4169.

JULY 25, 1903.

Clinical RemarksON

SOME IMPROVEMENTS IN THE METHOD OFLOCAL ANALGESIA.

Delivered at University College Hospital on July 11th, 1903,

BY ARTHUR E. J. BARKER, F.R.C.S. ENG.,PROFESSOR OF SURGERY AT UNIVERSITY COLLEGE, LONDON, AND

SURGEON TO UNIVERSITY COLLEGE HOSPITAL.

HAVING for some five or six years past been in the habitof employing local analgesia for surgical operations of con-siderable magnitude the merits and faults of the procedureare tolerably familiar to me, and in spite of several draw-backs which attach to this method of abolishing pain therecan, I think, be little doubt that it has a future before it,and when the principles which underlie it are well under-

stood I believe it will be widely employed. But this last

condition appears up to the present to be imperfectlyfulfilled and consequently much disappointment has oftenresulted.

I should like now to mention some of my own experienceswith one or two forms of local anaesthesia and to sketch the

principles upon which they have been employed, their meritsand demerits, and the details to be observed in their use. Inthe first place it may be remarked that the dangers associ-ated with the injection of cocaine appear to limit its use somuch as to make it unsuitable for general employment inthe larger and therefore longer operations of surgery. And

though I have tested its efficiency in former years I per-sonally have abandoned it of late in favour of ;8-eucainewhich is less dangerous and gives results which are mostsatisfactory.

In using this agent, however, several points have to bespecially borne in mind. In the first place the principleestablished by Corning about 28 years ago in America thatthe infiltration of the trunk of a sensory or mixed nerve withone of these bodies in solution abolishes its sensation downto its most minute terminal distribution must be constantlykept in view. Next it must never be forgotten that the areas i

supplied by sensory nerves almost, if not always, overlapand that to render any part insensible to pain all its sensorynerves must be brought under the influence of the analgesiccompound. This is not always an easy matter, for althoughour general anatomical knowledge of the position of thetrunk of a nerve may be fairly accurate a slight deviationfrom its usual course may prevent our actually striking itwith the point of the injecting needle. And when three orfour different nerves supply any particular region such asthe groin one or other may not be reached by our injectionand analgesia will be imperfect. Again there are mechanicaland physical difficulties in infiltrating all the nerves supply-ing an extensive field of operation. Simply to inject thewhole area so as to reach all its nerves would mean in

many cases the use of much more of the toxic drug than isnecessary and indeed in some so much as to be dangerous.Further the substance employed may be only diffusedthrough the tissues to a limited extent and so each injectionmay fail to overlap those which are adjacent. It is for thisreason that we aim at reaching the trunks of the nervesthemselves, remembering Corning’s discovery.From all this it must follow that the less poisonous our

analgesic agent is the more freely and widely we mayemploy it if necessary and therefore the more likely weare to reach the nerves by one or other of our severalpunctures. But again it must not be forgotten that isotonic6uids injected into the living tissues are rapidly absorbedby the lymphatics or washed away by the circulating blood,and moreover some with analgesic properties are more

transient in their effects than others so that no operationlasting more than some 20 minutes or so can be performedwithout a constant re-infiltration of the tissues or nerves.

And besides all this it has been shown that the rapid absorp-tion of cocaine, for instance, produces a far more dangerouseffect than when it is slowly taken up from the area in-filtrated. Indeed, there seem to be strong reasons for thebelief, based upon the experiments of many observers, thatNn 41AQ.

