605OTHER METROPOLITAN MEDICAL SOCIETIES.

these gland collections to new growths was interesting, andit explained the presence of pigment in some of them.

Mr. PAUL, in reply, defended the use of the term "pre-cancerous." The reason why the lymphatic glands escapedinfection was possibly because the slow and plastic changesinduced by the growth blocked the surrounding lymphatics.The precise site of origin of the growth could only be studiedby means of very early sections.

Mr. BOWLBY, in reply, said that one case in his serieswhich clinically was a rodent ulcer showed groups of kera-tinous cells. He had met with no instances on the limbs.The following card specimens were shown :Mr. CECIL BEADLES : (1) Cystic Kidneys ; (2) Choleste-

rine Cyst of Kidney ; (3) False Bursaa from Arm.

OTHER METROPOLITAN MEDICALSOCIETIES.

HARVEIAN SOCIETY-A meeting of this society was heldon Thursday, March lst, Mr. GEORGE EASTES, President,being in the chair.-Dr. SILK read a paper on the Uses andMisuses of Anesthetics. After alluding to the fact that itwas in 1844 that Mr. Horace Wells first used nitrous oxidegas for producing anxsthesia, and that the introductionof ether and chloroform followed soon afterwards, Dr.Silk said he thought that in the present year and in theHarveian Society it was particularly appropriate that thenames of Wells, Morton, and Simpson should be re-

membered. With regard to the uses of anaesthetics hethought that itwould be universally conceded that these were(1) relief of pain, (2) diminution of shock, and (3) that theyhad contributed more than anything else to the advanceswhich had recently been made in the surgical art. Withreference to their misuses, Dr. Silk considered that therewere grounds for believing in the growing tendency to theformation of a " chloroform habit " ; that even if anestheticswere not actually given too frequently, at any rate they wereoften given without sufficient weight being attached to therisks incurred. He could not agree with the conclusionarrived at at the end of 1889 by the Hyderabad Com-mission that "chloroform anaesthesia is free from risk,"but thought, on the contrary, that as it was an unnatural

process more or less danger attached to all forms ofanesthesia and that it amounted to a misuse to administer amore potent when a less powerful drug would suffice. He alsodrew attention to the fact that in the years 1888 and 1889the total death-rates from anesthetics in England were 33and 36 respectively, the chloroform death-rate for each ’,year being 32. whereas in the two following years the totals ’,went up to 42 and 69, and the chloroform death-rates to I36 and 62. Dr. Silk thought, too, that inattention and over-dosage were undoubted misuses, and considered dilatoryinduction and under-ansesthetisation to be nearly as baderrors of maladministration, and said that the existenceof these troubles afforded a powerful argument in favour ofthe recognition of the systematic teaching of anaesthetics asa necessary part of the medical curriculum. He agreed withMr. Christopher Heath in deprecating "the exaggerated slow-ness of modern surgery," but again disagreed with theHyderabad Commission in the pronouncement that chloro-form and shock were incompatibles." He thought, on thecontrary, that shock was seldom completely abolished under Iany anoesthetic or in any stage of narcosis, though muchmight be done to mitigate the evil by subjecting the patient to a Icareful preparatory regimen, taking care not to underfeed him, ’iand if necessary to give a nutrient enema just beforehand.- I,The PRESIDENT remarked that the severer degrees of anaes- !’thesia were accompanied by danger, and some anestheticsnotoriously more so than others. He arranged them in an iascending series thus : (1) local anesthesia, includingrefrigeration by ice, chlor-ethyl, or ether spray, and cocaine ;(2) nitrous oxide gas ; (3) A.C.E. mixture ; (4) ether ; and(5) chloroform. He considered it a misuse to employ ananxsthetic of the more dangerous description where one lessrisky would suffice ; again, it was a misuse to produce adeeper degree of anesthesia than was required for the opera-tion on hand; and, lastly, it was a misuse to continue theanesthesia longer than was absolutely necessary.-Mr. T. R.ATKINSON insisted on the importance of students receivingadequate instruction at the London hospitals in giving anaes-thetics. Patients heard so much about the advantages of anaes-thetics that general practitioners found that they insisted

