COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX64166619 RC311 .Y4 The contagiousness RECAP S ON CONSUMPTION BURNEY YEO Columbia Winibtviitf- intljeCitpofiSetogorfe COLLEGE OF PHYSICIANS AND SURGEONS Reference Library Given by Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/contagiousnessofOOyeoi LECTUEES ON PULMONAHY CONSUMPTION JUST PUBLISHED, BY THE SA.ME AUTHOR, Crown 8ro, 8^. HEALTH EBSOETS AND THEIR USES: ^cing ITaration .§tui)ics of ITnrious Jicalt^ Resorts. CONTENTS. Chaptkk I.— Sea or Mountain ? a Study of the Action of Sea and Mountain Air. II. — The Engadine. III.— Davos Platz: a Study of High Altitudes for Consumptive Patients. IV. — Health Resorts in the Pyrenees. V. — Some French Health Resorts. VI. — Rhenish Healih Resorts. VII. — Winter Quarters. VIII.— The Health Resorts of the Western Riviera. CHAPMAN AND HALL (Limited), 11, HENRIETTA STREET, COVENT GARDEN, W.C. THE CONTAGIOTJSNESS OF PULMONAEY CONSUMPTION ANTISEPTIC TREATMENT TWO LECTUEES DELIVERED IN KING'S COLLEGE HOSPITAL IN THE SUMMEE SESSION OF 1882 WITH APPENDICES AND NOTES BY J. BUENEY YEO, M.D. FBLIOW OF THB ROTAL COLIBGE OF PHTSICIANS; PHTSICIAN TO KING's COllEGB HOSPITAl AKD HON. FELLOW OF KING's COI.LKGe; FOBMKBLT SENIOR ASSISTANT PHTSICIAN TO THE BBOMPTON CONSUMPTION HOSPITAL " That Man, who is rapidly subduing all the most Titanic forces of the universe to his commonest uses, sliould always remain at the mercy of these ignoble things, is an antithesis too extreme to be permanent. The subjection of the powers of nature to our will has always seemed to me to imply, as a strictly correlative achievement, the putting the plagues of nature under our ieet/— Quoted in Dr. William Budd's Essay on 'Typhoid Fever.' LONDON J. & A. CHURCHILL 11, NEW BURLINGTON STREET 1882 PREFACE I HAVE not hesitated to accede to tlie request that I should publish the following Lectures in a separate form. They refer to subjects of such vast importance^ upon which it is so neces- sary that the observations of every member of our profession should be thoughtfully directed, that I venture to hope the prediction of a dis- tinguished correspondent, that their publication '' must do good/' will be fulfilled. I have endeavoured to avoid all exaggeration, and to set before the profession, as clearly as possible, the state of the argument as based on the results of the latest pathological inquiries. In an appendix to the first Lecture I have reproduced the original memorandum on the ' Nature and the Mode of Propagation of Phthisis,' published by the late Dr William Budd, of Clifton — a document of peculiar inte- VI PEEFACE rest at this moment. And I have collected, in an appendix to the second Lecture, a consider- able amount of testimony from practitioners of eminence and reputation bearing on the anti- septic treatment of phthisis. I have also added an account of the proper- ties of the various antiseptic agents which may be employed in the treatment of pulmonary con- sumption, as well as other notes which I have thought calculated to throw light on these inquiries. Heetfoed Steeet, Matfaie ; Juhj, 1882. COISTTENTS. LECTURE I Out THE Contagiousness of Pulmonaet Consump- tion ...... Appendix. — Memorandum on the Nature and the Mode of Propagation of Phthisis, By Dr. Wm. Budd, of Bristol ...... Note I. Views of Prof. Rindfleisch „ II. Influence of Temperature on the Development of Infective Organisms „ III. M. Giboux's Experiments „ IV. On the Method of Examining for the Bacillus of Tubercle ..... PAGE 33 38 39 40 41 LECTURE II On the Antiseptic Teeatment of Pulmonaey Con sumption ..... Note I. On Antiseptic Treatment of Phthisis „ II. On the Inhalation of Sulphuretted Hydrogen in Tuberculosis . . . .70 „ III. On Benzoate of Soda in Phthisis . . 71 Appendix. — Opinions and Experiences of the Antiseptic Treatment of Phthisis . . . .78 43 69 Vapoeisable Antiseptic Substances applicable to THE Teeatment of Phthisis . . . 109 LECTURES o» PULMONARY CO:\STJMPTIO:s LECTURE I ON THE COXTAGIOUSXZSS OF PULilOXAPA' COXSUilP- TIOX Gextleaiex_, — Within the last few weeks,, you have had an opportunity of seeing"^ in the Physioloo-ical Laboratory of Kingr's Colleo-e, specimens of certain micro-organisms^ prepared by Koch of Berlin^ and described by him as the bacillus of tubercle. This organism is believed by him to be the active agent in the origin and spread of tuberculous diseases. You have also had an opportunity of seeing that this micro- organism can be artificially cultivated and suc- cessive generations produced^ each retaining with undiminished virulence the power of pro- ducing tubercle when introduced into the bodies of certain animals. Xow, this demonstration^ which you have seen 1 2 Pulmonary Consumption with your own eyes, introduces you to problems in pathology and in practical medicine the importance of which it is impossible to exag- gerate. Never, in the whole of the past history of medical science and of medical discovery, have propositions been advanced of greater import than those which have been advanced and maintained in connection with this discovery. Let me state to you, in language as clear and simple as 1 can, what these propositions are. 1. Tubercle is an infective malady, origina- ting in a specific virus, and propagated by the conveyance of that virus from body to body, and originating in no other way. 2. The specific virus of tubercle consists of a particular micro-organism, found only in tubercle ; this organism can be seen in the cells of tubercle, can be obtained in a separate form, and cultivated in successive generations, without losing its original properties. 3. Certain forms of disease, termed '' scrofu- lous,'^ are essentially tuberculous ; and their characteristic anatomical morbid products con- tain the infective organism peculiar to tubercle. 4. The disease known as pulmonary consump- tion is, in the main, a tuberculous disease, and is dependent on the presence and propagation Its Contagiousness 3 in tlie body of the infective organism charac- teristic of tubercle. 