cocaine, j8-eucaine, and their allies are actually taken upcocaine, ß-eucaine, and their allies are actually taken cupinto the protoplasm of all tissue cells as well as the nerveswhen injected hypodermically and that if retained therelong enough are broken up and eliminated as material nolonger possessing any general toxic properties.Having now used j8-eucaine for several years in scores of

cases I have been able to see that for the larger operationsit has the following drawbacks though with practice theymay be overcome :-1. It is not easy to hit off a given nervetrunk with the injecting needle through the skin and oftenthrough a thick layer of fat. This difficulty has been over-come occasionally by a second infiltration of the nerve whenit has been exposed by dissection. But the inconvenience ofthis modification of the procedure must be obvious where afield of operation is supplied by several nerves. 2. This

being so it has been necessary to infiltrate the wholeneighbourhood of the nerve trunks and to trust to the widediffusion of the analgesic agent to reach them. This hasmeant the use of a rather large quantity of the mediumwhere a region supplied by a number of nerves has to berendered insensitive. And though up to three grains ofj3-eucaine may be safely injected (= 100 cubic centimetres ofa solution of 2 in 1000) it is more or less cumbrous and anartificial oedema is produced which somewhat, though notalways, too greatly obscures the anatomical details in opera-ting. Moreover, the agent injected is rapidly absorbed indiffusing itself and its action cannot be counted on for morethan 20 minutes or so.Having recognised these drawbacks I was very much

interested in reading some observations by Dr. Braun of

Leipsic on a method of overcoming them and began to

employ it in March last and I have since used it in numerouscases of long operations with very great satisfaction. It isbased upon an old experience that anything which retards ordiminishes the eirouzation of the blood in a part infiztratedwith one or another analgesic agent enhances thepotency ofthe latter. This is the case with cold, or, as was shown longago by Oberst, when a constricting band is placed round anaccessible part, such as the finger, the wrist, or the ankle,before the infiltration is begun. Here a small injection of&bgr;-eucaine will produce, as anyone can prove on himself, afar greater effect than a much larger dose injected into apart not chilled or constricted and the effect lasts as long asthe constriction slows the circulation.

The observations alluded to aimed at investigatingwhether the diminution of the stream of blood in a partproduced by the injection of adrenalin would not have thesame result. A very small quantity of the latter was there-fore injected with the solution of a-eucaine (or cocaine) intothe observer’s own arm in the first instance and subsequentlyinto those of numerous patients. It was found that after thelapse of about 20 minutes the part was quite blanched andwholly insensitive to pain and that this loss of feeling lastedon an average for about two hours. It was found thatadrenalin alone used in the same way had no analgesiceffect.Having tested this method on my own arm with the pro-

portions of adrenalin and /3-eucaine recommended and havingobserved the effects claimed I have been employing theprocedure for several months past with results far superiorto those produced by (3-eucaine alone. The most convenientway I find to prepare the solution is as follows. Powders of8-eucaine and pure chloride of sodium sufficient to make100 cubic centimetres (= 3-2L ounces) of the solution are keptin thick glazed paper ready for use. The amounts in each ofthem are 3-euoaine 0’2 2 gramme (= 3 grains) and purechloride of sodium 0 8 gramme (= 12 grains). 100 cubiccentimetres of boiling distilled water are measured off and tothis the contents of one of the papers are added and thenone cubic centimetre of Messrs. Parke, Davis and Co.’ssolution of adrenalin chloride when the fluid is cool. Asthe adrenalin preparation is of the strength of 1 in 1000 wenow have 100 cubic centimetres of normal saline solutionwith 2 in 1000 S-eucaine and 1 in 100.000 of adrenalinchloride in it-i.e., distilled water, 100 grammes ; purechloride of sodium, 0’8 gramme; a-eucaine, 0’2 gramme ;and adrenalin chloride, O. 001 gramme.

-

The best way practically to measure out the requisiteamount of the adrenalin solution from the one-ounce bottlein which it is sold without exposing what remains to theaction of air and light, which spoils it, is simply to loosenthe stopper and to drop out of it 18 drops into the alreadyboiled water and then to stopper it tightly again. I havemeasured it drop by drop into a standard cubic centimetre

D

204

measure very often and I find that taken from the lip of thebottle from 15 to 18 drops go to the cubic centimetre on theaverage. The form of the lip of the bottle may affect thisand therefore a standard cubic centimetre measure should beat hand to test each bottle in the first instance, but when ithas been once seen how many drops go to the cubic centi-metre the glass measure may be discarded. Before usingany bottle of the solution it should be held up to the light inorder to see that it is quite clear and free from precipitate.If it is not it is spoiled and must not be used. But drawnon as above and at once re-stoppered it will keep well forseveral weeks ; exactly how long is, I believe, not yet known.If all the 100 cubic centimetres of the solution prepared asabove were injected at one sitting into a patient theamount of the drugs would be well within the limits ofsafety. But, as a matter of fact, I have found that anextensive operation can be done with 50 or 60 cubiccentimetres.