upon being anmstbetised for very trifling operations, evenwhen they could not pay for the services of an expert. Restin bed for a day or two sometimes appeared serviceable.-Mr. Ilt[CICARD LLOYD emphasised the increased safetyobtained by an administrator using an anaesthetic andmethod with which he is familiar,-Dr. F. W. HEWITT saidthat Dr. Silk’s most interesting paper admitted of much dis-cussion. There were, however, two side issues to the subjectwhich appeared to him to call for a few remarks. He referredto the question of surgical shock during or after the use ofanesthetics, and to the proper preparation of a patient beforeaumsthesia was induced. As to the question of shock, hehad seen all grades of surgical shock during anaesthesia, andwas by no means prepared to say that such conditions couldbe avoided by keeping the patient very profoundly anaesthe-tised. He bad, indeed, met with numerous cases in which,during operations upon exhausted and anaemic subjects, alight anaesthesia seemed to him to be attended by less dis-turbance of the circulatory and respiratory functions than amoderately deep or deep anaesthesia. Patients who were ina bad state of health at the time of operation were fortu-nately rather tolerant than otherwise of a light anaesthesia.He did not mean by this that the patient should be onlyhalf anaesthetised, but rather that it was possible to

secure tranquility, freedom from reflex movement, and a,

good circulation with remarkably little of the ana;sthetic,the conjunctiva usually remaining sensitive throughout.He now came to the second point- viz., the preparation ofthe patient for the administration-and here he fully agreedwith Mr. Woodhouse Braine that it was a wrong practice togive patients any food by the stomach for at least severalhours beforehand. He had repeatedly come across cases,especially in children, in which milk and other food whichhad been given five and six hours before the administration hadnot been assimilated. He contended that there was less riskof depression from giving ether after a fast of five or sixhours than from the subsequent nausea and vomiting whichmight occur had food been taken three hours before ; more-over, if food was present in the stomach the anaesthetistmight have considerable difficulty in securing true anees-

thesia. He had found in such cases that very large doses ofthe ansesthetic were often needed, that repeated swallowingwith temporarily suspended breathing was common, and thatdelay and difficulty arose which would certainly not haveshown themselves had the stomach been empty. He fullyadmitted that with exhausted subjects this abstinence fromfood was undesirable ; but even in these cases it was oftenpossible to administer nourishment by the rectum, andso to avoid vomiting and its after-depression. With all’the other points raised by Dr. Silk he fully concurred.--Dr. H. F. LANCASTER, referring to the remarks of the lastspeaker, said we had sufficient facts to prove the risks of.’commencing an operation before the superficial reflexes were.abolished, and that it should be a constant rule to an2astbe---tise the patient fully prior to any incision being made. He.also thought that, while more prolonged fasting beforehandwas no disadvantage in etherisation, as had been said, it-.might be less favourable when chloroform was used and thepatient exhausted.-Mr. HAZEL said that he frequently gave.chloroform to his patients during labour, and he had neverseen any ill effects from its administration. It was his experi-ence that women were less able to bear the pains of labournow than formerly, and therefore required the use of ananaesthetic.—Mr. G. EVERITT NORTON said he quite agreedwith Dr. Silk in his remark that the long induction ofanaesthesia was to be avoided. -Dr. ROBERT BOXALL remarked’that the frequent use of anaesthetics might lead to "chloroformhabit," and quoted some cases in support of this view.-Mr. WOODHOUSE BRAINE also took part in the discussion.-In reply, Dr. SILK said that from the point of view of safetyhe should be inclined to place the A C.E. mixture rather-below ether, but above chloroform itself. He quite agreedthat over-feeding, especially with ether, was impolitic, and,he thought that by the use of enemata this might be avoided’without actually starving the patient. He strongly objectedto the plan in vogue at the dental hospitals of allowing theadministration of nitrous oxide gas to be a source of pecu-niary benefit to the institutions. Mr. Atkinson’s opinion as ageneral practitioner that systematic teaching in anaesthetics.was really much wanted was a most valuable confirmation.of what Dr. Silk had for some years been insisting on, and,he hoped that the time was not far distant when such teaching-would be properly included in the curriculum. With regardto the use of chloroform in labour, Dr. Silk thought that.