5. Pulmonary consumption is a contagious malady. Of these five propositions, it is claimed for the three first that they rest on demonstration, as I propose to show you; the last two are, mor3 or less, of the nature of inferences from the three preceding ; and, in connection with these, we may expect to find there will exist some differences of opinion. The idea that consumption is a contagious disease is not a new one. It is a doctrine which has always been maintained in the South of Europe — in Italy, Spain, and Portugal. Galen believed it, Morgagni believed it, and great names in the history of medicine, from their time to ours, may be found both for and against it. Pidoux, in France, who had unusual oppor- tunities of becoming acquainted with the his- tories of a large number of consumptives, declared that his own experience was directly opposed to this doctrine ; and that he had never seen a single case of consumption that he could refer to contagion. One of the most distinguished physicians of 4 Pulmonary Consumption our own times^ formerly Professor of Medicine in this College^ Sir Thomas Watson, in a course of lectures delivered in that very college where you have recently seen demonstrated the exist- ence of a tubercle-bacillus, thus expresses him- self on this subject. " Is phthisis contagious ? No ; I verily believe not. A diathesis is not communicable from person to person. Neither can the disease be easily (if at all) generated in a sound constitution. Nor is it ever imparted, in my opinion, even by one scrofulous individual to another/^ From my own experience of consumption — and, as I shall show you presently, it has been a very large one — I cannot doubt that this was the judgment of sound common sense at the time it was uttered, and with such evidence as was then, and has been until quite recently, attainable. But it would be unscientific now to tie oneself to this opinion in the face of such facts as recent researches in experimental patho- logy have established. On the other hand, another very eminent physician, a brother of another former Professor of Medicine in this College, Dr. William Budd, of Bristol, long ago promulgated the view that Its Contagiousness S pulmonary consumption was a disease ^^ strictly analogous to the ordinary eruptive fevers in everything but the slowness of its progress ; that^ among European populations^ tuberculous disease had undergone mitigation of its original severity by long prevalence ; but he entertained no doubt of its eminently contagious character.'' We must not be surprised that Dr. Budd's views met with little acceptance at the time. Insight^ however penetrating_, is not demon- stration and scientific belief rests wholly on demonstration. Then (and even now)^ the evidence derived from practical experience against the contagiousness of consumption^ in at all the same sense as smallpox and scarlet fever are contagious, seemed overwhelming ; and, if we yield now to the teaching that phthisis is a contagious disease, we shall yield solely to demonstration and experiment. For such evidence as we obtain from the experience of physicians in their practice amongst con- sumptive patients affords, at most, but a weak presumption ; and the facts I shall bring before you certainly show that consumption is by no means contagious in the sense which is ordinarily and popularly attached to that word. But the modern methods of experimental research are 6 Pulmonary Consumption doubtless destined to widen our conception of ""contagion/^ as they have widened and cor- rected our conceptions in respect of many other pathological doctines ; and it is quite possible that, under certain given conditions, consump- tion may be a contagious disease. During ten years of service in an institution devoted to the treatment of consumption, I saw over 27,000 persons who came to that institu- tion for treatment, and a large proportion of that number were actually suffering from phthisis. Throughout this period, many problems naturally came into my mind as to the nature, the causes, and the treatment of this terrible malady ; and, a few years ago, I endeavoured to obtain some data, from this extensive field of observation, as to the contagiousness or non-contagiousness of consumption. I followed the following train of reasoning : if consumption be a contagious or infectious malady, in the same sense and at all in the same degree as other maladies which are known to be contagious, the conveyance of the disease from husband to wife and from wife to husband, especially among the poorer classes in this country, ought to be a common and not a rare occurrence ; for, amongst these classes, the husband and wife almost invariably occupy Its Contagiousness 7 the same bed, and live a life of close personal intimacy. The rooms they occupy are, more frequently than not, overcrowded, close and badly ventilated. In short, the external con- ditions amongst which consumption commonly appears amongst the working classes, are precisely those which would favour the dissemi- nation of a contagious malady. If consumption in this country were, under ordinary conditions, a contagious malady, it would follow, so fatal as its course usually is, that in dealing with large numbers of consumptive patients taken from the poorer classes, we should often find, amongst the males, the survivors of wives who had died of phthisis ; and, amongst the females, the widows of men who had succumbed to this malady. This fact must, I think, be clear to every one. So also we should expect to find husband and wife frequently the victims, together, of this disease. But this is compara- tively rare. For the purpose, then, of throwing some light on this question, I collected, a few years ago, the particulars of 1055 cases of consumption that had come under my case, consecutively, in the institution to which I have referred. Of this number, 621 were males and 434 females. 8 Fidmonary Gonsumjption Of the 621 males, 306 were married, 297 were single^ and only 18 were widowers ; about 3 per cent, of the whole, and about 6 per cent, of those who had been married. Of the 18 widowers, two could only state positively that they had lost their wives by consumption, and one of their wives had been dead thirteen years ; six of them had lost near relatives by consump- tion (father, mother, brother, or sister), giving a presumption in favour of hereditary predis- position, and in 10 no precise information could be obtained. Of the 434 females, 199 were married, 206 were single, and 29 were widows ; the widows being about 7 per cent, of the whole, and about 15 per cent, of those who had been married. Of the 29 widows, 5 only were able to state positively that their husbands had died of consumption, 1 lost her husband " in a fit,'^ 6 had lost near relatives (father, mother, brother, or sister) by phthisis, pointing to hereditary predispositions, and 17 could give no precise information. At the same time that I was collecting these particulars from my out-patients, Mr J. Bartlett, at that time acting resident medical officer, was good enough to obtain the following particulars from those who were then in-patients. Of the Its Contagiousness 9 94 males in the hospital with phthisis, 53 were married, 37 were single, and 4 were widowers ; of these 4, 2 had lost their wives by consump- tion. Of the 53 whose wives were alive, all the wives except two were quite healthy. Of the 83 females who were then in the hospital with consumption, 62 were single, 15 married, and 6 widows ; of the 6 widows, 3 had lost their husbands by consumption ; in 2 of the 3 there was marked hereditary predisposition, and in 1 there was none ; in the remaining 9 cases the husbands were healthy. Taking these figures for what they are worth, it seems certain that the communication of con- sumption from wife to husband, even among the class in which the conditions of life favour to the utmost the communication of contagious disease, is very rare ; while it would seem that communication (assuming, for the sake of argument, the disease really was communicated) from husband to wife is more frequent. About the same