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very vague and consist at most of some slight dizzinessduring attempts to exercise the deranged function. In thecase we are considering and in Dr. Frank Smith’s case

cerebral symptoms have been prominent, and, once estab-lished, persistent, and in no sense intermittent. Why shouldthis be ?

I would offer the following explanation :-Muscular actsdiffer encrmously in the amount of cerebral effort theydemand. In some muscular acts we are unconscious of anycerebral effort. This is notably the case in walking, whichappears to be almost a purely reflex act, and is often accom-plished unconsciously. The woman who walks about gossip-ing and knitting will do an extraordinary amount of workwithout apparently giving a thought to her knitting-needles.Even writing-i.e., quill-driving and copying-may be donealmost automatically, and so, indeed, may any act in whichthe tactile sense is largely employed to guide the limb inits movement. An incident which once occurred to myselfwill serve to show how very automatic a delicate act maybecome. Some years ago I got a small flake of iron rustinto my eye while railway travelling. This caused slightannoyance at the time, but in a day or so I began to sufferfrom catarrh of the eye, which was excessively painful attimes, causing a spasmodic flood of tears and the forcibleclosing of both eyes. It was in the days when I used arazor, and one morning I was shaving my chin before alooking-glass when suddenly the eyes filled with tears andI closed them; but, nevertheless, I unconsciously finishedmy shaving, and shaved my chin quite smooth with my.eyes shut. There must have been very little cerebration inthis act; in fact, had I appreciated what I was doing, Ishould inevitably have cut myself. My shaving on thismorning must have been almost a pure reflex, brought aboutby constant daily repetition of the same act.

Other acts, again, can never become automatic, and this isnotably the case when the movement of the limb is notguided by tactile sense in the performance of the special act.When, for example, did anyone ever thread a needle autormatically or unconsciously? During such an act as thisthere is evidence of strong cerebral effort, as is shown inthe face of the sempstress. The taking aim-whether itbe at a needle’s eye, a bull’s eye, or the bit of iron to beforged into a nail-involves the bending of the mindtowards the object aimed at; and the aiming at an objectagainst time, as occurs to the pieceworker forging nails, isan act, one would think, which is calculated to cause brain-fag rather than muscle-fag. And the limited number ofclinical facts at our disposal seem to point to the correctnessof this assumption. When the work done by the muscle isgreat, and the cerebral effort involved is small, we may wellexpect the muscle, rather than the brain, to show signs offailure. When, however, the cerebral effort is out of pro-portion to the mechanical work, as in the repeated act ofaiming with a hammer, it is not surprising that, if break-down occurs, it should occur in the brain. It might beurged that this is not a "professional" trouble-that it ismerely a hemiplegic attack followed by post-hemiplegicspasm occurring accidentally in a nail forger. Against thissupposition we have to put the fact that his first sign oftrouble was in connexion with the professional act; thatthe spasm of the arm is only seen at its maximum when heattempts to perform the professional act; and that the casedoes not stand alone, two of Dr. Frank Smith’s cases havingbeen very similar in character.

In the average case of writer’s cramp I have always con-tended that, although peripheral evidence of mischief isalways present, the evidence does not enable us to say thatthe lesion is central, although, of course, I very well knowthat brain cell, nerve fibre, and muscle are practically one.Ordinarily professional ailments never spread to oher func-tions, and certainly the man with writer’s cramp is notmore likely to become hemiplegic than anyone else. In thecase we are considering the trouble, from being merely pro-fessional to begin with, quickly spread. This in itself isevidence that in one case the lesion is peripheral and in theother case central, for at the centre where the nerve fibresconverge almost to a point any sudden lesion is not likely tobe limited to the cells connected with one small functiononly. The nervous system may be compared to a railwaywith branch lines and a " central " terminus. Now, a fire atHolyhead would not cause any disturbance at Carlisle, not-withstanding that they are both stations on one system ofrailway, but a fire at Euston would certainly derange thefunctions of both these outlying stations, and of many others.

The lesion in our case probably began in the part of thecentre corresponding to the serratus magnus muscle (for aseach limb has its controlling " centre" in the train, so, wemust assume, has each muscle of each limb), and thencequickly spread until the right upper limb, the right sideof the face, the right half of the tongue and the right leg (?)became involved.