K 3

606 OTHER METROPOLITAN MEDICAL SOCIETIES.

there might be some truth in the theory that the immunityenjoyed by parturient women was partly due to the slightcardiac hypertrophy said to exist at that period. In themore serious operations of midwifery he would be inclinedto treat such women as ordinary patients and give themether if possible. Dr. Silk did not agree with the adminis-tration of alcohol by the mouth immediately before theoperation.SOCIETY OF MEDICAL OFFICERS OF HEALTH.-A meeting

of this society was held on Feb. 19th, Dr. WOODFORDE,President, being in the chair. A discussion on Vaccinationand the Laws relating thereto was opened by Dr. SEATON,who expressed his belief that any changes in the law thatmight come from the report of the Royal Commission would bebased on the evidence and recommendations of Mr. Stans-feld, who, recognising the" overwhelming balance of medicalopinion " in favour of vaccination, advocated moderatecompulsion " (whatever that might be) and a decentralisationof control. Mr. Stansfeld did not discuss isolation and theinfluence of hospitals, on which he, Dr. Seaton, held decidedopinions, being convinced that the benefits were enor-

mous and the dangers had been grossly exaggerated.Mr. Stansfeld’s recommendations, with which he entirelyconcurred, were (1) to bring the administrative andexecutive more into touch, and by reducing the areas

to render the control more efficient. This would be attainedby transferring the powers now exercised by the LocalGovernment Board to the councils in each county or countyborough, and the supervision to their medical officers ofhealth, the councils being in their turn responsible to theLocal Government Board. Dr. Seaton would alco substitutebhe sanitary authority for the board of guardians as the vacci-nation authority. The guardians had done their duty well, butbhey were hampered by the traditional parsimony of thePoor-law system, and the suggested association with

pauperism tended more than anything to foster a repugnancetowards vaccination among the poor. He was not verysanguine as to the results of the proposed decentralisation,though good in principle, unless the county councilsshould display considerably greater interest in publichealth than they had hitherto, very few having ap-pointed county medical officers of health or even availedthemselves of the advice of officers whom they hadalready at hand. During the epidemic at Nottinghamthe town council had, indeed, given him cccrte blanohe andvoted £500 for the extension of vaccination ; but if severalof the large towns in different parts of the country wouldopen stations for the supply of animal as well as humanlymph, like the Government station in Lamb’s Conduit-street,it would be very much easier for local authorities to stampout outbreaks. It would be at such times that the advan-tages of decentralisation would be most felt and it might assistin eliciting a popular interest in this and kindred questions.-Dr. PARKES agreed in the necessity of popularising vaccina-tion, but did not believe it would be possible until compulsionwas abolished. He admitted that in the days of gratuitousand optional vaccination the mortality from small-pox washigher than it was now, but he would trust to the spread ofeducation, and thought that more vaccinations might beperformed henceforth without compulsion than were done atpresent with it. Certainly the taint of pauperism should beremoved.-Dr. SYKES could on no account give up compul-sion, and while strongly urging the transfer of vaccinationfrom the Poor-law to the sanitary authorities he doubtedwhether anything would be gained by devolution fromthe Local Government Board to the County Council. Popu-larly elected bodies would not voluntarily spend money ortake action except in the presence of an epidemic, when itwas impossible to carry out vaccination efficiently. Privatepractitioners should be compelled to state the number or

area of vesicles, and mis-statement should be made penal.-Dr. WIGHTWICK maintained that compulsion was a failurewhen 20 per cent. of all the children in a workhouse schooland 40 per cent. of the youngest were found on admission to beunvaccinated. Vaccination might be popularised if persuasionwas substituted for compulsion. The operation should beexplained and treated as an important one, to be performedwith strict antiseptic precautions by competent men withfixed but liberal salaries.-Mr. VACHER’s experience wasvery different. With an active inspector he found that, afterdeducting deaths and postponements, not more than 2 percent. of the infants in Birkenhead who survived threemonths remained unvaccinated, though he admitted thatmany private vaccinations were utterly insufficient. The