There are many excellent syringes with which theinfiltration can be made but that which appears to offer thegreatest advantages is a very simple one made of glass andmetal with rubber washers. It can be boiled in plain waterwithout alkaline additions for sterilisation and comes to

pieces and can be put together by a turn of the hand. Itholds 10 cubic centimetres of the fluid and is accuratelygraduated. I have had adapted to it Frienstein’s needleswhich add much to its convenience. The solution as aboveis left in the Jena glass beaker in which it has been boiledand is carefully covered with a glass dish. The beakershould stand in warm water to keep it at blood heat.In describing an operation carried out under the influence

of this analgesic agent no better example can be taken thanthat of a radical cure of an inguinal hernia. The operation isnot a short one if carefully done ; the region to be dealt withis a very sensitive one and primary union is of the first

importance. Besides all this the prevention of all vomitingafter operation is highly desirable.

In infiltrating the field of this operation four nerves atleast have to be taken into consideration. These are the

ilio-inguinal and ilio-hypogastric, the genital branch of thegenito-crural, and the inferior pudendal branches of thelesser sciatic. The superficial perineal nerve from the pudicwill also probably give twigs to the parts to be manipulatedin the operation.To reach all these nerves with the injected fluid the modus

operandi which I have found to be the best is as follows.The hernia is first reduced and the index finger is thrustwith the skin into the external ring as far as possible.Along this finger the needle is entered and the inguinalcanal is filled with 10 cubic centimetres of the solution,an endeavour being made to inject it all round the neckof the sac so as to reach at one spot or other the genitalbranch of the genito-crural nerve. The needle is thenentered at the external end of the line of incision in theskin and is made to infiltrate the superfloial layers of thelatter down to the root of the scrotum, making the result-ing weal at least an inch longer at each end than theincision is to be. Again, the needle is entered about halfan inch to the inside of the anterior superior spine of theilium and pressure on the piston is at once begun slowly asit is thrust towards the ilio-inguinal nerve to the depth ofabout one inch in moderately fat patients. The needleshould then be partly withdrawn and be thrust in differentdirections towards the usual course of the nerve trunk untilthe whole 10 cubic centimetres have been used up. Thesame manoeuvre is repeated at a point about one inch abovethe middle of Poupart’s ligament where the ilio-hypogastricnerve is most conveniently met. Then the leg is raised andanother syringeful is injected along the ramus of the pubisand the root of the scrotum or labium. Thus about 50cubic centimetres of the solution have been used up,equalling one and a half grains of B-eucaine and half amilligramme of adrenalin chloride. :

It is necessary now where adrenalin has been used to wait lfor 20 minutes from the last injection for the full effect of 1the agent to develop. This time can be employed on some

other small operation or in finally sterilising the hands and <preparing the patient for operation, or two or three shorter <

cases can be infiltrated at the same time. At the end of the 20 ’.minutes the whole field of operation ought to be blanched andthe primary artificial oedema will have almost disappeared. i

If the skin is not white and bloodless the solution is bad. f

The part to be operated on can now be tested with the point ‘of a needle and will usually be found to be insensitive to i