time that I was making these observations, Dr Hermann Weber brought the subject of the communicability of consump- tion from husband to wife before the Clinical Society, and in his paper he states that he possesses the history of ^^ Q^ persons, male and 10 Fulmonary Consumption female, who, with a more or less pronounced consumptive taint, have married healthy part- ners. One or several of the partners of 10 out of these 68 cases became consumptive. The question, however/' he says, " takes a different aspect if the originally tainted husbands and wives are considered separately. Of the 68 persons, 39 were husbands, 29 wives. Only one of the husbands of the 29 wives became diseased, while the wives of 9 out of the 39 husbands became affected. These 9 husbands lost 18 wives, viz. .1 lost 4 wives, 1 lost 3, 4 others lost 2 each, and 3 only 1 each. One of Dr H. Weber's cases is certainly very remarkable. A young man, who had lost his mother, two brothers, and a sister of phthisis, and who himself had twice had haemorrhage from the lungs, had quite recovered, and married at twenty-seven years of age, being then perfectly well. His first wife was in good health, and came of a healthy family. She died of consumption after her third confine- ment. The man shortly married again, an "apparently healthy woman,'' and this second wife, after a year of married life, died of '^ galloping consumption." He again married a third wife, a healthy young woman of twenty- Its Contagiousness 11 five, belonging to ''an exceptionally healthy- family/^ During her second pregnancy, she developed symptoms of phthisis, which ran a rapid course, and ended fatally in about eight months. Undaunted by his previous experi- ence, this man, who seems to have had a mania for matrimony, married a fourth wife, a perfectly healthy young woman, twenty-three years of age, of healthy family antecedents. Three months after her first confinement, she too began to show symptoms of phthisis, and, not- withstanding two sea- voyages, died after an illness of nine months, with tubercle in liver, spleen, and intestines, as well as in the lungs. Though the husband of these four wives, who was a sailor, remained in apparently good health, physical examination revealed the exist- ence of morbid changes about the apex of the left lung. It is possible that the life at sea kept his disease in abeyance ; for, when he had to lie by on account of a severe fracture, the disease became active, and he died of consump- tion within two years. I have called your attention to this case, because it is perhaps one of the most remark- able on record bearing on the communicability of consumption from husband to wife. 12 Pulmonary Consumption In Dr "Weber^s second case, tliree wives in succession of a consumptive husband died of phthisis, the husband ultimately dying of that disease himself. The disease in the wives appeared during pregnancy, or soon after delivery. The same story is repeated, with but little variation, except as to the number of wives, in Dr Weber's seven other cases quoted in his paper. Altogether, he had observed thirty-nine diseased husbands, and the wives of nine of them became consumptive after marriage; but, as several of the diseased husbands married repeatedly, it would appear that, out of fifty-one such marriages, eighteen wives became consumptive after marriage. As a set-off against this, out of twenty-nine marriages between consumptive wives and healthy husbands, only one husband became consumptive. Another noteworthy observation of Dr Weber's was, that in the infected wives the disease manifested itself in an unusually active florid form, and ran an unusually rapid course ; while in the husbands it was chronic, stationary, and apyretic. The fact of the onset of the disease following or occurring in connection with impregnation and utero-gestation, as well Its Contagiousness 13' as tlie fact of the immensely greater proportion of wives infected by husbands compared with that of husbands infected by wives^ naturally provoked the suggestion that the latter became infected through impregnation and from the foetus in utero, just as constitutional syphilis is conveyed from husband to wife. But there is another hypothesis equally tenable, and perhaps more in accordance with modern research ; which is, that, during the puerperal state, the female constitution is peculiarly prone to the reception and cultivation of the germs of infective disease ; and^ assuming for the sake of argument that tubercle is propagated through the agency of an infective organism, the puer- peral state may supply one of the conditions (such, for example, as we should conceive an increased body-temperature to supply) necessary for its cultivation and spread. These valuable and striking observations of Dr Hermann Weber, while they give weighty support to the belief that consumption is, under certain circumstances, communicable from hus- band to wife, corroborate also the suggestions I have already made that, if phthisis be a con- tagious malady, it is so under very peculiar conditions and laws ; that it is not contagious 14 Pulmonary Gonsumptioii in precisely the same sense as is ordinarily and popularly attached to that word. I have said enough to show you that it would be extremely difficult to prove from clinical observations alone, or from experience, however extensive, of cases of consumption encountered in this country, that phthisis is an infective and contagious malady. Many, w^ho have had the largest opportunities of judging, have formed an opinion altogether opposed to this view, and would regard Dr H. Weber^s experience as quite exceptional. And yet it seems very pro- bable that consumption is in a sense contagious — contagious under certain conditions ; and the practical question, at this moment especially urgent, is, " Under what conditions is con- sumption contagious V But, before attempt- ing to answer this question, it wnll be necessary to go back to the consideration of the remain- ing propositions which I formulated at the commencement of my lecture, and see on what kind of evidence they rest, and what is the exact relation of that evidence to the final proposition which forms the special subject of my lecture. The first of these propositions was, that " tubercle is an infective malady, originating in Its Contagiousness 15 a specific virus, and propagated by tlie convey- ance of that virus from body to body, and originating in no other way/^ It has taken many years to obtain for this proposition any- thing like general acceptance amongst patho- logists and physicians, and even now there are not a few who hesitate to accept this doctrine. It is some years ago (1865) since Yillemin published the results of a series of methodical experiments, which he had undertaken for the purpose of showing that tubercle was an infec- tive malady. His method was to take a small portion of tuberculous matter, as big as a pin^s head, from the body of a man, a dog, cow, or a rabbit, and introduce it under the skin of the ear, the groin, or the axilla, in rabbits and dogs. He