fear of syphilitic infection not being groundless, arrange-ments should be made for completely stripping infant vacci-nifers, and he had always found farmers ready to lend calvesfor the purpose, the animals being returned in three weeks inno way deteriorated and fatter. As to tubercle he believed thatthe use of goats, which were almost insusceptible to tubercle,might be tried.-Dr. WILLOUGHBY pointed out several defectsin the form of certificate, and urged that in Schedule C thenumber of insertions and of vesicles raised should be statedthus : "Successfully vaccinated in [ ] of [ ] inser-tions," with a note : "N.B. The insertions must be threeor more in number, and three good vesicles are required toconstitute sufficient vaccination. Unless three be obtainedthe child must be brought again within [one, two or three]years." " The vaccinator should be identified, as in othercertificates, by his address and registered qualifications, andall alleged cases of insusceptibility should be referred to apublic vaccinator for verification. He doubted the existenceof such a condition, and Dr. Cory had not met with it onceamong the 15 000 persons he had vaccinated some years ago,yet there were men who filled in Schedule B in a large per-centage of their cases. It was at present possible for a man,with the connivance of the parents, to go through the formof vaccination with pure water or infinitesimally dilutedlymph three times, and by signing Schedule B to leave thechild unprotected ; but compulsory revaccination about pubertyor at the termination of school attendance, as carried out inGermany, was scarcely less necessary. It was the immunityenjoyed by Frankfort in 1871-72, when the other German townswere decimated by small-pox, introduced by the Frenchprisoners of war, that led to the extension in 1874 to the wholeempire of the law that had long been in force in Frankfortand Nassau. Since then, though surrounded by badlyvaccinated countries, where epidemics of small-pox recurredevery few years, the deaths in any German town had rarely,if ever, exceeded units, and for the last ten years the caseshad been, without exception, of foreign origin, either aliensrecently arrived or Germans who, born before the year 1860,had not come under the Act of 1874, who contracted thedisease from the former or while travelling abroad, andamong the secondary cases a few infants not yet vacci-nated. Were it not for the free communication withFrance, Italy, Austria, and Russia small-pox wouldalready have been completely stamped out through theentire empire, with its forty-five millions of people. Ifwe could not otherwise learn wisdom, he would welcomesuch an experience as that of Germany in 1871-72.-Dr. LITTLEJOHN, jun., feared that even that would notsuffice. The people of Sheffield had learned nothing from thegreat epidemic there, and he had the greatest difficulty inenforcing vaccination. -After some remarks by Dr. S. DAYIE8and Mr. E. HAUGHTON (a visitor), Dr. SEATON replied. Withregard to compulsion, which he did not discuss in view of thenear issue of the report of the Royal Commission, he wouldnow say that, while advocating compulsory vaccination, hehad no hope of seeing revaccination made obligatory exceptwhen notification revealed a case of small-pox in a house orfactory.WEST LONDON MEDICO-CHIRURGICAL SOCIETY.-The PRE-

SIDENT, Dr. DONALD HooD, occupied the chair at a meetingof this society on March 2nd.-Mr. NEVILLE WOOD reported acase of Haemophilia. The patient was a male child aged fourmonths, who had shown symptoms of the disease since hewas three days old. It began with severe epistaxis; he hadalso had melasna twice and intra-muscular haemorrhages.The subcutaneous swellings had been as large as Tangerineoranges, but there had been no certain intra-articular hæmor-rhage. The cause was probably slight traumatism in asubject predisposed to haemophilia. The father alone of hisprogenitors or relatives was a bleeder.-Mr. S. PAGET broughtunder notice a case of Myositis Ossificans in a boy aged five.He quoted other published cases and drew attention to the

great-toe deformity and the history of rheumatism in thegrand-parents previously described.-Mr. KEETLEY thought

the condition was secondary to some inflammatory actionand was a specific disease.-Mr. BIDWELL related a.

case of Alveolar Cyst in connexion with the Stump ofan Upper Bicuspid.-Dr. BENNETT quoted a case some-

: what similar.-Dr. MORGAN DOCKRELL instanced two casesof Psoriasis which had been successfully treated with thyroid’ extract, and Mr. STEER and Dr. GARDNER related cases of! Myxcedema which were effectually treated by the same

; remedy. The merits of the treatment were discussed by’ several members of the society.-Dr. CHAPMAN submitted

607PROVINCIAL MEDICAL SOCIETIES.

the notes of a case of Hæmoptosis in a patient suffering fromMitral Stenosis.—Finally, Dr. ABRAHAM read the report of acase of Lupus relapsing three years after successful treat-ment with tuberculin.