I pricks though not to the touch, for, be it remembered, this ist analgesia, not anaesthesia in its fullest meaning. If not quitei insensitive a few minutes longer may be allowed to elapse.! Then the incision may be made with confidence that no pain, will be felt. The absence of oozing of blood is the first

thing noticed. Only the larger vessels bleed at all. Whenthe sac is exposed it should be dissected cleanly without anydragging. If it is much pulled upon a strain is put uponthe parietal peritoneum which possibly may not have:beenreached by the eucaine and may therefore still be sensi-tive, while the sac itself may be pinched in forceps,cut, or stitched without producing any pain providedthe infiltration round its neck has been thoroughlydone. In the female it must also be remembered thatthe round ligament is specially sensitive and its nerve-

supply from the genital branch of the genito-crural nervemust be adequately treated with the solution. The samemay be said of some of the components of the spermaticcord. But it is possible to render both these structuresperfectly insensitive and some of my last cases illustrate thisadmirably. Two recent ones were those of neurotic menwith tubercle of the lung and haemoptysis as well as tuber-culous testes. The organs were disorganised and verysensitive. After infiltration by this method castration wasperformed without any pain. Their faces were carefullywatched while the cord was dissected out ; its componentswere tied and divided and no sign of suffering was observed.One of them in leaving the theatre called back his thanksthat we had given him the choice of this method.The whole success of the procedure depends upon a

mastery of the principles and practice in the details. It isnot enough to inject a certain amount of the analgesic fluidunder the skin generally. Due regard must be had to theposition and course of the nerves supplying the structures tobe dealt with, and in injecting around or into the nerves theaim should be to make each area of diffusion overlap thepreceding one. This diffusion is fortunately rendered moreeffectual by the use of the adrenalin compound which, byslowing the circulation through the part, prevents theeucaine from being rapidly washed away.Of course, what is possible in the groin, which is pro-

verbially sensitive, ought to be equally so for other partsand is so if the same lines are worked upon. In operationson the veins, for instance, the method is simplicity itself ;and in the hand and foot numerous operations can be donewithout any pain. In all ordinary cases of strangulatedhernia the operation can be done painlessly if the mesenteryhas not to be dragged upon. This is an enormous gain toaged patients who suffer so much, as a rule, from prolongedgeneral anaesthesia. I have quite recently operated on twosuch cases with perfect results. One was in a feeble woman,aged 70 years, with extensive bronchitis, a dry tongue, andfive days of stercoraceous vomiting. Both are now quitewell.As to the general question when to use chloroform or

ether and when a local anxsthetic each surgeon, of course,must decide for himself. To me it appears desirable to givethe patients a choice after putting the facts before them.One cannot forget that for many operations nowadays thechief danger is the general anxsthetic, whether we regardthis as small or great. But with old and feeble people whenit is a question, for instance, of a strangulated hernia orcolotomy, or when a younger patient is suffering fromphthisis or empyema, I feel justified in urging them stronglyto have the local anaesthesia or simply to take it for grantedthat they will and to say nothing about it to them, havingchloroform at hand in case at one point or other a shortinhalation may be necessary.In all cases much may be done in distracting their atten-

tion by a little conversation with a nurse or assistant or

giving them a cup of tea to remove any impressions due totheir not being unconscious. Not long ago in the case of aman whose varicose veins I tied in the country, he smokedhis pipe peacefully while the operation was going on andbhought but little of it and also enjoyed a cup of tea.Besides this, if patients are nervous, perhaps even in all3ases it may be well to give a small dose of morphia hypo-3ermically just before the operation as a soothing agent.rhey are usually placid after this and quite easy to manage.

It goes without saying that all operations performed in thisnanner should be aseptic and further that the reagentsshould be pure and sterile. ;8 eucaine in powder mixedwith pure chloride of sodium appears to keep and toremain dry indefinitely. But this is not so with adrenalin

205

chloride. It is supplied in amber-coloured bottles containingone ounce and must be kept from the light and air and fromall admixture with an alkali. Thus guarded it keeps in astoppered bottle for at least several weeks. The solutiononce made will keep for a number of hours, but then losesits properties of checking the blood flow. It is, when firstmixed, of a pale pink colour. This it changes to lightbrown as it becomes inert and also throws down a slightprecipitate. Boiling for a few minutes, at all events, doesnot seem to affect its properties at all, but this is probablyan unnecessary precaution. If boiled too much I think itloses its properties sooner.