Seeing that the leg is very slightly and doubtfully in-volved, the lesion, whatever it may be, is apparently almostlimited to the left ascending frontal convolution, to an areato which the blood is brought by the ascending frontalbranch of the Sylvian artery. Seeing that the onset of thetrouble was comparatively sudden, it is not probable thatthe change which has taken place in the brain is of the natureof a slow degeneration or sclerosis. It is to the vessels of thepart to which we must look for an explanation, to hmmor-rhage in the area of the ascending frontal artery or embolismor thrombosis of it. There are manifest difficulties in accept-ing the theory of haemorrhage or embolism, and against thelatter supposition is the absence of any source of emboli.On the whole, I adhere to the belief that the physical basisof our patient’s trouble will be found in thrombosis of theascending frontal branch of the Sylvian artery. In favourof this theory is the fact that his trouble at its com-mencement was always worse on Monday morning, whenthe overworked area of his brain had had a period of rest,and when the circulation through it had been, presum-ably, slow. If we imagine a clot forming in one ofthe smallest branches and gradually spreading backwards,so as to involve the larger branches of the ascending frontalbranch of the Sylvian branch of the middle cerebral artery,we have conditions which, automatically and pathologically,would account for the clinical facts. Thrombosis on theside of the veins leading from this area might conceivablylead to a similar condition, and cause such derangement ofnutrition as to prevent the proper control of movement andlead to such a state of things as we are confronted with.The prognosis in this case is, I fear, not good. Between

September, 1885, and February, 1886, his progress has beennil, in spite of complete rest, good nourishment, and thetherapeutic skill in at least three of our metropolitanhospitals. The deficient irritability of the serratus magnushas disappeared, but even this has not caused more benefitthan a similar recovery of normal irritability causes inordinary hemiplegia. With the exception of this diminishedirritability, there have been no indications for treatment inthe affected limb. No tender nerves have seemed to demanda blister (which is often of very great use in cases of pro-fessional trouble), and no massage or shampooing of thelimb would be likely to influence the brain. Rest, if any-thing, should lead to recovery or improvement; but sixmonths’ rest has done nothing, and I very much fear thathis trouble is likely to be permanent, and that his loss ofcontrol over the affected group of muscles will continue.

AddressON

MICROBES AND DISEASE,INTRODUCTORY TO THE DEMONSTRATIONS IN

BACTERIOLOGY,

Delivered before the British Medical Association at Brighton,August, 1886,

BY EDGAR M. CROOKSHANK, M.B.

GENTLEMEN,-Many, perhaps, may have expected thatthe formation of this bacteriological laboratory would bemade the occasion for reading papers or holding discussionsin connexion with bacterial pathology; it might have beenregarded as an opportunity for publishing the discovery ofsome interesting micro-organism, or for giving an accountof recent researches in connexion with the etiology of somemorbid process which has been hitherto veiled in obscurity.This, however, is not the case, and for this reason. As is

only too well known, we have in England no laboratorydevoted to this particular line of research; we have, so far

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as I am aware, in London, no institution to which a medicala

man can be directed where he would obtain a course ofinstruction or a series of systematic demonstrations. Withperhaps one exception, there is no hospital or medical schoolin London that can be said to give substantial encourage-ment to this branch of study. Obviously, then, an occasionlike the present affords an opportunity of forming a tempo-rary laboratory which may in some measure supply thiswant, by enabling the busy practitioner, and many otherswho have not time to visit the laboratories abroad,some opportunity of gaining a practical acquaintancewith the subject. Instead of papers and discussionson points of doubt in the past or of hopes of whatmay be done in the future, we are met to have demon-strations of what has already been done, and more par-ticularly illustrations of those points which, being basedupon absolute proof, will undoubtedly bear the test oftime and experience. To afford an opportunity of explain-ing the methods employed in bacteriology, of showing culti-vations of micro-organisms, and of demonstrating themicroscopical appearances of the pathogenic species, is thepurpose for which this laboratory has been arranged. That

you should be able to understand the meaning of thesemysterious tubes and to appreciate the value of the prepara-tions under the microscope, I will endeavour to brieflydescribe a few points which indicate the lines of research.

