374

Dr. IIugblings-Jackson, the results of this method are dig-tinctly of an encouraging kind.On the physiological side the strange influence which has

been exerted in this case upon the site of the premonitoryaura by the application of the blisters is very interesting.There has been a transfer of the aura from the right footand leg first to the left foot, and later to the right groin.Here again I am able to state that we are dealing withsomething which is not a chance coincidence but a resultof the application. I drew attention to the phenomenonof transfer for the first time, so far as I know, in myearliest paper upon this method of treatment,3 and havesince described numerous examples of it.’ There is nomarked uniformity in the mode of transfer in such cases.For example, in one patient a tickling in the left arm hadalways preceded the fit. After the application of a blisterencircling this limb the tickling was transferred to the leftleg. In another case characterised by a similar aura, thefits, as well as the tickling, ceased after the application ofa ring of blister. In a third a sense of numbness in the lqftwrist was transferred to the right wrist. This was a caseof cerebral tumour, as a subsequent autopsy showed. Anotherpatient was a woman whose tits had always been precededby cramp in the right hand, and who, after the blister, wasaffected with cramp in both hands before her fits. Inthe case of a patient whose fits had always been pre-ceded by cramp in the left foot and shaking of it, withnumbness of the lcft leg, a ring of blister was appliedto this leg and in subsequent attacks it was the rightleg which became numb and shook. Tingling in theleft arm was the aura in another case, and after blisteringa jerking of both arms and the left leg would takeplace at the beginning of a fit. Strangest perhaps ofall was the case of a female patient whose attacks alwayscommenced with cramp in the left hand. She had sufferedfrom a severe fit two days before she came to the hospital,and the left hand then still remained quite powerless, asindeed she told us was always the case for a few daysafter a fit. An encircling blister was applied to the leftwrist. Next day the left hand had quite regained itspower, but the patient complained that the right handhad ipso facto become weak. A few days later, when shecame to the hospital, the dynamometer showed 40° as thegrasp of the left hand, and only 18° as that of the right. Ina young woman with hemiplegia from old depressed fractureof the skull, convulsion of the muscles of the limbs and faceon the opposite side of the body to that which had formerlybeen affected followed the application of two rings of blisterto that forearm which had been the seat of the initiatoryspasm. My experience as regards both the therapeuticalvalue of this method and the occurrence of transfer of theaura has quite recently received independent corroborationat the hands of Professor Hirt of Breslau, who has publishedseveral interesting examples, 5 In one case of unilateralconvulsions without loss of consciousness, in which theattacks were exceedingly numerous every day, and alwayspreceded by a tickling in the left arm above which theblister was applied, the attacks ceased, and did not recurduring the six months preceding the report. In a secondcase, the aura was a trembling of the great toe of the rightfoot. Blistering was followed by cessation of attacks fortwo months, and in a fit which then occurred it was noticedthat the trembling affected the big toe of the left foot. Athird case is that of a shoemaker, in whom the cessationof attacks consequent on the treatment was attended bysuch feelings of discomfort as to cause him to regret hisprevious condition ! In another example there was transferof the aura, which consisted of over-extension of the ourthand fifth fingers of the left hand to the other side. At the esame time, as happened also in a case of mine, to which Ihave just referred, a transitory loss of power, which waswont to be experienced in the right hand for a day or twoafter the fit, was now noticed in the left limb. In a fifthcase there was transfer of an aura in the little finger to theother side. In four of these cases the therapeutical resultswere highly satisfactory, especially in the second, in which,after the transfer of the aura, rings of blister were appliedsimultaneously to both feet.

3 Practitioner, October, 1868.4 Clinical Lectures on Diseases of the Nervous System. 1882. Lecture

24 : On Phenomena of Transfer produced in Epileptic Patients by theApplication of Encircling Blisters.5 Ueber das Auftreten von Transfert-Erscheinungen während der

Behandlung der partiellen Epilepsie. Neurologisches Centralblatt,No. 1, January, 1884. Leipzig.