found that the wound at first healed over j but, after four or five days, the seat of the inoculation began to be red and swollen, and a tuberculous mass became developed there causing an ulcerated wound. If these animals were killed after the fifteenth day from the inoculation, tubercles were always found in the viscera; in the lungs, they were usually abun- dant ; grey granulations, as well as extensive infiltrated masses of tubercle, more advanced according to the length of time that had elapsed 16 Pulmonary Consumjption since the inoculation^ and cavities, were some- times found : while at the seat of inoculation a caseous mass was usually found, surrounded by small yellowish granulations. The correspond- ing lymphatic glands were enlarged, and often contained scattered nodules of tubercle, some having undergone caseous degeneration. Cats and guinea-pigs were readily inoculated ; but sheep, goats, and birds escaped infection. He obtained the same results from injecting hypo- dermically the sputa of phthisical patients in very small quantities, mixed with water. Blood taken during the life of animals with phthisis gave negative results ; but, taken after death from phthisical men, it readily produced general tuberculosis in rabbits. Chauveau, of Lyons, corroborated Villemin's results, by means of experiments on oxen, animals disposed to tuberculosis. He gave to oxen, by the stomach, tuberculous matter ob- tained from the human subject or from other oxen, and they all became tuberculous, the lesions varying from trivial ones to the gravest possible. Typical tubercle granulations were found in the lungs, as well as caseous masses in all stages. The same results followed inoculation into the connective tissue, and in- Its Contagiousness 17 jection into the veins of water holding in sus- pension tuberculous matter after filtration. Other experimenters (including Drs Burden Sanderson and Wilson Fox, in this country) soon opposed other views to those of Yillemin and Chauveau. They stated that, in order to produce tuberculosis in rabbits and guinea-pigs, it was not at all necessary to inoculate these animals with tuberculous matter; that they might be rendered tuberculous by other means. They stated that, in the guinea-pig and some other animals, tuberculosis might be produced by inoculations with pus, or with caseous matter of inflammatory origin, or with sarcoma, just as well as with tubercle ; that, in the guinea- pig, tuberculosis had been produced by the application of a simple seton ; and that, in the rabbit, deep wounds, without inoculations of any sort, would produce pulmonary tuberculosis. Wilson Fox, in his experiments on guinea-pio"s, introduced under the skin various substances portions of putrefied muscle, fatty liver, and even vaccine virus, with the same result ; and it was maintained by others that such sub- stances as aniline blue, cinnabar, caoutchouc, cotton, &c., caused similar effects; and that carnivorous animals might be fed long on 2 18 Puhnonanj Consiimiotion tuberculous lungs without the production of tuberculosis. Tlien^ it was said by otliers that the lesions produced by Yillemin were not tubercle at all, but simply inflammatory lesions or embolic infarcts ; and some went so far as to say it was impossible to produce tuberculosis experi- mentally. At the same time, Chauveau, Klebs, and Bollinger, maintained the correctness of the experiments and views of Yillemin. Two physicians mentioned in the ' Nouveau Dictionnaire de Medecine et de Chirurgie ' (Art. " Phthisis "), went so far as to inoculate them- selves with the serum of a blister applied to a phthisical patient, and we are not surprised to hear, without effect : for, if the peculiar micro- organisms which we have recently seen be the active agent in the production of tubercle, we should scarcely expect to find it in the serum extracted from the blood by the action of a blister. Another remarkable case of human inoculation is mentioned in the work I have just cited. Three medical men of Syra (in Greece), in 1874, inoculated a man, fifty-five years of ao-e, with tubercle. He was suffering from gangrene of the left great toe, due to oblitera- tion of the femoral artery, and was in a mori- Its Contagiousness 19 bund state. They inoculated some of the sputa of a phthisical patient into the upper part of the right leg. The lungs were previously examined with great care, and found to be perfectly sound. Three weeks later there were signs of commencing induration at the right apex. On the thirty-eighth day after the inoculation the patient died of gangrene. At the necropsy, there were found, at the apex of the right lung, seventeen small tubercles, varying in size from that of a mustard seed to that of a lentil. Two similar tubercles were found at the left apex — two others on the convex surface of the liver. The authors of the experiment considered the embryonic state of the tubercles, and their limited number, to correspond with the short space of time that had elapsed from the inocu- lation. It is not likely that an experiment of this kind will be often repeated ; but though it stands alone, it is none the less an important observation. Tappeiner and others have shown that animals could be rendered tuberculous if tuber- culous matter (such as the sputa of phthisical patients) were diffused in spray in the air which they breathe. 20 Pulmonary Consumjytion It has also been stated by Professor Gerlach that, in the variety of tubercular disease which affects oxen, the infection can be introduced by the stomach, if portions of the tubercular organs be mixed with the food, or if the healthy animal be fed with milk from the animal which has tubercle (Simon, ' Proceedings of Inter- national Congress '). Now, as tubercle is a malady which is very common among cows, this observation is one which may have a vast im- portance in connection with the feeding of young children. Cohnheim has also made numerous observa- tions on the infective nature of tubercle. He introduces the tuberculous matters either into the subcutaneous tissue or into the pleural or peritoneal cavity, or into the anterior chamber of the eye. After introduction in the latter situation, the primary irritation soon passes away, the small piece of tuberculous matter becomes smaller and smaller, and may even wholly disappear ; for a time the eye appears quite clear and intact, when suddenly in the iris a number of delicate grey nodules appear, grow to a certain size, and then cascate. In rabbits and guinea-pigs, fourteen days after the introduction of the virus, disseminated Its Contagiousness 21 tuberculosis will appear in the various organs ; in other animals^ twenty-one days is the usual period of incubation. He has succeeded with pieces of lung affected with caseating pneu- monia, or with pieces of caseating testicle, or with freshly excised scrofulous gland from the neck ; but he has never found any result from introducing caseated sarcoma or myoma, or simple lymphoma. But some of the most instructive and con- clusive observations and experiments on this head are those of Dr Hippolyte Martin, of Paris. They are related in an article on the " delations between Tuberculosis and Scrofula/^ in the ' Revue de Medecine ' for April of this year ; and also in the ^ Archives de Physio- logie ^ for 1881, on the '^Infective Properties of Tubercle. ^^ The object of his original ex- periments was to show that inoculation with true tuberculous matter was alone capable of producing true, general tuberculosis, and that all the lesions produced by the introduction of foreign bodies of non-tuberculous nature were not true tubercle, but what he terms false or " pseudo-tubercle.