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ANTHRAX AT NÜRNBERG

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747 several have told us that they object to do this." They sught have said "many" " object-it is a matter of common knowledge ; but I have never heard an explanation from anyone whose opinion was valuable from the side of those who prefer to take their x ray work to non-medical people rather than to their "professional brethren who have made a study of the subject." I am, Sirs, yours faithfully, F. HARRISON Low, M.B. Aberd. Henrietta-street, W., March 7th, 1905. F. HARRISON Low, M.B. Aberd. IRRIGATION IN PERFORATED GASTRIC AND DUODENAL ULCERS. To the Editors of THE LANCET. SIRS, -In the recent correspondence upon duodenal ulcer marked difference of opinion has been expressed as to the advisability of irrigation in operations for ruptured ulcers. The same difference of opinion was evident in the discussion which followed a paper on 50 Consecutive Cases of Perforated Gastric and Duodenal Ulcer which I read before the Royal Medical and Chirurgical Society in November, 1903. Since that time I have carefully studied the question of irrigation in cases upon which I have operated personally or have seen others operate and I have come to the conclusion that irrigation is advisable in all cases of acute perforation, whether operated upon early or late, and for the following reasons. Firstly, the mortality has been lower in those cases treated by general irrigation at St. George’s Hospital during the last two years than in those treated without irrigation. Mr. G. R. Turner has already referred to a series of 12 cases of ruptured gastric and duodenal ulcer with nine recoveries ; in these cases thorough irrigation of the peritoneal cavity was a prominent feature in the treat- ment. Secondly, complications have been far less frequent in cases in which irrigation has been employed and this is a very trustworthy test of the extent to which the peritoneal cavity has been cleansed. Thus in three cases upon which I have operated recently three and a half, five, and seven hours respectively after perforation, and in which I flushed out the peritoneal cavity with some 10 to 20 pints of saline solution, convalescence was absolutely uninterrupted. I Thirdly, I have not yet seen a case in which the abdomen was opened above the pubes without a large quantity of turbid fluid being found in the pelvis even in the earliest cases. It seems to me that the thorough removal of this fluid, which can only be effected by sponging and irrigation, must greatly assist in the patient’s recovery. Further, this proceeding will lead to the formation of far fewer adhesions in the pelvic cavity-a matter of especial importance in females. In two instances I have met with severe dysmenorrhœa and sterility following directly upon perforation of a gastric ulcer in which no attempt was made to cleanse the pelvic peritoneum. In each case the pelvic organs were felt bimanually to be firmly matted together. These facts appear to me to form a strong argument in favour of thorough irrigation in these cases. I am, Sirs, yours faithfully, Grosvenor-street, W., March 7th, 1905. T. CRISP ENGLISH. T. CRISP ENGLISH. CHLORÆTHOFORM. To the Editors of THE LANCET. SIRS,-It is not in our province to express any opinion of our own on a therapeutic or pharmacological question, but we may be permitted to point out that the statement that chloroform prepared from alcohol is superior as an anaesthetic to chloroform prepared from acetone is by no means generally accepted by medical authorities. Some eminent surgeons use regularly the chloroform prepared from acetone and a vast number of general practitioners find the same anaesthetic quite satisfactory. We have been told by more than one anaesthetist that the so-called chlor- æthoform does not give them any better results than the pure acetone chloroform. If no appreciable difference can be detected in the behaviour of a mixture containing 0 ’ 25 per cent. of ethyl chloride from that of pure chloroform, it seems highly improbable that a mixture containing only 0’05 per cent. can comport itself differently from pure chloroform. Yet 0’05 per cent. is all that is alleged to be present in chloroform prepared from alcohol. It may further be noted that Mr. H. Finnemore and Dr. J. Wade in their communication to the Chemical Society 1 do not describe how their chloroform was prepared or give evidence that chloroform formed from ethyl alcohol must necessarily con- tain ethyl chloride. In some samples of alcoholic chloro- form we have not been able by the usual analytical methods to detect ethyl chloride, which must therefore have existed, if present at all, in very minute quantity. It seems to us that up to the present time sufficient evidence has not been adduced to establish the views favoured by Mr. Finnemore and Dr. Wade.