It must be remembered that we have to deal with organismswonderfully minute, and that we have to study the life-history of each individual species. When we realise theubiquitous character of microbes, their presence in the airwe breathe, the water we drink, and in the earth on whichwe move and have our being, the difficulties of isolating oneparticular form from another would seem to be insuperable;nevertheless, with delicate methods and with minute pre-cautions we are able to effect this. The medical man beinginterested more especially in those micro-organisms whichare related to disease, it will be sufficient to give illus-trations of the methods which are employed in investi-gating the life-history of the pathogenic microbes. It mustnot be supposed that it can be, or ever is, considered suffi- icient simply to discover by the aid of the microscope amicro-organism connected with a disease in order to pro-claim it as the actual cause of the disease. Even if we can, inaddition, cultivate it apart from the diseased body, the merefact of its being able to increase and multiply, and to exhibitpeculiar macroscopical characteristics, affords us no evidencewhatever of its being pathogenic. From such evidence as thisconclusions would be only conjectural, instead of beingbased upon absolute proof. One cannot, therefore, too oftenrepeat the necessary requirements for accepting the beliefin a micro-organism as the causa causans of a disease. ToKoch we are indebted for laying down concisely what therequirements are. In the first place, the micro-organismsmust be constantly found in the blood, lymph, or tissues ofthe diseased man or animal. To ascertain their presence wemust apply our knowledge of practical histology, augmentedby many special staining reactions, and in some cases micro-chemical tests. In the second place, we must isolate themicro-organisms from the blood, lymph, or tissues, and culti-vate them apart from the diseased body in suitable media,and we must carry on these pure cultivations throughsuccessive generations. To isolate and cultivate microbesrequires special apparatus-in some cases simple, in otherscomplicated and expensive. It is at this stage of the inquirythat the investigator requires aid from his medical school orfrom the pathological department of his hospital, otherwisethe expense of the apparatus will probably be such a burdento his finances as to prohibit his prosecuting his researches.The suitable medium must be a pabulum which has beenrendered free from all pre-existing micro-organisms. Thisis effected by sterilisation by means of hot air or steam insuch apparatus as you have exhibited before you.We will suppose that we are anxious to investigate some

material, such as blood or pus, in which we suspect thepresence of a micro-organism. We take a glass rod furnishedat one extremity with a platinum wire; we deprive it ofany micro-organisms which may have alighted upon it byheating it in the Bunsen burner, and then, as platinumrapidly cools again, we can almost immediately dip thepoint of the wire into the material to be examined. Thistest-tube, which is, as you see, plugged with cotton-wool,is filled about one-third with a nutrient jelly. Holding thetube mouth downwards, and twisting out the plug, thenoculating needle is steadily thrust into the jelly and

withdrawn, and the plug replaced. These tubes with theircontained medium-nutrient gelatine, nutrient agar-agar,blood-serum, hydrocele fluid, as the case may be-are alsoperfectly germ free; the tubes themselves have been cleansedand sterilised by a temperature of 150° C. for an hour or longer,the cotton-wool sterilised by similar means, and the nutrientmedium itself sterilised by exposure to prolonged heat or byboiling on several successive days. If it were not so, thenutrient jellies would in a very short time fall a prey tobacteria of putrefaction, or, in simple language, "go bad."’It is sufficient to introduce an invisible quantity of micro-organisms. Nothing will be observable immediately afterthe inoculation, but in the course of a day or two accordingto the rapidity of the growth of the particular micro-organism, the temperature of the room, and the nature ofthe nutrient medium, the germs will increase and multiplyin the needle track, and produce some visible change. Theresulting appearances are very varied. You have manyexamples before you: in some there is the appearance of awhite thread or a delicate cloud; or the medium has liquefiedor become milky, or tinged a pea-green or smoky brown; ora growth or deposit has resulted, of a blood-red, vermilion,purple, or yellow colour.