^'' But he insists that it is of prime importance that all these inoculations should be performed with strict antiseptic 22 Pulmonary Consumjytioii precautions ; and that if^ perchance^ the inocu- lation of non-tuberculous foreign substances have been followed by an eruption of true tubercle, it is because these precautions have been disregarded. He also points out that the anatomical structure of the true and false tubercle, as revealed by microscopical examina- tion, is identical, and that the only means of distinguishing between them is by inoculation in series — by a series of successive inoculations. True, infective tubercle is reproduced in an indefinite series, producing always a general tuberculosis as a consequence of local infection, the infectious properties becoming, if anything, more energetic as the series is prolonged. The same method proves the absolute innocuousness of false (pseudo) tubercle. Some of his experiments are so important that I make no apology for citing them to you. First, Dr. Martin tested the effects of injecting irritating animal and vegetable powders, such as cantharides, lycopodium, and pepper, into the peritoneal cavity of guinea-pigs. In one instance he injected sixty centigrammes of lycopodium diffused in water into the peritoneal cavity of a guinea-pig; the animal died four months afterwards of general adhesive perito- Its Contagiousness 23 nitisj but all the viscera were healthy. Into the peritoneum of another guinea-pig he injected a large quantity of powdered cantharides mixed with water : nine months after the infection the animal was quite well. His next experiments were with fragments of morbid growths^ non-tuberculous. Four pieces^ of a cubic centimetre each^ were cut from an epithelial tumour freshly removed from the neck of the uterus ; two pieces were placed in alcohol, and two pieces in bichromate of ammonia. After a week the two preserved in alcohol were introduced into the peritoneum of an adult; rabbit, and rather more than three months afterwards the animal was killed j both fragments were found encysted in different parts of the peritoneal cc^vity ; all the viscera were healthy. The two other fragments were introduced into the peritoneum of another rabbit, and about a month later the animal was killed, and the fragments were found enveloped in a fold of omentum, their angles rounded, and absorption evidently commenced. All the viscera were healthy. In another experiment, two pieces of a sar- coma of the testicle, freshly removed, were immediately introduced into the peritoneal 24 Pulmonary Consiimption cavity of a guinea-pig; about a montli later the animal was killed, and no trace of the foreign bodies was to be found, and all the viscera were perfectly healthy. The same ex- periment was repeated with portions of mam- mary carcinoma, on a large and strong female guinea-pig in a state of advanced utero-gesta- tion. She was confined with two healthy little ones a few days after, and, when killed two months afterwards, two free masses were found in a cyst in the abdomen, wholly caseous, and dry like crude tubercle. All the viscera were healthy. The same kind of results followed the intro- duction in the same manner of a piece of the femur of a rabbit, with periosteum and some fragments of muscles adherent ; half the tibia of a new-born infant that died of erysipelas ; three squares of a hard pear ; two squares cut out of a ripe apple. In one of these cases, about six weeks after the operation, the two pieces were found surrounded by yellow pus in a large vascular cyst. There was no peritonitis ; the viscera were healthy. The next experiment is very significant. In the centre of a large sarcoma removed from the thigh of an infant there was a large completely Its Oontagiousness 25 caseous nodule ; a portion of this caseous matter^ weighing 50 centigrammes^ was introduced into tlie peritoneal cavity of a rabbit, witli careful antiseptic precautions. A year after- wards the animal was in perfect health. These experiments prove conclasively that those observers were certainly in error who asserted that almost ai.y kind of foreign body — animal or vegetable — would produce tuberculosis in guinea-pigs. In other experiments, Dr Martin has shown that foreign bodies having irritant properties, non-specific, may set up inflammation, the pathological products of which may have a com- plete anatomical resemblance to true tubercle, no distinction being possible by microscopical examination ; and he has obtained by means of cayenne pepper, lycopodium, and cantharideSj the finest specimens of pseudo-tubercle; but these lesions, in spite of their special anatomical structure, have no specific virulence. He had repeatedly injected, with antiseptic piecautions, the caseated inflammatory products of such experiments, and always failed to produce an eruption of tubercle. He insists strongly on the necessity, especially in a pathological labo- ratory, of these antiseptic precautions. All the 26 Pnlmonanj Consumption instruments should be washed in alcohol and heated in a flame ; and before each operation all parts of the syringe should be taken to pieces and treated in the same way. On the other hand, pus from a scrofulous gland in the neck, as well as scrofulous products not yet degenerated, not caseous, inoculated immediately after surgical removal, produced a series of cases of generalised tuberculosis. Dr Martinis experiments completely establish the following conclusions: — 1. Tubercle, inocu- lated locally, determines, after incubation, the formation of a local tubercle, and, after a variable time, general tuberculosis ; and the virus seems to acquire increased activity by inoculation in series of animals of the same or allied species. 