It seems probable that ,a. eucaine, as well as cocaine, actsdirectly upon living cells, becoming incorporated with theirprotoplasm, and that if it be retained there for any longtime it becomes altered in composition and loses its

general toxic properties. If this be so it is an extrareason for the admixture of adrenalin which by pre-venting its rapid washing away from the tissues helps toretain it in the cells until they have destroyed its generalpoisonous effects. There is the further advantage that bythis method the analgesia is prolonged for about two hours,sometimes much longer, which gives a margin of timeduring which even long operations can be done withoutfurther infiltration. Another point is also worth considera-tion. It is generally held by experimenters that adrenalin isa cardiac stimulant and that by the contraction of theperipheral capillaries and small vessels it increases the bloodpressure generally. If this is so there is a good reason forusing this admixture of adrenalin in cases where greatasthenia is present-as, for instance, in strangulated herniain old people. In those cases where under these conditions 1have used it I have thought the patient’s general strengthimproved thereby, but this is not an easy matter to settleclinically unless a large number of cases are observed veryclosely indeed. Pulse tracings with a sphygmometer willalso probably help in arriving at a conclusion and when alarger number has been made than up to the present hasbeen the case the point will be settled.

There are many other matters, physiological, physical, andpharmacological, touched upon in Dr. Braun’s interestingpaper relating to this method. It is not possible to allude tothem here. My object has been rather to give my ownpersonal experience of the method after a close study of itin its many details. These have to be learned by eachoperator for himself, and they are well worth learning.Without a knowledge of them we cannot possibly obtain goodresults.The question is often asked by those who see this procedure

as to the possibility of secondary haemorrhage following whenthe effects of the adrenalin have passed one To this myreply is that I have never yet observed it as a sequel in caseswhere the drug has been used in the way described. In onecase which seemed to offer a good test of its possibleweakness in this respect I took special pains in watching itseffects. This was a case where large Thiersch grafts had tobe removed from the front of the patient’s thigh. Here a

simple sterile gauze dressing was applied to the raw blanchedsurface and I directed my house surgeon carefully to watchfor the return of the circulation every half hour or so andespecially for any reactionary bleeding as the effect of theadrenalin passed off. From the beginning to the end therewas hardly a stain of blood upon the white gauze. In thiscase about four hours elapsed before sensation had returned.Two days later when I next saw the patient there was stillno bleeding ; the surface was then naturally hypersesthetic.The following is a list of all the cases in which I have

employed this procedure :&mdash;

No. of No. ofoperations. operations.

Radical cure of hernia- Removal of varicose veins... 5

Inguinal............... 8 Psoas abscess ............ 5 jFemoral............... 1 Loose body in knee ...... 1 ’

Umbilical ............ 0 Tumour of neck (actino-Strangulated hernia- mycosis) ............... 1

Inguinal............... 2 Colotomy ............... 1

Femoral ............... 2 Thiersch skin grafting...... 1

Umbilical ............ 0 Cystic adenoma of thyroid... 1

Castration for tuberculous -

testis ............... 2 Total ............... 30 t

1

In all these cases the analgesia was most satisfactory and farexceeded in completeness and comfort in working anything i

of the kind which I have seen before. In one case of

strangulated hernia in a man with great pain from draggingon the mesentery due to the tight nipping in a small ringthe first part of the operation was quite painless ; but whenI came to attempt to draw down the loop to examine itscondition the patient complained of an increase of his Epainin the abdomen and I gave a little chloroform for the rest ofthe operation.In addition to the above cases there are three in which

from some error in preparing the solution it failed to producethe desired effect as indicated by the absence of blanchingof the tissues and imperfect loss of sensation as seen on