The method just described is simple and effectual whenwe have to deal with the presence of one micro-organismbut it may be well asked, What is the course of procedureif there are different species of micro-organisms presenttogether? How can a mixture of micro-organisms betreated so as to isolate them one from another and to testthe properties of each ? How can they be separated so as.to ascertain which are pathogenic and which are harm-less ? In such a case there is a method which isas simple as it is beautiful. Instead of inoculating ourmedium in the solid state, it must be first liquefied, andwhen the mixture of microbes has been introduced theinoculating needle is stirred round and round, and the test-tube tipped and rolled between the fingers. The microbes-introduced become disseminated throughout the liquidmedium, and if the gelatine is poured out upon a smallpane of glass the individual microbes are fixed by the settingof the gelatine, eich in a particular spot. In order toeffectually separate the different species of micrococci,.bacteria, or bacilli, which may be present, from each other,,we must employ a method of dilution. A fresh tube of’liquefied jelly is inoculated with a droplet from the firsttube, and a third tube from the second, and a fourth fromthe third. Then in the "plate cultivations" which weprepare with these diluted inoculations we shall find thatthe micro-organisms have been completely separated fromeach other; the colonies resulting from each microbe givingrise to its own species will be so completely isolated as toleave no chance of their commingling. From these colonieswe inoculate fresh tubes of nutrient media, so that at lastwe have growing in separate tubes all or nearly all themicrobes present in the original mixture. The appearanceof these colonies before inoculation should be carefullystudied, for in some cases they are absolutely characteristic,and in others help to distinguish micro-organisms whichresemble each other in form. As an example of a verybeautiful and characteristic colony growth, I would drawyour attention to the impression-preparations of colonies ofanthrax, and several other micro-organisms exhibited underthe microscopes. The same method has been also extensivelyused for studying the various microbes in water; but wemust remember that nutrient gelatine is not a suitablepabulum for each and every microbe, and we must thereforesupplement our test by means of cultivations in other-media. As an example of another medium I would point-to the growths on sterilised potato. The outside of thepotato is covered with microbes found in the earth, andthese must be removed by thoroughly cleansing them andsoaking them in a solution of corrosive sublimate. Whencut in half with a sterilised knife, the cut surfaces presenta germ-free soil, which is particularly suitable for the rapidgrowth of many, particularly the chromogenic species. Theinoculations traced over the potato with no immediatevisible effect, will in the course of a day or two developsuch a growth-for example, of the bacillus violaceus ormicrococcus prodigiosus - that one might imagine thatsome violet or red ink had been spilt over the surfaceof the potato. These pigment-producing microbes are ofthe greatest interest, for not only is there a wide field forresearch in the investigation of the chemistry of these

pigments, but the very fact that these simple organisms

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,are endowed with the power of producing such strikingcolours-are, indeed, miniature laboratories of these beautifulpigments-helps us to understand that other species areequally capable of manufacturing the most virulent poisonor of inducing some chemical change, some fermentation,in the blood or tissues which produces a fatal result.By such means having obtained a pure cultivation, we

must carry it on through successive generations. The im-

portance of the successive cultivation cannot be over-

estimated, for the process does away with the possibility ofthe fatal result being due to some chemical poison trans-ferred from the material examined to the nutrient jelly. Ifafter carrying on a cultivation through a hundred or athousand tubes the growth is as virulent as in the first tube,it surely cannot be held that the result is still due to any.chemical poison mechanically carried over in the first inocu-lation, for the original fraction of a drop must have become- diluted to such an extent as to be absolutely inert. We mustbe able wth a pure cultivation to produce the disease inquestion; and, lastly, we must be able to find the micro-organism again in the blood, lymph, or tissues of theinoculated.animal. It may be asked, Are there any micro-organismswhich undoubtedly comply with all these requirements ?’The answer is, Most assuredly there are. We may, indeed,

I

very roughly divide the so-called pathogenic microbes into’three great classes: first, those which absolutely answerthese tests in every particular, and which are thereforeundoubtedly the cause of disease; secondly, those in whichthe chain of evidence is not absolutely complete, but whichwe nevertheless believe to be the cause of the disease;and, lastly, those which are very probably only accidentallyassociated with disease. Of the first class, the bacillus ofanthrax, the bacillus of mouse septicaemia, or the micrococcustetragonus may be given as examples. In all these caseswe can easily isolate the microbe, we can carry on anynumber of successive pure cultivations, and we can alwaysreproduce the disease and find th same micro-organismagain. Of the second class, we may give as examples thebacillus of tubercle and of leprosy. In the case of the firstnamed the evidence is very strong; but the chain is not abso-lutely complete, in that, in some cases of tuberculosis, intissue sections it is very difficult to demonstrate the existenceof the bacillus at all, and therefore, until such cases

are explained, or until it is more generally acceptedthat there are forms of tuberculosis etiologically different,of which bacillary tuberculosis is one, there may continueto be doubt in the minds of many as to whether thediscovery of this ba,cillus is of any importance at all.So, too, with the bacillus of leprosy the chain is in--complete, for the bacillus has not been cultivated apartand the disease reproduced by inoculation, and yet, fromthe veritable invasion of the affected tissues by thebacilli, there can be but little doubt that the bacilli arethe active agents in producing the disease. Lastly, wehave the class which includes many micrococci, bacteria,and bacilli, present, for example, in the mucous membranesof the respiratory and alimentary tracts, or in the skin,which have been described as characteristic of certaindiseases, but about which we must have far more certainevidence before we can maintain that they are more thanaccidental associates.