Until our information as to the position of receptivecentres for impressions of common sensations is more exactthan it is at present, it would be idle, I think, to wastemuch time in speculating upon the ?nOd1tS operandi of peri.pheral irritation in producing these results. There wouldseem to be sufficient evidence to show that epileptiformconvulsion beginning unilaterally depends upon a lesion ofthe cortex cerehri. Thanks to the clinical researches ofHughlings Jackson and the experimental observations ofHitzig and Ferrier, we know a good deal about the locatisa-tion of centres for movements in the cortex, and somethingrespecting those for certain forms of special sensation. Butas regards the situation of the centres which receive im-pressions of common sensation, we can do little more thaninfer that the place of reception for impressions coming fromthe skin covering a limb is probably in close associationwith the centre for the movement of its muscles. If thisbe so, the irritation of a blister causing a molecular change,,which is propagated centripetally, may be supposed capableof influencing in some way the liberation of movement.As a matter of detail I would say that in my experience a

distinct advantage has shown itself in the blister beingemployed in the form of a ring or bracelet encircling thelimb. An effect has been produced where the previousapplication of a quadrilateral blister has failed. A ring ofblister applied, as it has been in the case of JohnM—,above the ankles, involves cutaneous branches derived fromthe lumbar as well as the sacral plexus through the anteriorcrural and sciatic nerves. A blister acting upon these nervesmay be conceived therefore to be capable of producing amore intense impression than one which should only affectthe branches derived from one or other of these largenerve?. But I am disposed to doubt whether it is requisiteto employ blisters so wide as those which I have used inthis case. In some of my cases they have been narrower,and, so far as I am aware, this has been no disadvantage.Those which Professor Hirt says that he employed were buthalf an inch in width, and I think it very probable that.a still narrower ring than this would be found sufficient.That is certainly the case when Paquelin’s thermo-cauteryis used. It is, of course, desirable to avoid inflicting unneces-sary discomfort, but, as a rule, I have not found that thepain of the blister presents any serious obstacle to itsemployment.

Annual AddressDelivered on February 6th at the

OBSTETRICAL SOCIETY OF LONDON,BY HENRY GERVIS, M.D. LOND., F.R.C.P.,

PRESIDENT OF THE SOCIETY.

(Concluded from p. 331.)

THUS much for our work, our success, and our aspirationsin the year that is gone. Would that my few remarks mighthave ended here, but there yet remains a duty that I wouldgladly escape, the duty of offering you some slight memorialnotices of those whom death has claimed from among us.

[After briefly passing in review the careers of Mr. B.

Spaull of Hammersmith, Mr. T. Blease of Altrincham,Mr. Jardine Murray of Brighton, and Mr. AinsworthSchofield, the medical missionary, of whom obituary noticeshave already appeared in our columns, Dr. Gervis continued -.1

In Mr. Philip Harper, who died on Nov. 29th, we lost anoriginal Fellow of toe Society, reducing now the number ofthose who shared in its inauguration to thirty-eight Mr.Harper was a Fellow of the Royal College of Surgeons,of the Royal Medical and Chirurgical and Zoological andEntomological Societies. In the earlier years of our Societyhe was a contributor to our Transactions, and took a frequent share in our debates. In the very first volume of ourTransactions I find an important paper from him "On theMore Frequent Use of the Forceps as a Means of Lesseningboth Maternal and Fcotal Mortality," and in looking throughhis paper and the account of the debate which followed, onecannot but be struck with the change which twenty-fiveyears have brought about in tne general estimation of thevalue of the forceps. Every speaker on that occasion, and

375

among them I find the great name-’ of 1,i 41)Y, B1 nrpli,y, ’1’vlerSmith, R. Druitt, and &bgr;ctrnCH, thought the proportion ofcases in which Mr. Harper had used the forceps, one in

twenty-six, far too high, and some indeol "quite iiiiwar-rantable." Twenty years afterwards, in the debate whichtook place in this room on the use of the forceps, wefind this proportion far exceeded by men of the highestposition; Dr. Malins of Birmingham, for example, declaringthat for five years he had used the forceps once in fivetimes, and with the best results. Dr. Atthilt !?aid thatduring his Mastership of the Rotunda the forceps hadbeen used once in fourteen cases among the io-patients,but still once in twenty-nine among the extern maternity ;and Dr. Daly that during a. practice of fifteen years hehad used the forceps in 10 per cent. of his cases, with amortality of but two out of the total number. And theseexamplei might be largely multiplied. This, of course, is buta fresh illustration of the changing views which occur in theprogress of time with reference to so many questions of prac-tice. I think from it one may fairly learn two lessons :not, on the one hand, to be too dispirited if mw V1e11’iin which we are interested do not at once meet with generalacceptance, sustained by the conviction that if based on truththey will certainly win their way ; and on the other, whennew views not coinciding with our own are advocated byothers, not to be too hastily positive that those viewsmust be unsound and unwarrantable Mr. Philip Harpermay, I think, be therefore fairlv regarded as one of thepioneers in the movement which placed the forceps inthe first position as at once the most important and mottrustworthy of our resources in the management of lingeringlabour.

t3 0

There now remains for me to say something of thoseof our honorary Fcllows who during the year have alsodied.