the patient and on my own arm which I injected as a

control observation. What the error in preparing the solutionactually was is not yet quite certain, but I believe thatit was the spoiling of the original adrenalin chloridesolution, either by exposure or by some contaminationwith an alkali. But these failures convince me that greataccuracy will always be necessary in preparing the analgesicsolution. I hope to trace the causes of error in future casesan"l to be able to formulate rules for the avoidance of them.One thing seems proved at all events&mdash;i.e., that a bottle ofthe adrenalin chloride solution which has been opened evencarefully several times and which may show no signs ofturbidity or change of colour may nevertheless be inert. ThisI have proved by the injection of such a solution on myselfas contrasted with a sample taken from a perfectly freshbottle. But exactly when such a change takes place and howto recognise it I have not been able to determine. If themakers could supply the drug in small amber-coloured glasscapsules containing one cubic centimetre of the sterilisedadrenalin chloride solution (= one milligramme of the

chloride) it would be a great convenience. These might bemade of very thin glass like those in which nitrite of amyl iskept and could be broken into the ;8-eucaine solution withthe certainty that their contents were sterile and unalteredby contact with air, of which the capsules should containlittle or none. It must not be forgotten that the more ofthe adrenalin chloride solution we take from a bottle themore air must take its place. But if kept in the little

glass capsules suggested or in thin tubes of the same

capacity there would be no action of air on it. More-over, greater accuracy of dosage would be gained and thepreparation of the analgesic solution could be intrusted to anunskilled assistant, which is not the case now. If it werepossible in somewhat larger capsules or tubes to combinethe three grains of 6-eucaine and 12 grainb of the chloride ofsodium with the one milligramme of adrenalin chloride itwould be still more convenient, but the question whether theindividual drugs would remain unaltered for a long time inthis combination would first have to be settled by observa-tion. Fortunately anyone can make these observations

upon himself. My experience with ;8-eucaine and chlorideof sodium in the solid form does not encourage me to

hope that with the addition of the adrenalin a practicallyserviceable solid can be made which can be used withthe simple addition of 100 cubic centimetres of boilingwater. Bat perhaps the ingredients as indicated above maybe furnished to us in glass capsules as suggested.The following are the notes of the surgical registrar,

Mr. Wilfred B. L. Trotter, from personal observations ofoperations performed under local analgesia with eucaine andadrenalin :-

Orchidectomy (two eases).-1. Male, aged 37 years; infiltration of theinguinal region and the scrotum ; no pain. The patient was verynervous. 2. Male, aged 21 years ; infiltration as above ; no pain.

Varicose veins (four cases).-1. M.1e, aged 25 years; four incisions; no-pain ; sensation returned in four hours. 2. Male, aged 38 years ; threeincisions; no pain. 3. Male, aged 17 years; two incisions; no pain.4. Female, aged 25 years ; four incisions ; no pain.

Stra’flg1tlated hernia (three cases).-l. Male, aged 33 years. Analgesiawas perfect until the neck of the sac was manipulated in dividing avery deep structure. Retching then came on and chloroform wasgiven. Inguinal hernia. 2. Female, aged 72 years. The patient was veryill with a dilated heart and bronchitis. Femoral hernia; knuckle tightlystrangulated ; herniotomy and radical cure ; no pain. 3. Female, aged46 years; herniotomy and radical cure; no pain.Radical cure oj hernia (eight cases).-1. Female, aged 34 years;

femoral hernia; usual radical cure; no pain. 2. Male. aged 20 years-inguinal hernia; Bassini’s operation; no pain. 3. Female, aged 25years ; inguinal hernia ; Bassini’s operation ; no pain. 4. Male,aged 24 years; inguinal hernia; Bassini’s operation; a little painwhen the cord was pulled on; none throughout the rest of theoperation. 5. Female, aged 21 years; inguinal hernia; some painwhen the sac was being isolated from the round ligament; none

during the rest of the operation. 6. Male, aged 46 years; scrotalhernia of the size of a man’s fist ; some pain when the sac was beingstitched; pain in the wound two and a half hours later. 7. Male,aged 29 years; scrotal hernia of the size of a man’s head ; painin the posterior part of the sac, and when the contents were being

