growth, and rheumatism,acute and chronic. The last-named shows itself in theshape of lumbago, sciatica, and other like sufferingslocally; whilst acute rheumatism is, as usual, accountablefor frequent heart disease. To this list must be added theprevalence of nystagmus among them, as pointed out, amongothers, by Dr. Taylor, of Nottingham, and Mr. Jeaffreson,surgeon of the Newcastle Infirmary. The lecturer had metwith this disturbance in the movements of the eye in colliers,but was not fully convinced of its frequent occurrenceamong them. Among several hundred colliers who resortto the North Staffordshire Infirmary for treatment everyyear, not half a dozen apply on account of nystagmus.Still it may be regarded as a morbid condition, havingsome peculiar relation to the employment pursued. Itoccurs in other people who from some eye malady-as, forexample, leucoma-suffer from imperfect and irregularaccess of light to the fundus oculi, and the suggestion ariseswhether the flickering lights of lamps, amid surrounding-darkness, may not set up irregular muscular action-a sortof chorea of the ocular muscles. And why it happens insome and not in other colliers may be attributed to-inherent nerve weakness, constitutional or acquired, inthose that suffer. Miners are pallid, with a dusky, un,healthy complexion, but their pallor is usually not fromordinary ansemia, and may be attributed to the absence

669

of sunlight at work causing a sort of blanching, to the

begriming of the skin affecting cutaneous circulation, andgenerally to the absence of fresh healthy breezes to stimulatethat circulation. Dr. Paul Fabre, from a microscopicanalysis of the blood, asserts that the number of blood-corpuscles and the quantity of haemoglobin are normal, andthat true anaemia is not more common among them thanamong other workmen. The prevalence of ankylostomumis another reputed circumstance his inquiries do not confirm.Colliers, again, prematurely look old; the expression oftheir faces grows anxious and depressed; they are seldomstout, are weak-kneed, have a shambling gait, and ofttimesbowed backs. Their occupation is generally exhibited byMuish scars on their faces and hands, the results of smalllacerations into which the coal dust has entered and per-manently stained, just as happens in tattooing with gun-powder. In the diseases prevailing among 211 cases, Dr.Arlidge found that bronchitis, acute and chronic, constitutes36’5 per cent. of the whole number; rheumatism, 1 per cent.;dyspepsia, 9’17; and phthisis, 4’23 per cent.

FURTHER IMPROVEMENTS IN THE TREAT-MENT OF MALIGNANT STRICTURE OF

THE ŒSOPHAGUS.

BY CHARTERS J. SYMONDS, M.D., M.S. LOND., &c.,ASSISTANT-SURGEON TO, AND SURGEON IN CHARGE OF, THE THROATDEPARTMENT, GUY’S HOSPITAL ; JOINT TEACHER OF PRACTICAL

SURGERY IN THE MEDICAL SCHOOL ; LATE SURGEON TOTHE EVELINA HOSPITAL FOR SICK CHILDREN.

{Concluded from p. 624.)

THE following cases are given for the purpose of furtherillustrating the use of the method of tubage.CASE 1. Malignant stricture j tubage two and a half

fJ,,’1,onths.-Mr. F-, aged fifty-four, was brought to me byDr. Marmaduke Hart on January 10th, 1888. He had had

dysphagia nine months. He had been restricted to fluids forone month, and for a week had hardly swallowed anything.He had lost 4 st. in weight. This patient was so emaciated, soweak, and so cold, and had such a feeble pulse, that I wasobliged to place him before the fire and get him warm beforeattempting treatment. He had seen several of the leadingconsultants in London. The stricture was found eleveninches and a half from the teeth. A No. 10 short tube waspassed, and he at once took milk and brandy, though withstill some difficulty. There was a foul odour on the bougie,and some bleeding. In any case, after nine months theremaining duration must have been short; the evidence ofulceration strengthened this view. He returned in a

fortnight, looking a very different man. His pulse wasstrong, his colour had improved, and he had gained flesh.No. I:! was passed. Ten days later he returned with the tubeblocked, and on removing it I found a hard piece of meat inthe funnel. No. 16 was passed easily. The tube whenremoved was extremely foul. On February 22nd (i.e.,eighteen days after insertion) the tube became blocked, andon withdrawal a piece of growth was found in the funnel.On microscopic examination it showed carcinoma. Thepatient had been able to go out and attend to his businessat times. At his request I left the tube out, but he wasunable to swallow, and after two days a fresh one was

inserted, but he was unable to swallow next day. I thenvisited him, and found that he had never swallowed so

freely as he ought to have done. I then inserted a longrubber tube, specially made and described above. Thisanswered admirably, and was worn ten days. He, however,although now getting weaker and suffering from pulmonarycomplications, begged for a short tube. In thinking overthe case, it seemed clear that the growth was a fungating ’,,one, that the passage was wide and obstructed by masses of i