0

On Dec. 14tb, 1882, and so realfy in the presidency of mydistinguished predecessor, died Dr. Carl Heckcr of Munich.Strangely enough, no notice whatever of his death anperedin any English periodical, and only by chance, as it were,was the fact noticed by our librarian, Mr. Savage, in theMarch number of the 2VgM) York l11edicÛ Jo it 1-it,t 1.,From anobituary notice by Prof. Amann, published in a Munichpaper, I am however able to offer you some particulars ofDr. Hecker’s life and work. Carl von Hecker was lorn inBerlin in 1827, where his father was a professor of medicine.After passing through a distinguished university career, andhaving served in the army as assistant-surgeon, he publishedin 1853 a work on Retroversion of the Cravid Uterus, andcommenced practice in Berlin. In 18.58 he was elected intheUniversityof Marburg Professor of Obstetrics and Directorof the Lying-in Hospital ; but within a very few weekshe was appointed to the much more important Professorshipof Obstetrics in the University of Munich. Here he soongained a great reputation both as physician and lecturer.His first large bo)k, "Clinical Observations in Obstetrics,"he published in 1861, in conjunction with Prof. von Buhl,who died three years before him. Besides this, he wrotemanv valuable essays in professional papers, and so recentlyas 1881 another large work, entitled " Ob-ervations audInquiries at the Lying-in Hospital at Munich from l8oJ to1879." This contains the result of observation of more than17,000 birth-. Besides obstetrics Dr. Hecker took muchinterest in medical juriqprudence, and edited, after Buchner’sdeath, his work on Forsenic Medicine. He married adaughter of the celebrated jurist and privy councillor vonBluntschle, and his domestic relations appear to have beenas happy as his reputation was great and his distinctionsnumerous. Forsomethreeyears previous to his death his healthhad not been good, but up to the day on which he died he hadcontinued to perform all the duties of his appointments.Between five and six in the evening of the 14th he gavehis customary lecture to his class, and returned to hisfamily cheerful and lively as usual, "satisfied with himself,"says his biographer, "as some one who had well done hisday’s work." Shortly after seven he died suddenly seatedin his arm-chair. Professor Amann concludes his notice ofHecker thus: " Through his excellent work in the field ofscience, through his useful activity in the different practicalbranches of his profession during a period of twenty-fouryears, he gained the high esteem of all scholars, while hisaffability and social disposition gained him many friends.Thus he lived an active, although too short a, life, and hewill long survive in the remembrance of the representativesof science, of the university, of his colleagues, and of his

fricnd", His own wonia," adds Amann, "which he usedin his inaugurj.1 addrcs-t as roctor rnaguilicns uny givo useoum consolation for his early death-

1,-ago teben i4t nicht viel lehen,Viol wirkon ist viol lebon.’ "

I had written the above when I received from Dr. MatthewsDuncan — in response to a suggestion of mine that as

von Hecker had died during his presidency it wouldbe a gratification to the Society to receive from himsome obituary notice of Hecker-the following interestingpaper :-

" I have repeatedly been told that Hecker was a man ofsufficient private fortnne, who, therefore, was able to anddid pursue the study of obstetrics and gyt)t,-olo(.fy from loveand reaped for these sciences, and untrammeled by con-siderations which are a strong impulse to most of us toper-everance in work, but which do not do so much to ensuregoo(In,9,; of work 11’1 simple love of knowledge does.Hecker’s great life occupation was teaching and practisingmidwifery ; and constant hospital attendance was his dailyfo’d. His honorary position in this Society, held since18(!t, shows how highly he was esteemed abroad; and Iknow he was held in like honour in his own country.One of our best means of judging a man’s value in Germanyis his selection to fill lirgh and responsible positions-aprj’e-’sorship in a great university or the charge of a greathospital; and, when speaking with Germans of contestsgoing on for such posts, and especially of the various candi-dates, I have said, ’Hecker!’ and have got for answer,’Of course, he is our first man; but he will not leave hisfine position at Munich, with his beautiful villa and propertyin the vicinity.’ So in Munich he livei, worked, and died.Hke other great teachers, he had a large following ofadmiring ptiptli, among whom we may name Poppel, whosework on the force of labour will keep his name living inobstetrical history. The power of producing followers andexcitiog them to good work is a valuable product of teaching.In no one was it more clearly observe! than in the greatPaul Dul))i; and in a less degree it was exemplified inHecker. Hi work was all of the best kind, whether itowned hi-i sole parentage or was a joint production with apupil. Facts and careful observation abound ; theory andhvpothe-ds, kept within due limits, luxuriant yet not rank.We know only two volumes bv him. One was published in18(31, " K’inik der Geburtkundp," by Hecker in conjunctionwith Buhl, the prote-sor of pathological anatomy ; theother, under the same title, by Hecker alone in 1881. Bothwere rec)rds of observations and researches mde in theLying-in Hospital of Munich. Besides these volumes, heproduced rmny mimr works; and one cannot forget hisingenious piper on the dolichocephalous head as a cause offace presentation, a paper whose results still stand fast,though modified by great additions of other authors, espe-cially by the recent researches of Winckel on the influenceof s ight contraction of the pelvis in producing this in-teresting presentation."Oa Sept. 27th died Jean Henri Depaul. He was born on