206

squeezed back (? pull on parietal peritoneum) ; some pain duringstitching of the conj. tendon (? chief structures had escaped infiltra-tion). 8. Male, aged 67 years ; scrotal hernia half of the size of a foot-ball ; pain when the neck of the sac was isolated and stitched ; restof operation was painless; hernia on the opposite side had beenoperated on under eucaine alone and chloroform had to be given.Loose body in the knee-joint (one case).-Male, aged 27 years; body

localised and cut straight on to; no pain.Chronic ulcer of leg; skin-grafting (one case).-Male, aged 42 years ;

infiltration of the base of the ulcer and of the area grafted from ; nopain, except at a small spot of the ulcer which had escaped infiltration;no bleeding after scraping the ulcer. The ulcer was two inches indiameter.Psoas abscess (four operations on the same patient).-Each operation

included incision, scraping, flushing, and stitching up; no pain;inside of the abscess was insensitive, except apparently for some vaguesense of touch.

Note.-Since the above was written I have operated onfour cases by this method : one strangulated omental inguinalhernia (a very complicated case), one radical cure of inguinalhernia, one psoas abscess, and one cystic adenoma of thethyroid. I have included these in the above table. _y

The Milroy LecturesON

THE CAUSES, PREVALENCE, AND CONTROLOF PULMONARY TUBERCULOSIS.

Delivered before the Royal College of Physicians of Londonon March 5th, 10th, and 12th, 1903,

BY H. TIMBRELL BULSTRODE, M.A.,M.D. CANTAB., D.P.H.,

INSPECTOR, MEDICAL DEPARTMENT, H.M. LOCAL GOVERNMENT BOARD ;LECTURER ON PREVENTIVE MEDICINE, CHARING CROSS

HOSPITAL A MEDICAL SCHOOL.

LECTURE 11.1

Delivered CM March 10th. ’

THE BEHAVIOUR OF TUBERCULOSIS IN UERTAIN EUROPEANAND OTHER COUNTRIES. :

MR. PRESIDENT, FELLOWS, AND GENTLEMEN,-I proposein this, my second lecture, to pass briefly in review themanner in which tuberculosis has apparently behaved incertain European and other countries during the periods forwhich I have been able to obtain statistics. :

Although I have a somewhat voluminous collection ofmaterial I shall refer here only to certain instances whichappear to afford food for special reflection, reserving thebulk of the matter for the expanded lectures which are incourse of preparation. Let me, however, preface my remarksby an expression of opinion that all these statistics must beaccepted with the greatest circumspection and reserve. Thisis more particularly the case in any attempt to contrast thebehaviour of the statistics of one country with those ofanother, but even in respect of the different periods of thesame country there are obviously difficulties. These diffi-culties are due mainly to altered nomenclature, better dia-gnostic methods, greater facilities for obtaining medicalassistance in hitherto inaccessible districts, and the applica-tion of bacteriology to medicine. Even with regard to thestatistics of our own country, which are probably the best theworld possesses, Dr. J. Tatham warns us that we must acceptthem for what they are worth and that it is not unlikely thatpart of the decrease in the death-rate from pulmonary tuber-culosis may be apparent rather than real. But it is im-

portant to keep in mind the fact that it is to statistics thatappeal is sometimes being made for action of a rather com-prehensive nature, involving in its detailed application gravedisabilities, such as the weakening of family ties, loss ofemployment, and the creation of a leper class.The measures advocated by the extremists are far-reaching

in their issue, not only to the individual but to the com-munity, and it is by way of asking how far all thesemeasures are necessary and what result is to be hoped forfrom their adoption that I am venturing to submit to the

judgment of the Royal College of Physicians certain of thedata which are brought forward as a basis for action. WhileI am largely in sympathy even with the extremists, I feel I

1 Lecture I. was published in THE LANCET of July 11th, p. 73.

that it may not be entirely useless at this juncture to exa-mine, I trust quite dispassionately, into what are apparentlythe facts.