2. But if we inoculate matter obtained from those tubercles secondary to the injection of non-tubercular foreign bodies, they never give rise to general tuberculosis ; and, after two, or, at most, three terms of the series, they even lose the power of producing a local inflammation and become absolutely inoffensive. Here, then, he remarks, we have two inflam- mations ; one specific, infective, and truly tuberculous ; the other non-specific^ non-infec- Its Contagiousness 27 tive^ and not true tubercle ; but botli baving the same anatomical structure, and the former differing from the latter by the presence of the properties of a morbid agent at the present time unknown. It is this '^ unknown morbid agent ■'-' which Koch believes he has made known to us and shown us — an agent which the microscope had failed to discover until those special methods of preparations were employed which Koch has had the honour of dis- covering. Soj then^ the proof of our first proposition /I seems complete ; that " tubercle is an infective j malady, originating in a specific virus, and j propagated by the conveyance of that virus from body to body, and originating in no other way/^ And Koch''s experiments appear to have ^ ^ proved the truth of the second proposition, that this " virus '' is the property of a micro- j organism peculiar to tubercle, and which may ■ be called the tubercle-bacillus. i ^ I need not repeat what has already been ^ published as to KocVs methods of investigation. I may, however, say that the tubercle-bacilli | appear as " delicate rods from a quarter to half jj the diameter of a blood-corpuscle in length '' ; Jj that they have been found '' in large numbers 28 Pulmonary Consumption in all places where the tubercles are of recent formation and spreading rapidly, more especially at the border of the cheesy masses/^ They possess a special relation to the giant-cells, being found in their interior sometimes to the number of twenty in each cell. Tliey do not appear to possess any power of movement. In some of the rods oval spores have been seen. They have been seen in the human subject in cases of miliary tuberculosis, in cases of caseous broncho-pneumonia, in tubercle of the brain, in intestinal tuberculosis, in freshly extirpated scrofulous glands, and in certain cases of syno- vial degeneration of joints. Nor need I repeat the account of the beautiful series of experiments by which Koch has shown that it is to the presence of this organism, and to this alone, that tubercle owes its infective property. One fact, however, let me mark, en i)assant, for future comment. ^^ It was found that these bacilli required a temperature approaching that of the human body for their growth.^^ The minimum temperature of Slained. 2. The late Dr Rush, of Philadelphia, who made very accurate inquiries to determine this point, satisfied himself that when America was first discovered phthisis was un- known among the native American Indians. Now it is very fatal to them. The very significant contrast here exhibited between the past and present history of these two races in respect of phthisis is exhibited at once, and at the present time, among the negro race in Africa in different parts of the area of that great continent. It is well known that negi'oes are peculiarly liable to phthisis. Now, everywhere along the African seaboard, where the blacks have come into constant and intimate relations with the whites, phthisis causes a large mortality among them In the interior, where intercourse with the whites has been limited to casual contact with a few travellers or other adventurous visitors, there is reason to believe that phthisis does not exist. Dr Livingstone and other African travellers have given me the most positive assurances on this point. The idea that phthisis is a self-propagated zymotic disease, and that all the leading phenomena of its distribution may be explained by supposing that it is disseminated through society by specific germs contained in the tuberculous matter cast off by persons already suffering from the disease, first Its Contagiousness 37 came into my mind unbidden, so to speak, while I was walking on the Observatoiy Hill at Clifton in the second week of August, 1856. The close analogy, in many quite fundamental points between this disease and typhoid fever had often impressed itself on me with very great force while I was engaged in the study of the latter, and in the prepara- tion of the papers I have published on it. I now saw with a clearness which had never occurred to me before that, with the exception of the qualifications necessary for their appli- cation to a chronic disease — for the most part of slow evolu- tion and widespread duration — the leading conclusions to which I had been led respecting the propagation of fever might be applied with the same strictness to phthisis also. This idea had no sooner taken possession of my mind than considerations of great force and in overwhelming numbers crowded upon me in illustration of it. In the course of the same evening I drew up some notes on the subject, and before the end of the month my views upon it had taken, in outline, the exact shape which they now have. The long interval which has occurred between the sum- mer of 1856 and the present date has been occupied in col- lecting data bearing on the various questions raised by the new theory — in accumulating evidence of various kinds, and in examining and carefully weighing difficulties. During the whole of this long time the subject has scarcely ever been absent from my mind. The result has been only to confirm me more and more in the truth of my first conclu- sions. I earnestly hope that they will not be lightly rejected. At any rate, I can say that they have not been brought forward in haste or without due deliberation. I have, in fact, consider- ably exceeded the ten years which, with a fine sense of what is due to such an enterprise, the Eoman poet prescribed as the time to be given to every composition intended by the writer to endure. Many causes have helped to prevent me from giving my views on this subject sooner to the world. Chief among 38 Pulmonary Consumj^tioii them I may name want of time to put them into that scientific form and clear logical order, under which alone an innovation so daring has any chance of being entertained, much more of being accepted, by the profession. This task however, I hope to complete in the course of a few months ; meanwhile I have thought it well to place this memorandum, by way of record, in the hands of a fiiend, to be made public at any moment should occasion seem to require it. Manor House, Clifton, December 1st, 1866. NOTE I Views of Pbof. Rd^dfleisch In juxtaposition with the views expressed in 1867 by Dr. William Budd, it is interesting to place the lately-expressed views of Professor Rindtleisch. Professor Rindtleisch {' Archiv fiir Path. Anat. und Phys.,' t. Ixxxv, p. 71) has recently stated his belief that tuberculosis is an eminently infectious malady, that it is readily trans- mitted by inoculation from man to animals, and that the reason there are so few facts in support of its transmissi- bility from man to man is because the human species has become, to a certain point, acclimatised to the disease. Originally tuberculosis must have been a disease analogous to what syphilis is at present. It possessed, and still pos- sesses, the property of hereditary transmission. With the lapse of time the poison has become, as it were, a common heritage to all the successive generations, which, on that account, have acquired a certain immunity against infection from without. On the other hand, as soon as the general physiological state of health becomes lowered tuberculosis manifests itself afresh. Its Contagiousness 39 NOTE II Influence of Tempeeatuee on Development op