-We are, Sirs, yours faithfully, Edinburgh, March 6th, 1905. J. F. MACFARLAN AND CO. J. F. MACFARLAN AND CO. ANTHRAX AT NÜRNBERG. (FROM A SPECIAL CORRESPONDENT.) A VISIT to Nurnberg on the way through from Geneva to Berlin has given a good opportunity of studying on the spot the method of steam disinfection as a preventive against anthrax, on which Dr. T. M. Legge will be giving full information in the Milroy lectures this month. Nurnberg is a town of 285,000 inhabitants, including amongst others many brush and bristle factories. By far the largest concern in this line is the "Vereinigte Pinsel Fabriken," which has combined the chief brush factories, and in one of these is a complete steam disinfecting apparatus through which all the raw material used in this company’s works is passed before undergoing any other treatment. The apparatus is to all intents and purposes a Washington-Lyons disinfector, built into a wall so as to divide the infected in-take room from the non- infected out-take room in our ordinary disinfecting installa- tions. It is made by Rietschel and Henneberg of Berlin and Dresden. The disinfecting house is a small separate building, surrounded by air on all sides and fed by steam at a pressure of two atmospheres from the same boilers which supply steam for treatment of the material at a later stage at a pressure of eight atmospheres. The disinfecting house is well ventilated directly by doors and windows as well as by more elaborate inlets and outlets, the air entering by inlets near the floor being warmed by the radiators which maintain the general warmth of the two rooms. The door of the apparatus, which is eight feet high and fastened by eight strong screw bolts, is opened on its hinges and the cage is run out on wheels. The bundles of bristle are loaded on the transverse trays, which slide in one above the other, the material likely to afford resistance to the penetration of the steam being opened out, while some packets wrapped up in paper are slashed with a knife. In the midst of one of the lightest bundles is stowed away an electric contact thermometer, in which the contact of two halves of a sphere, one half fitting into the other, is prevented by an axial cylinder inside them composed of fusible metal which melts at 103° C. and then allows contact, notifying the fact by the ringing of a bell outside the apparatus. The caged bales are protected from moisture condensing out of the steam by a metal roof and between this metal roof to the cage and the outside metal of the disinfector the steam is eventually let in, being thus well distributed through the chamber. Two maximum thermo- meters are hung in the interior to record for trade purposes the highest temperature reached during the process. While the cage is wheeled out on metal runners a glimpse into the air-jacketed chamber shows its lower part occupied by horizontal radiators which warm up the chamber by dry heat so as to prevent condensation of moisture when the steam is admitted, for moisture and a high temperature are both alike injurious to the bristles. The cage, fully loaded, is now run in, the door is closed and bolted, and after any time from one to three hours, as may be convenient to the staff, steam, sent across from the boilers at a pressure of two atmospheres, is admitted to the disinfector. An out- side manometer shows when the pressure inside reaches the , limit of 0 15 atmospheres required by imperial regulations , and the ringing of the bell records the fact that a tempera- ture of 103° C. has been attained in the interior of the , bundles inside. Not until both these records have been obtained, after a period varying between 17 and 27 minutes from the start, is the electric circuit broken by hand so as to 1 Journal of the Chemical Society, July, 1904.
Transcript
Page 1: ANTHRAX AT NÜRNBERG