In the collection of data which I am about to bringbefore you I wish especially to acknowledge my indebted-ness to my distinguished colleague, Dr. R. Bruce Low, andalso to express my thanks to Dr. Pannwitz, the courteous

secretary-general of the German Association for the Erectionof Sanatoriums.

THE BEHAVIOUR OF TUBERCULOSIS IN PRUSSIA.

In the first place let us consider Prussia, because it is in

respect to Germany as a whole, and Prussia in particular,that the tuberculosis problem acquires very great interest.The statistics which were contributed by the ImperialStatistical Bureau to the recent Congress on Tuberculosis inBerlin relate to the behaviour of tuberculosis as a whole inthe State of Prussia for the six census years 1876, 1881,1886, 1891, 1896, and 1901 inclusive, and they have thereforeabout them an element of accuracy which it is difficult toobtain in countries such as ours where the census is takenonly at intervals of ten years.As regards, then, the mortality from all forms of tuber-

culosis in Prussia we find that in the year 1886 the totalnumber of deaths from this cause reached 88,283 and thatat each quinquennial period succeeding this the grossnumbers, notwithstanding the remarkable increase of popu-lation, fell to 80,151 in 1891, 70,373 in 1896, and67,292 in 1901, the death-rates per 10,000 for the severalcensus years being as follows : 1876, 31 ; 1881, 31; 1886,31 ; 1891, 27 ; 1896, 22 ; and 1901, 19. It would thus

appear that in so far as the statistics of the State of Prussiaare concerned the tuberculosis death-rate up to 1886 waspractically stationary, but that after this year and at sometime between 1886 and 1891-it was, as a matter of fact, in1887-a very substantial fall took place, a fall which hascontinued up to the present time. This fall seems to havebeen participated in by nearly all the towns of Prussia,although in one or two instances the fall was a little’delayedand in some it was not maintained in 1901. For instance,in Berlin the rate remained stationary until after 1891, whilein Breslau the rate in 1886 was 53, it fell in 1891 to 34, androse in 1896 to 40, at which rate it still continued in 1901.Within recent years Charlottenburg has manifested thesmallest rate&mdash;i.e., 15 per 10, 000-among the large towns ofPrussia. The most remarkable fall of any has been in thetown of Crefeld, which in 1876 had a rate of 86 per 10,000,fell in 1881 to 51 and has rapidly decreased ever since untilnow it is only beaten by 1 per 10,000 by’ Charlottenburg inthe race for the lowest place. But this fall in Crefeld is soremarkable that it suggests some altogether exceptional force,such as some modification in the method of recording thedata. But whether we have regard to the country or urbandistricts, or whether we take the groups of towns havingpopulations up to 20,000, or from 20,000 to 100,000, or over100,000, there is a fall manifest since 1886 (see Table I.).The high, and in some cases persistently high, rates incertain large towns and in certain university towns are

ascribe.d by the Bureau of Statistics to the large number ofpatients who come for treatment to these towns from countrydistricts and who there help to swell the local death-rate.We have therefore these figures to deal with. In 1886 the

death rate from all forms of tuberculosis per 10,000 livingwas 31 ; it had fallen in 1901 to 19. There have evidentlybeen some new factors operating since 1886 which wereabsent before that date. Now there are certain associatedfacts which we have to consider in relation to this drop, adrop which is in excess of that observed in this country.I will briefly recount the more important of these associatedfacts.

1. In 1885 there were in Prussia 2,000,000 working peoplebelonging to the sickness banks. In 1900 this number hadrisen to over 5,000,000. What this increase may mean inregard to the prevention and cure of tuberculosis I shallconsider in my next lecture.

2. In 1885 there were 16,379 persons treated in the publicsanatoriums of Prussia, the figures for each of the four years1887, 1889, 1890, and 1891, being respectively 17,532, 19,423,23,812, and 30,812. But in 1892 the number fell to 21,342.In 1897 the figures had again reached 26,511, and in 190037,432. Now the remarkable fall in 1892 in the numbertreated in the sanatoriums was coincident with, and appa-

rently in consequence of, the disappointment and failurewhich followed the pronouncement and application of the