growth, and that the reason why the former tube did not actwas either that the funnel passed too far, orthat, alengthypartof the gullet being involved, the end did not reach beyondthe disease. To meet these difficulties I made a tube out’of a piece of large rubber drainage-tube, drawing it over thefunnel cut off an ordinary tube. The end of the rubberwas cut obliquely and sewn up to make a conical end ;two large openings were made, one near the point, and onetwo inches up. It was about one foot in length. It was

passed easily on the whalebone guide, and at once heswallowed with the greatest ease, and continued to do sountil his death on April 1st, three weeks and a half after itsinsertion. I have referred to the method of manufacturingthis tube above. The total duration of the case was oneyear; before treatment, nine months and ten days ; aftertreatment, two months and twenty days. This man was soill that I believe he would have succumbed to any operation.The account shows that severe ulceration and sloughing ofthe growth existed before tubage was commenced.CASE 2. Malignant stricture; tubage two months. -

E. B-, aged fifty-three. This poor fellow I saw withDr. Angus Hunt of South Hornsey. He was emaciated tothe most extreme degree I have ever seen. He spent histime in bed, alternately taking and rejecting fluids. Yetwithal he managed to preserve an amount of good humourand fun which was quite surprising. Dr. Hunt had detecteda stricture fourteen inches and a half from the teeth. Theman said he had been ill one year, and had had dysphagiasix months. On March 1st, 1888, a short tube could not beintroduced, owing probably to the tortuosity of the stricture.A long silk-web feeding-tube was inserted, with a view ofdilating and straightening the passage. Through thisabundance of fluid nourishment was given. On the 13th,a No. 10 short tube was passed easily, and he swallowedhalf a pint of milk at once. A week later the tube becameblocked, and was removed, the long one being reintroducedto prevent closure. Two days later Dr. Hunt passed theshort tube, and a week later (March 27th) inserted a No. 13.The man now began to have symptoms of pulmonary affec-tion, and died of gangrene of the lung on April 28th. Dr.Hunt, to whom I am indebted for these notes, says: " Thepatient improved markedly up to the end of March, put onflesh, swallowed all sorts of strained fluids freely, andmoved about briskly; from that time he began to go down-hill, refused the beef-tea because of the nasty taste it had,and took gradually less, but he swallowed without apparentdifficulty up to the last, and died from gangrene of the lungsand exhaustion, not from starvation." This man’s improve-ment was like a resurrection. He was dying of starvation,and would probably have done so before pulmonary com-plications set in ; these, on reading the case, seem to have ebeen precipitated by treatment; they may have been, butthe evidence in other cases is against it. Total duration ofcase, eight months or more; before treatment, six months;after, two months; duration after lung complication, onemonth.CASE 3. Malignant stricture of cesophagus twelve inches

and a half from teeth; intubation for two months and ahalf; death from exhaustion and pulmonary complications.-James E-, aged fifty-four. Dysphagia for solids beganeight weeks before admission to hospital. For six weeks hehad been restricted to fluids. On admission, on Aug. 16th,1886, he was only able to swallow small quantities, andthese very slowly. On Aug. 21st a No. 10 bougie waspassed. The stricture was situated twelve inches and a halffrom the teeth. On the 23rd a No. 16 was passed. On the31st a short tube was introduced and retained; on Sept. 7thit was’removed. He could not swallow without it, so aNo. 12 was inserted. He was discharged on the 8th, wearinga tube. On Sept. 15th he came to the hospital, and thetube was removed. As he could swallow fairly without it,the tube was not again inserted. The next day he returned,unable to swallow; a No. 10 was therefore passed, and hewent home. On the 23rd the old tube was removed, and aNo. 12 inserted. On Oct. 1st a No. 10 was introduced. Onthe 9th he was admitted into Philip ward, and on the12th the tube was changed. On Oct. 9th he was discharged,wearing a tube. The man died on Nov. 9th. His son, inwriting to me, said that his father had been able to swallowwell up to the time of his death, the tube remaining inposition. He suffered from a severe cough for a week beforehis death. Total duration of case, five months; beforetreatment, two months and a half; tubage, two months anda half.CASE 4. Malignant stricture of aesophagus treatment by

bougics and tubage.-Fred. C-, aged forty, came to

Guy’s Hospital on October 7th, 1886. Dysphagia for sixmonths. Stricture ten inches from teeth. He stated thathis mother had died from " cancer in the throat." A bougiewas passed, and the next week he was much better. Up toMarch 10th, 1888, he was treated as an out-patient bybougies twice a week. He could take solids on most

days, and continued his work. A cough commenced in