747

several have told us that they object to do this." Theysught have said "many" " object-it is a matter ofcommon knowledge ; but I have never heard an explanationfrom anyone whose opinion was valuable from the side ofthose who prefer to take their x ray work to non-medicalpeople rather than to their "professional brethren who havemade a study of the subject."

I am, Sirs, yours faithfully,F. HARRISON Low, M.B. Aberd.

Henrietta-street, W., March 7th, 1905.F. HARRISON Low, M.B. Aberd.

IRRIGATION IN PERFORATED GASTRICAND DUODENAL ULCERS.

To the Editors of THE LANCET.

SIRS, -In the recent correspondence upon duodenalulcer marked difference of opinion has been expressed asto the advisability of irrigation in operations for rupturedulcers. The same difference of opinion was evident in thediscussion which followed a paper on 50 Consecutive Casesof Perforated Gastric and Duodenal Ulcer which I readbefore the Royal Medical and Chirurgical Society inNovember, 1903. Since that time I have carefully studiedthe question of irrigation in cases upon which I have

operated personally or have seen others operate and Ihave come to the conclusion that irrigation is advisablein all cases of acute perforation, whether operatedupon early or late, and for the following reasons.

Firstly, the mortality has been lower in those cases

treated by general irrigation at St. George’s Hospitalduring the last two years than in those treated withoutirrigation. Mr. G. R. Turner has already referred to a

series of 12 cases of ruptured gastric and duodenal ulcerwith nine recoveries ; in these cases thorough irrigation ofthe peritoneal cavity was a prominent feature in the treat-ment. Secondly, complications have been far less frequentin cases in which irrigation has been employed and this isa very trustworthy test of the extent to which the peritonealcavity has been cleansed. Thus in three cases upon whichI have operated recently three and a half, five, and sevenhours respectively after perforation, and in which I flushedout the peritoneal cavity with some 10 to 20 pints of saline solution, convalescence was absolutely uninterrupted. IThirdly, I have not yet seen a case in which theabdomen was opened above the pubes without a largequantity of turbid fluid being found in the pelvis evenin the earliest cases. It seems to me that the thoroughremoval of this fluid, which can only be effected by spongingand irrigation, must greatly assist in the patient’s recovery.Further, this proceeding will lead to the formation of farfewer adhesions in the pelvic cavity-a matter of especialimportance in females. In two instances I have met withsevere dysmenorrhœa and sterility following directly uponperforation of a gastric ulcer in which no attempt was madeto cleanse the pelvic peritoneum. In each case the pelvicorgans were felt bimanually to be firmly matted together.These facts appear to me to form a strong argument in

favour of thorough irrigation in these cases.I am, Sirs, yours faithfully,

Grosvenor-street, W., March 7th, 1905. T. CRISP ENGLISH.T. CRISP ENGLISH.

CHLORÆTHOFORM.To the Editors of THE LANCET.

SIRS,-It is not in our province to express any opinionof our own on a therapeutic or pharmacological question,but we may be permitted to point out that the statementthat chloroform prepared from alcohol is superior as an

anaesthetic to chloroform prepared from acetone is by nomeans generally accepted by medical authorities. Someeminent surgeons use regularly the chloroform preparedfrom acetone and a vast number of general practitionersfind the same anaesthetic quite satisfactory. We have beentold by more than one anaesthetist that the so-called chlor-æthoform does not give them any better results than the pureacetone chloroform. If no appreciable difference can bedetected in the behaviour of a mixture containing 0 ’ 25 percent. of ethyl chloride from that of pure chloroform, itseems highly improbable that a mixture containing only0’05 per cent. can comport itself differently from purechloroform. Yet 0’05 per cent. is all that is alleged to bepresent in chloroform prepared from alcohol. It may furtherbe noted that Mr. H. Finnemore and Dr. J. Wade in their

communication to the Chemical Society 1 do not describehow their chloroform was prepared or give evidence thatchloroform formed from ethyl alcohol must necessarily con-tain ethyl chloride. In some samples of alcoholic chloro-form we have not been able by the usual analytical methodsto detect ethyl chloride, which must therefore have existed, ifpresent at all, in very minute quantity. It seems to us thatup to the present time sufficient evidence has not beenadduced to establish the views favoured by Mr. Finnemoreand Dr. Wade.-We are, Sirs, yours faithfully,Edinburgh, March 6th, 1905. J. F. MACFARLAN AND CO.J. F. MACFARLAN AND CO.

ANTHRAX AT NÜRNBERG.(FROM A SPECIAL CORRESPONDENT.)

A VISIT to Nurnberg on the way through from Geneva toBerlin has given a good opportunity of studying on the spotthe method of steam disinfection as a preventive againstanthrax, on which Dr. T. M. Legge will be giving fullinformation in the Milroy lectures this month. Nurnbergis a town of 285,000 inhabitants, including amongst othersmany brush and bristle factories. By far the largestconcern in this line is the "Vereinigte Pinsel Fabriken,"which has combined the chief brush factories, andin one of these is a complete steam disinfectingapparatus through which all the raw material usedin this company’s works is passed before undergoingany other treatment. The apparatus is to all intents and