July 26th, 1811, and had therefore attained the age ofseventy-two. Left an orphan at an early aga Depaul wasintended by his guardian for business, and was sent withthat intent to I’arm. Bjt his natural tastes inclined him tothe science of medicine, and after at first spending all hisfre3 evenings attending the lectures of the Ecole Pratique,he ultimately entered upon the usual hospital course, andin 1832 dressed under Prof. Paul Dubois. With Prof. DuboisDepaul soon became on extremely intimate terms, and con-tinued to devote himself mainly to surgery in associationwith Dubois for many years. His first hospital appointmentwas at the Hupital des Eofants Assistés, where he remaineduntil his election as Professor of Obstetric Medicine in 1862.M. de Soyre, who writes of him in the At,c7tives de Tocologie,of which Depaul was editor in chief, gives the followingfurther particulars of his life and character. " M. Depaul"says M. de Soyre " was a man of prodigious activity, whichhe showed from the commencement of his career by thenumerous works which he published, the thorough prepara-tion he made for the various meetings he had to attend, andbv making a practice which rapidly became considerable.He performed operations admirably and made an excellentdiagnosis. M. Depaul was in general little given to newmethods. He only accepted them a long time after theirappearance and when they had stood the test of time. Itwas with respect to the method of preventing the spread of puer-

376

peral fever in the service hospitaliers’ that a cloud arose for atime between Depaul andhismaster, P. Dubois. The latter, inadvance of his day, wished to isolate the patients, attributingthe frightful mortality which then attacked lying-in-womento the crowded state of the Clinique and the Maternité.M. Depaul was not of this opinion, and it was only later,when he presided over the erection of the new Cliniqued’Accouchements, that he observed the new ideas. Butonly very reluctantly did he ever use antiseptics, and neveradopted intra-uterine injections. He never used any forcepsbut the forceps classique.’ He was a strong partisan of theinduction of premature labour in cases of pelvic deformity,and when this was not available, cephalotripsy was hisfavourite operation. Without being an orator, he was atluent speaker. As a clinical teacher, he was particularlyattentive to his duties. His reputation was universal. Notonly did he constantly receive at the Clinique medical menfrom all lands, but since the foundation of the Journald’Accouchements, with which bis name was associated, bewas in close correspondence with most professors of mid-wifery in Europe." A warm tribute to his personalcharacter closes this sketch of the life and work ofDepaul.