Infective Oeganisms The influence of temperature on the development of infec- tive organisms and on the propagation of infectious diseases, to which I have alluded in the foregoing lecture, has received some important elucidations by the experiments of M. Gibier. M. Pasteur had proved that the microbe of charbon could not be developed in fowls on account of their relatively high temperature (109° — 111° ¥.), the virus of charbon losing much of its activity at a temperature of more than 100° ; but when M. Pasteur cooled the fowls by plunging their feet in cold water, he found he could communicate this dis- ease to them. M. Gribier has made the counterpart of this experiment. He has taken a cold-blooded animal — the frog — and has raised its temperature until it attained the degree at which the microbe is susceptible of development. Liquids infected with the virus of charbon were injected subcuta- neously into frogs, and at their ordinary temperature no results followed. But when, by plunging them in warm water, he raised their temperature to 98° P., then he found the virus infected the frogs and a certain number of them died. A very curious circumstance was noticed in connec- tion with these experiments, viz. that the frogs which had been inoculated cold without result were unaffected by the second inoculation after warming ! This may have been only a coincidence, or it may have been that they were pro- tected by the first inoculation. He also found that the bacterium of charbon, when deve- loped in the blood of frogs, was much longer than those in warm-blooded animals, and he suggests that the cause of this is the slowness of circulation in these animals : that in warm-blooded animals the more rapid currents break the small rods or hinder their development. 40 Pulmonary Consumption NOTE in M. GiBoux's ExPEBi3iE3n:s In connection -with the discussion as to the communica- bilitj of phthisis, M. Giboux in 1878, and again quite recently, reported to the Frencli Academie des Sciences experiments which he had made on the nocuous properties of the air expired by phthisical patients, his later experi- ments corroborating those he had formerly repoi-ted. His method of procedure was as follows : — He obtained daily forty to fifty litres of air expired by patients in the second and third stages of pulmonary consumption. Half of this he passed daily into a cage which contained two rabbits born of liealthy parents, as asceiiained by post-mortem examina- tion. Two other i-abbits of the same litter were kept in an absolutely similar cage, and through this cage the other half of the contaminated air was passed after having been filtered through cotton wool impregnated with carbolic acid. The two couples were kept in separate rooms. The experiment was maintained from the loth of January to the 2(^h of April, at the end of which time the two rabbits in the second box were in a state of perfect health ; those, on the contrary, in the other box, began to lose appe- tite, to be very thirsty, to suffer from diarrhoea and emacia- tion ; and at the autopsy tubercles were found in tlie prin- cipal viscera, the pulmonary lesions being far more advanced than the others. Tlie rabbits in the other cage, when killed and examined, showed organs in perfect health. It does not, of course, follow that the same air would be as hurtful to men as to rabbits, but the reporter, in the 'Gazette Medicale ' of Paris, mentions two instances which came under his own observation of persons in perfect health, with no hereditary taint, who contracted a rapidly fatal form of tuberculosis after li\'ing in close intimacy with consump- tive persons. In these cases the tuberculae were most marked Pulmonary Oonsumption 41 in tlie lungs, and in one case the fatal event was hastened bj oedema of the glottis. NOTE IV On the Method of Examining foe the Bacillus OF Tubeecle Dr Ehrlich has devised a mode of preparation, recently modified by Professor Eindfleisch, of Wtirzburg, by which the presence of the bacillus of tubercle is more easily detected than by any other hitherto made known. In doubtful cases, this mode of preparation may serve as a valuable agent in diagnosis. In treating the sputum of phthisical patients, or the matter resulting from scraping a tubercle, the thin layer necessary for examination is obtained by placing a small quantity of the matter between two cover-glasses, which are gently pressed together, and easily separated by sliding one over the other. The cover- glasses are then gently heated during a few seconds over a gas-flame, or, what is preferable, they are placed in a stove heated at 100° Cent. (212° Fahr.), for the purpose of coagulating the albumen. Afterwards, they are placed in an alkaline solution of fuchsine (the f uchsine used is only soluble in alcohol), or in violet methylaniline prepared as follows : — A mixture of five parts of oil of parafiine and four parts of distilled water is well shaken for some time ; then filtered through a damp paper. The filtenng gives several cubic centimetres of liquid, to which are added some drops of concentrated solution of aniline. ' This alkaline solution and the cover-glasses are placed in a cup with a glass cover. The cup, with its contents, is kept half an hour in a stove heated to 40° Cent. (104° Fahr.). The next step is to let the mixture drain off the cover-glasses by gently shaking them. They are then washed in water containing 2 to 3 per cent, of nitric acid, and afterwards in distilled water. The preparation is then mounted in gum dissolved in glycerine, 42 Its Antiseiotic Treatment to whicli is added a small qjianfity of ai-senious acid to prevent the development of fungi, or carefully dried in ordinary Canada balsam, and examined with the Abey illuminating apparatus and homogeneous immei-sion. Sec- tions of tubercle hardened only in alcohol are treated in the same way, with the necessaiy modifications. — Brit. Med. Joum., July 22nd, 1882. LECTUEE II ON THE ANTISEPTIC TEEATMENT OE PULMONARY CON- SUMPTION Gentlemen, — It is but a short step from the consideration of the '^ contagiousness of con- consumption ''^ and the infective quality of tuberculosis, concerning which I last addressed you, to the question of the antiseptic treatment of that disease. If the expectoration, if the matters discharged from the air-passages of a phthisical patient, swarm with infective micro-organisms, as we are assured on the highest authority is the case, if the active invading area of the diseased portion of the lung be also crowded with these same infective bacilli, what treatment can be more rational and more appropriate than that which aims at destroying the life and activity of these organisms ? indeed, I might ask, what treatment can be rational or appropriate which neglects to follow this indication ? The only 44 Fuhnonarij Consumption questions that admit of argument in connection with this subject are these two: — 1. Are we satisfied that the presence of these infective organisms in phthisical lungs, and their casual relationship with phthisis, have been demon- strated ? And, 