purposes a Washington-Lyons disinfector, built into a wallso as to divide the infected in-take room from the non-infected out-take room in our ordinary disinfecting installa-tions. It is made by Rietschel and Henneberg of Berlinand Dresden. The disinfecting house is a small separatebuilding, surrounded by air on all sides and fed by steam at apressure of two atmospheres from the same boilers whichsupply steam for treatment of the material at a later stageat a pressure of eight atmospheres. The disinfecting house iswell ventilated directly by doors and windows as well as bymore elaborate inlets and outlets, the air entering by inletsnear the floor being warmed by the radiators which maintainthe general warmth of the two rooms. The door of theapparatus, which is eight feet high and fastened by eightstrong screw bolts, is opened on its hinges and the cage is runout on wheels. The bundles of bristle are loaded on thetransverse trays, which slide in one above the other, thematerial likely to afford resistance to the penetration ofthe steam being opened out, while some packets wrappedup in paper are slashed with a knife. In the midstof one of the lightest bundles is stowed away an

electric contact thermometer, in which the contact oftwo halves of a sphere, one half fitting into the other, is

prevented by an axial cylinder inside them composed offusible metal which melts at 103° C. and then allows contact,notifying the fact by the ringing of a bell outside theapparatus. The caged bales are protected from moisturecondensing out of the steam by a metal roof and betweenthis metal roof to the cage and the outside metal of thedisinfector the steam is eventually let in, being thus welldistributed through the chamber. Two maximum thermo-meters are hung in the interior to record for trade purposesthe highest temperature reached during the process. Whilethe cage is wheeled out on metal runners a glimpse into theair-jacketed chamber shows its lower part occupied byhorizontal radiators which warm up the chamber by dry heatso as to prevent condensation of moisture when the steam isadmitted, for moisture and a high temperature are bothalike injurious to the bristles. The cage, fully loaded,is now run in, the door is closed and bolted, and afterany time from one to three hours, as may be convenientto the staff, steam, sent across from the boilers at a pressureof two atmospheres, is admitted to the disinfector. An out-side manometer shows when the pressure inside reaches the

, limit of 0 15 atmospheres required by imperial regulations,

and the ringing of the bell records the fact that a tempera-ture of 103° C. has been attained in the interior of the

,

bundles inside. Not until both these records have beenobtained, after a period varying between 17 and 27 minutesfrom the start, is the electric circuit broken by hand so as to

1 Journal of the Chemical Society, July, 1904.

Page 2: ANTHRAX AT NÜRNBERG

748

stop the bell ringing, and the actual time is recorded in abook as the time at which disinfection began. A current of

superheated steam is now flowing through the apparatus,guarded by a safety valve, and at the end of half an hour thetime is again recorded in the book and the steam is turned offfrom the chamber and on again through the pipes which keepthe chamber warm. The disinfected material is thus allowed tocool down gradually for from two to seven hours, while steamis replaced by warm air ; and, finally, the further door is

opened, the cage is run out into the non-disinfected room andunloaded in safety by the workmen who have cast off thewashable overalls in which they loaded the infected materialand washed their hands and faces in soap-and-water and dis-infectant. The overalls are sterilised each time. This processis repeated with fresh material every morning; two workmenare sufficient for the work, and the average cost comes onlyto four marks per 100 kilos, about 2s. per hundredweight-a quite insignificant amount. Small factories in the citydisinfect their material in the disinfectors erected by thecity authorities to serve both this purpose and also that ofdisinfection in cases of other infectious diseases. Here thecost to the owner is five marks per 100 kilos. Full and detailedinvestigation by the Imperial Health Office in Berlin issaid to have proved the complete efficacy of this procedurein killing even anthrax spores. The procedure has been invogue in these factories owing in some degree to demandsfrom the workmen, since the promulgation of rules to thiseffect by the city in 1895. It was not, however, till 1902that the Imperial Government issued an order on the sub-ject ; and in this Imperial order only foreign material is

subjected to disinfection.But the proof of the pudding is in the eating, of the spore

in the pathology. Have these regulations diminished thenumber of cases of anthrax ? ‘! To determine this question itwas necessary to consult the Statistical Bureau, whichreferred to annual reports for its tables of mortality, andthe police-office which turned up a memorandum in MS. asto the cases notified. The results thus obtained are the

following :-

All cases are notifiable by all medical men diagnosing thecondition, but unfortunately these notifications for the lastseven years have simply been filed and never compiled, stillless published, and the office will have very great trouble insorting them out, which, however, the staff hope to be ableto do as a result of to-day’s visit, although it may mean a