Dr. J. Marion Sims was born in South Carolina inJanuary, 1813. He graduated at Jefferson College, Phila-delphia in 1835, and in the following year commencedpractice in the town of Montgomery in Alabama. He musthave early given special attention to gynaecological practice,for in 1845 ne established a small hospital with twelve bedsfor negro women, in which, after what he speaks of as fouryear of incessant experiment, he worked out the problemof he curability of vesico-vaginal fistula. In 1853 he tookup his residence in New York, where he founded theWc»nan’s Hospital; and although for some years, bothbefore and during the Civil War in America, he practised inLondon and Paris, and for shorter periods at other times,New York was the chief seat of his practice and teachingfor the last thirty years of his life. It can, perhaps, scarcelybe said that Sims was a man of quite the highest rank ingyn:pcology; but we are unquestionably indebted to himfor two most notable additions to our resources, the use ofsilver-wire sutures in vaginal and perineal surgery, and theadoption of the principle of perineal retraction in the exami-nation of the uterus by means of the duckbill speculumnamed after him; and of these two very considerable achieve-ments I am not sure that the latter is not the more important,as by the use of the duckbill speculum not only has the generalexamination of the uterus been singularly facilitated, butthe opportunity of surgical operations on the uterus andvagina, including much more than the treatment of vesico-vaginal fistula, has been greatly enlarged. Over and beyondbeing the first operator to employ silver sutures in the treat-mentof vesico-vaginalfistula, there can, I think, benoquestionthat while not originating anything with respect to theoperation which was not known before (for even in thematter of metallic sutures he had been anticipated byGosset of London, who in 1834 used leaden ones), Simswas yet undoubtedly the first who by combining what Dr.Thomas calls the two essentials of success, the use of aspeculum by which the vagina could be distended and ex-plored, and a suture not liable to excite inflammation orulceration, placed the operation on a footing which hasrescued vesico-vaginal fistula from being what it previouslywas, the opprobrium chirurgice. Of his splendid personalskill in the treatment of vesico-vaginal fistula, the result ofpersevering work, great natural ingenuity and large oppor-tunities well used, one can speak without hesitation and in thehighest possible terms. Of the pamphlet war connected withhis surgeoney to the Woman’s Hospital, which ended in hisquitting for a time the field of his greatest surgical triumphs,and of the storm of adverse criticism which fell on him inconnexion with the publication of his views as to the treat-ment of sterility in his work on uterine surgery, I need heresay nothing. We may be glad, at all events, that thoseviews gained no footing among English gynaecologists, andthat it is the deliberate opinion of the profession that whenwe have done our best to put the generative organs of ourpatients into a healthy state, we have done all that isrequired of us towards the establishment or restoration oftheir functions. But putting aside any discussion of whatwe may deem to be errors of j judgment, and not forgettingthat to such all are liable, humanum est errare, we shallyet, I think, agree that Marion Sims will ever occupya niche of honour in the temple of professional fame

as i surgeon of highly inventive genius, practical skill,and great resource, and the introducer to general use ofthe speculum, which has only been second in its influenceto Simpson’s sound in revolutionising the practice ofgynaecology.With these poor tributes to the memories of those we have

lost my present duty ends, but I cannot close this imperfectaddress without offering my best thanks to the Society forthe considerate way in which it has borne with my short.comings during the year that is past, and to my colleaguesin office for their ever ready and efficient assistance. Maythe year on which we enter to-night surpass the one whoseannals have just been occupying us in every element ofprosperity !

_____________

ON THE

QUANTITATIVE DETERMINATION OF SUGARFOR CLINICAL PURPOSES BY THE

AMMONIATED CUPRIC TEST.

BY F. W. PAVY, M.D., F.R.S.

FOR a long time past I have been intending to give adescription of the mode of application of the ammoniatedcupric test for clinical purposes. Ever since I brought thetest under notice at the Royal Society in 1879, it has beenused in the investigations conducted in my laboratory, andalso for the quantitative determination of sugar in the urineof my patients. Its accuracy and the ease and rapiditywith which it can be applied render it well adapted forclinical use.The ammoniated cupric test differs from the ordinary

copper test in the reduction which occurs, being unattendedwith precipitation of the reduced oxide. Instead of theresult of boiling in the presence of glucose being the forma-tion of a yellow or orange-coloured precipitate, the effect

produced is simply a removal of the blue colour of the test,and when sufficient sugar is present for the complete reduc-tion of the cupric oxide the product is brought to the clearcolourless state of water. Ammonia, as is known, is asolvent of the suboxide of copper, and the solution is quitedevoid of colour. Through this property of ammonia indissolving the reduced oxide as it is produced (the produc-tion of the reduced oxide, be it observed, is not in the

slightest degree impeded by the presence of ammonia) thereis nothing to interfere, as is the case when the reduced oxideis precipitated, with the gradually advancing process ofreduction being watched, and thus nothing to obscure thecondition and prevent its being seen when the preciseterminal point of reduction is reached. A solution of glucosedropped carefully into a flask containing the test in a boilingstate leads to a gradual fading of colour until the point ofcomplete disappearance is attained which is without theslightest difficulty susceptible of recognition.

COMPOSITION OF THE AMMONIATED CUPRIC TESTSOLUTION.

Dissolve the potassic sodic tartrate and potash together ina portion of the water and the cupric sulphate with the aid ofheat in another portion ; pour the solution of cupric sulphate