DROGHEDA UNION : THE LABOURERS ACT.-DrS.Delahoyde, Callan, and O’Keeffe, medical officers of thisUnion, having been refused a fair remuneration for inspect-ing labourers’ cottages, &c., under the Act, have served writson the guardians. The medical officers asked the moderatesum of 5s. for each inspection, and they were offered 2s. 6d.The guardians will defend the action, but there is littledoubt that they will be defeated with heavy costs.

SALFORD ROYAL HOSPITAL.-A new wing has justbeen added to this institution, at a cost of .620,000, which hasbeen paid out of a bequest under the will of the late Mr.John Pendlebury, no appeal having so far been made to thepublic. Amongst other features, the new wing has threewards, totally isolated from the remainder of the ouilding,for the reception of any cases of infectious di,3,ase whichmay be developed in the hospital, and an operating theatre.The out-patients’ department, with the accident ward, isplaced at the rear of the building. The hospital, whichhitherto has only contained sixty. beds, will now be pro-vided with 120. It is expected that the wing will becompleted for the reception of patients during the courseof next month.

CLINICAL REMARKSON

THE TREATMENT OF SYPHILIS BY SUB-CUTANEOUS INJECTIONS OF

MERCURY.

BY J. ASTLEY BLOXAM, F.R.C.S. ENG.,SURGEON AND LECTURER ON OPERATIVE SURGERY, CHARING-CROSS

HOSPITAL.

.TuB lecturer mentioned the excellent results which hehad obtained at the Lock Hospital and elsewhere in theeatment of syphilis by intra-muscular injections of a

solution of the perchloride of mercury. The solution for

injection contains six grains of the perchloride to the ounceof distilled water, and should be made fresh for eachséance. Since he had adopted this method, now a period ofsome eighteen months, upwards of 1500 cases had beentreated with the best results. The sore generally begins toheal very promptly after one or two injections, the secondarysymptoms are markedly modified, and after a course oftreatment extending over a year, more or less, the patientis enabled to discontinue his attendance. Towards thelatter end of the course of treatment the injections maybe given less frequently, and as a general rule not more thanfrom eight to twelve grains of the perchloride are injectedin all. It is undesirable to repeat the injections oftenerthan once a week, as otherwise salivation might be induced,and the quantity injected each time (one-third of a grain)is found to be quite sufficient until the next time. Thereare several advantages attending this method of exhibitingmercury. In the first instance it is only necessary tosee the patient once a week, when sufficient mercury isinjected to last until the following week; secondly, saliva-tion is not produced, as when the patient continued to takemercury for a whole week away from the supervision of hismedical attendant; thirdly, the gastric derangements whichare so apt to follow the administration of mercury by themouth are by this means avoided; lastly, the ease and

certainty of the administration, which enable the surgeonto do his own dispensing with a minimum of trouble. Alittle quinine is generally given during the course as a

tonic, but no other form of mercury is administered.The injection itself is a very simple operation, but

certain rules have nevertheless to be observed in order toobviate any inconveniences which might otherwise result.An ordinary glass hypodermic syringe is used with a fineneedle (the needle is apt to become very brittle from theaction of the mercury on the steel and requires to bereplaced frcm time to time), containing twenty drops of thesolution, equivalent to one-third of a grain of the perchloride.After filling the syringe the needle is freed from adheringsolutions by washing in order to avoid irritation in its track,and is then plunged deliberately into the muscular tissueof the buttock, selecting for this purpose the spot corre-sponding to the muscular mass of the glutei into the sub-stance of which the injection is made. If this precautionbe observed, no discomfort or absees formation follows,the only solitary case in which this has occurred beingattributable to the injection having been made into theareolar tissue over the trochanter. The pain of the injectionis but slight, and soon passes off. It is desirable that thepatient should not take active exercise immediately afterthe injection, as it has been noticed that blood may beeffused at the point of injection, giving rie to the sensationof a severe bruise of the part, which lasts for several days.The same effect has followed the puncture of a large vessel,but in any case the result is only transient, and disappearsafter the lapse of a few days. If for any reason the buttockbe objected to as the site of the operation, the injection maybe made into the trapezius muscle at a point two inchesabove the superior angle of the scapula, but the injectioninto the buttock is attended with less inconvenience.

bir. Bloxam mentioned that his own opinions werestrongly in favour of syphilis being bacillar in origin, thusaccounting for the specific action of mercury in the treat-ment of the disease. In support of this view he alluded tothe remarkable researches of Messrs. Eve and Lingard,whom he had furnished with blood and chancrous tissuefrom patients at the Lock Hospital, the subjects of syphilis.