PROVINCIAL MEDICAL SOCIETIES.

EDINBURGH MEDICO-CHIRURGICAL SOCIETY.

Continuation of the Discussion on Intra-eranial Surgery.ON the second night of the discussion cases bearing upon

Intra-cranial Surgery were shown by Mr. Annandale, Mr. Cath-cart, Dr. McBride. Dr. McKenzie Johnston, Mr. MacGillivray,Mr. Miles for Mr. Miller, Dr. W. Stewart, Dr. McPherson,Dr. Gibson for Dr. J!’elkin, Mr. Caird, and Dr. James. -Mr. JOHNDUNCAN opened the discussion. He said that intra-cranialoperations might be divided into aseptic and septic ones. Inthe aseptic cases there were many subjects on which theystill desired knowledge. One of these was the localisation offunction, and on this point he could confirm the observationsmade as to the apparent uselessness of the frontal lobes. A

boy, as the result of a kick on the forehead, had lost a

dessertspoonful of brain tissue and had had hernia cerebrifor six months, which ultimately closed. Three years laterhe died of phthisis, and during all that time he was regardedas being perfectly well, so far as his mental functions wereconcerned. They also wanted information as to the natureof nerve action and of its excitants and depressants. Experi-ments had to a certain extent shown the relationshipof various electrical currents to nerve action, but their

pathological knowledge was still exceedingly imperfect.Speaking generally, it might be said that an excess

of pressure diminished nerve action and that hyperasmiaand irritative conditions increased it. In this relationhe would point out that epilepsy was not to be looked

upon as a disease of pressure but of irritation. It mightbe connected with surgical injuries, but not in the way ofdirect pressure. The pressure only set up a hyperasmic anddiseased condition of brain tissue, which was likely to pro-duce epilepsy. In this connexion he referred to a child:suffering from severe epileptic fits. He trephined and foundthat there was a large hole nearly in the centre of the fore-head, through which the dura mater was tightly adherent tothe pericranium ; nothing else was found. The dura mater wasopened and the arachnoid seen, but there was nothing wrongwith it. As a result of the operation there was great diminu-tion of the fits, and for many months an entire cessationof them. After the patient went home they returned, butagain diminished on readmission to hospital. There wereso many factors bearing upon these epileptic cases thatthe investigation of the subject was attended with greatdifficulty. The centre of irritation was frequently not in the brain at all. He had seen a case of epilepsy in which the removal of a stone from the bladder was followed by extra-ordinary amelioration, and they all knew of cases in whichthe removal of a long prepuce had cured convulsions. Greatbenefit was derived from the removal of any well-definedsource of irritation, but he did not regard the mere trephiningof the skull with a vague idea of relieving pressure as anoperation likely to be followed by success. Another point onwhich information was required was the physics of thebrain. They knew very little of the conditions under whichthe tension of the cerebro-spinal fluid was produced andmaintained. There might be in the brain two kinds of com-pression, a general and a local. In illustration of this hereferred to a case brought into hospital comatose, with asmall cut in the temporal region ; he trephined at this pointand only found a little contusion of the membranes. Thepatient died, and there was found extensive haemorrhage on theopposite side covering the whole motor area and much more.Another case had hemiplegiafollowingadepressedfracture, andin it removal of the depressed bone successfully relieved theparalytic condition. In the one case there was general com-pression, in the other local pressure without any general effect. There were many complex conditions to be taken intoaccount in considering compression. There must be in thebrain a slow and a rapid adjustment of tension. The most:mportant factor was the cerebro-spinal fluid. In connexionwith its expression the relationship to the cord and theelasticity of its membranes were of importance. There wasseldom any effect upon the cord by increase of pressure inthe brain. The effect of sudden loss of fluid was seen in