fortnight’s work. It is incredible that in a town of suchsize and importance the wider value of notification should beabsolutely squandered on an office file. But problems of

public health are not dealt with on far-seeing lines in mostcontinental towns of my acquaintance.The police secretary was of the opinion that a certain

number of cases had been notified during the past few yearsand the 12 cases in 1898-99 do not look as if the number hadbeen decreased by disinfection. Moreover, he was inclinedto believe that many cases had passed unnotified. It appears

that in the early " nineties " only two medical men in thetown interested themselves in the disease and many cases

may have passed unnotified. Since then the disease is well

recognised, even by workmen ; but it is also well treated inan early stage by every practitioner and when a local pustulehas been simply excised without any general symptoms orunfavourable circumstance the case will not improbablyescape notification, especially seeing that the duty of notifica-tion is not so generally recognised on the continent as with us,even by many of the medical profession who openly plead theinterests of the patient as opposed to those of the State. Itis quite likely, therefore, that the total number of cases hasnot diminished since the introduction of steam disinfection.But there is no gainsaying the mortality figures, which showonly one certain and one doubtful death during the lastseven years. In addition to this may be added the state-ment of the director of the large factory already referred tothat they have not had a single case of infection since theintroduction of their steam apparatus and the general state-ment of the superintendent of the hospital, who till last yearwas also Stadt-arzt with many of the functions of a medicalofficer of health, that there had been no case notified orunder treatment in the hospital in recent years.

THE EPIDEMIC OF SCARLET FEVER ATNORTHAMPTON.

(FROM OUR SPECIAL SANITARY COMMISSIONER.)

Northampton, March, 1905.THERE has been an epidemic of scarlet fever at North.

ampton which presents some peculiar features. The popu-lation of the town must now amount to a little over 90,000.This is equal to a very small fraction under five persons ineach house and 26 inhabitants per acre. Thus, except it be

in certain localities, the town cannot be said to suffer fromovercrowding. Indeed, the death-rate is very low and inthe last report published, which is for 1903, it is estimated

that though the average death-rate for the previous ten

years was 15’6 6 per 1000 the death-rate for 1903 was only13’ 5 per 1000. At the same time it must be noted that thebirth-rate did not exceed 24’ 4 per 1000. This is the lowestbirth-rate on record. In 1893 the birth-rate was 30 per1000 ; in 1895, 31 5 per 1000 ; and since then it has steadilydecreased. The cause of this fall in the birth-rate is notto be ascribed to a decrease in the frequency of marriages;it is wholly due to a reduction in the fertility of marriage.In 1891 100 families produced on an average 26 childrenand ten years later the average was 22 children. Thoughsuch reduction in the birth-rate accounts in a measure forthe low death-rate there has also been a reduction in the

proportion of deaths of the infants born-namely, 137’2deaths per 1000 infants under one year of age, and thisis a low rate for Northampton. Thus, and taken alto-

getber, it may be said that the vital statistics testifyto satisfactory and to improving conditions. Neverthelessthere has been an extraordinary prevalence of scarlet fever.The epidemic has slowly developed itself and has nowentered upon its third year, though it is showing evidentsigns of abatement.During the first quarter of 1903 there were 129 cases of

scarlet fever notified, resulting in a case mortality of 2 - 3 percent. During the second quarter the number of notifications-127-was almost the same but there were 5’5 per cent. ofdeaths, and in the third quarter 139 cases resulted in 4’ 3per cent. of deaths. This is in all 395 cases for thefirst nine months of the year ; and now the more seriousdevelopment of the epidemic began, for there were 269cases notified during the last quarter of the year.On the other hand, the proportionate mortality fell to2’ 9 per cent. of the cases. Evidently matters were notlikely to improve in 1904 and, indeed, there ensued a muchmore serious epidemic. But, and before dealing with this, itis instructive to look back for ten years so as to realise the holdwhich this disease has on Northampton. The only two yearsthat can be compared with 1903 are 1897 and 1898, whenthere were 866 and 731 cases of scarlet fever notified. Thiswas equal to an attack rate of 14’ 2 and 11’ 9 per 1000 of thepopulation. In consequence of the increase of the numberof inhabitants the attack rate for 1903 is only equal to 7’ 36


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