accidental rupture of, or surgical operations on, spina bifida.There might be sudden death with convulsions if the fluid wasdrained right away. In such cases there could also be shownexceedingly well the adjustments to pressure that were

possible, for the fluid in a spina bifida of considerable sizecould be squeezed into the general cavity without producingthe slightest effect. It was due to the immense power ofsecretion and absorption present. He had had a case offracture of the spine in which for three weeks there was adaily drain of six or eight ounces of fluid. The effects ofpathological increase of pressure were more difficult to under-stand, it was so constantly associated with inflammatoryconditions. It was of great importance to consider whatkept up the pressure ; was the increase of fluid due to anevanescent or a persistent cause ? Or was it possibly due toa cause kept up by increased tension ? To drain a hydrocelefor two or three days would cure it; and along withDr. Aflleck he had with success put a glass tube for only afew days in the tuberculous abdomen of children. Thetension in these cases might produce a hyperasmia whichwould subside when the pressure was relieved. It wasjustifiable, he thought, to operate in cases of excessive intra-cranial pressure, even in tuberculous meningitis, in generalparalysis possibly, and in hydrocephalus if the conditionsdid not interfere. It was quite clear that they must drainfor a certain time. In hydrocephalus the large size of theosseous case made it exceedingly doubtful whether theycould benefit the disease much by operation. In other casesthere were various conditions that made it difficult to keep upthe drainage in an efficient way. He had found that it was

exceedingly difficult to maintain the issue of cerebro-spinalfluid from the surface of the cerebrum for more than twenty-four hours. Exudation of lymph took place, which cut offthe flow. Various suggestions had been made to overcomethis difficulty, but none of them were very satisfactory.There were two classes of cases, the irritative and the com-

pressive. In the irritative, of which epilepsy was the type, itwas necessary to remove the focus of irritative. In the com-

pressive the cause of pressure must be removed, and, if possible,the operation must be over the seat of the disease. -Dr. BYROMBRAMWELL alluded to the cerebral cases which he had seenand the very small percentage of cases in which operation wasfeasible or in which he was prepared to recommend it. Hethought that in tuberculous meningitis, where ordinary treat-ment was so unsuccessful, it might be desirable to trephine.-Dr. BATTY TUKE said that nothing struck him more on thefirst night of that discussion than that most of the speakersaccepted encephalic fluid pressure as a postulate-a proposi-tion to be accepted without proof. He continued as follows :" It appears to me that the existence of such pressure is thex in the equation presented in every head case in whichwe are sure that there is no solid pressure or pressurefrom blood or pus. It is true that in the working outof such equations certain of the factors are undeter-mined, and the result may be a mere empirical expression.Still the attempt generally brings out important matterbearing on the case. We all know the mistake whicharose from the acceptance of the theory that the skullis a ’practically closed sac.’ This we now know is notthe fact, and we also know that considerable variationsin its blood-supply may occur, and that such variationsare provided for by the ebb and flow of the cerebro-spinal fluid. Further, we have the strongest reasons forbelieving that exudate may be poured out more rapidly thanit can be removed by the lymphatic paths at the base and inthe spinal column. In the class of cases in which I amresponsible for advising trephining-viz., general paralytics-such pressure has been well marked. In the seven cases Ihave seen operated on there was considerable bulging of thedura mater into the trephine hole on removal of the disc ; infour early cases it filled the hole as fully as a cone can. Dr.

Macpherson can speak for his cases ; I shall restrict myself tothose four in which the symptoms had not existed for morethan two months. In all these the araclino-pia were found tobe distinctly inflamed, the difference between the healthy andinflamed conditions being as obvious in this membrane as theywould have been in a healthy and an inflamed conjunctiva. Mr..John Duncan, who operated in three of these cases, can confirmthis statement. Considerable amounts of fluid escaped fromthe subdural space and from the pial space. Having thusimported the three factors-an inflamed serous membrane,large quantities of exudative fluid, and bulging of the mem-branes-I submit that the x in my equation comes out as fluidpressure. In the case of any other organ this would be held