2. Have we the means of treating this disease antisepticallj — that is to say, do we possess, in an applicable form, the agents which will destroy these micro-organ- isms, and so arrest the progress of the disease ? With regard to the first question, I have lately had careful search made by very com- petent workers with the microscope in the ex- pectoration of patients with advanced phthisis, as well as in sections of typical tuberculous mesenteric glands ; but they have not yet suc- ceeded in finding the organisms described by Koch. But it does not follow that they were not there; the method of investigation needed for their discovery and demonstration is no doubt a difficult and delicate one, and we must not be surprised or discouraged if, notwith- standing our best efforts, we fail in our earlier attempts to demonstrate that which has cost Koch and others so much time and labour to discover. And already Koch^s method of demonstrating these organisms in the sputa Its Antiseptic Treatment 45 of phthisical patients lias been improved upon by Dr EMicli. (Since tbe delivery of this lecture^ Dr Barron, of University College, Liverpool, has been so obliging as to send me a slide of phthisical sputum stained after a slight modification of Ehrlich^s method, in which the characteristic bacilli are numerous and readily seen. The cell nuclei of the sputum are stained brown, and the bacilli appear as thin blue rods or threads, many of them containing spores. Dr Barron has found these organisms in the spu- tum of all cases of phthisis — about twenty in number — examined by him, except one of pneumonic origin. He has also found them in the lung itself, in the urine of a boy suffering from tubercular pyelitis, who afterwards died from basilar meningitis, and in the scrofulous material from the kidney of the same case. Dr Barron has found Ehrlich^s method much more certain and satisfactory than Koch^s.) But just as a belief in the contagiousness of phthisis has long existed in some minds, so / also a tendency to apply to it an antiseptic • mode of treatment has long prevailed with j some physicians. For my own part, I may say that, during the last ten years, I have repeat- 40 Puhnonarij Consumption edly prescribed the inlialation of antiseptic vapours in cases of phthisis, as well as other treatment which I have believed to be also antiseptic ; and you must often have noticed, in the wards of this hospital, that all my phthisical patients have been in the habit of wearing a form of respirator-inhaler for the purpose of inhaling antiseptic vapours, which I shall immediately describe to you. In a paper on " Recent Researches in the Treatment of Phthisis,'^ which I contributed to the annual meeting of the British Medical Association in 1870, I called attention to the progress that had been made in the direction of the antiseptic treatment of this malady, and I described several methods of applying this form of treatment ; and, since then, several physicians, who have had large opportunities of testing its usefulness, have published some very successful results as following this plan of treatment. Moreover, it would not be difficult to trace an antiseptic action (assuming phthisis to be dependent on the presence of an infective organism in the lungs) in some of the remedial measures of greatest repute in the treatment of this disease. The beneficial effects which Its Antisejptic Treatment 47 are reported from tlie employment of tlie sulpliurous waters of Eaux Bonnes (Dr Leudet, ' Les Eaux Bonnes dans le Traitement de la Phthisie Pulmonaire ^)j and of Cauterets_, and of tlie so-called '^ arsenical '^ waters of Mont Dore, may they not be due to an antiseptic action ? for the explanations of their mode of action hitherto put forth are eminently unsatisfactory. For example^ when it is suggested that the sulphurous springs of Eaux Bonnes cure phthisis by ^^the formation or arousing of constitutional maladies of a slighter kind^ which act as antagonists to the graver disease/^ we must feel that we are not very far off from such dogmas as the similia similihus of the homoeopaths. But^ even supposing we are on the right track in applying an antiseptic method of treatment to phthisis, and in assuming a unity and identity of origin in the great majority of cases which are recognised as pulmonary consumption, we must not ask more of this method or expect better results from it than it can possibly give. Nothing can be more certain than that tuberculous disease, whatever may be its inti- mate nature, tends invariably to be complicated with the products of inflammation. Wherever 48 Pulmonary Consumption there is tubercular disease present in the lung, there you will find the results of present or past inflammatory action. The course and aspects of pulmonary tuberculosis are so uni- formly overclouded with the phenomena of inflammatory action that some of this '' cloud^' seems to have settled down over the minds of many pathologists ; and, in regarding phthisis, they seem to be unable to see through this mist of inflammation ; and it must be admitted, if these micro-organisms cause destruction of lung-tissue, they do so by exciting a peculiarly destructive form of inflammation ; so that, in the treatment of phthisis, you must never lose sight of this inflammatory process, which always accompanies it, and plays a predominating part in its manifestations. If in phthisis, as seems most probable, we have to do primarily with a specific virus or infective organism, and secondarily with an inflammatory process excited by it, our treat- ment must have a twofold object — the destruc- tion of the virulent agent and the reduction of the accompanying inflammation ; and, in actual practice, my own experience certainly shows that the best results follow the combination in treatment of these two ends. Its Antiseptic Treatment 49 If we look through the whole of the literature dealing with the treatment of phthisis^ it seems to mo that two facts start out in remarkable prominence : one is the value of treatment which may be regarded as antiseptic — sea- voyages, mountain air, dry pure air in any locality, sulphur waters, terebinthinate va^pours, iodised vapours, &c. ; and the other is the value of counter-irritation, systematic and con- tinued counter-irritation ; treatment, you see, directed against a virus or an infective pro- perty — treatment directed against the results of present and past inflammatory action. But we must not expect more from antiseptic treat- ment than it can possibly yield. I have seen it remarked that cases of phthisis, though they might be benefited, are not cured, by antiseptic treatment. To this I would reply, that aseptic and antiseptic treatment, if they do not cure, are, at any rate, an essential condition of cure where cure is possible. Nature often herself erects an antiseptic barrier against the invasion of septic agents. And one of the most uni- versally admitted remedies for staying the progress of phthisis is the removal of the patient to some place where he shall breathe an aseptic, if not an antiseptic, atmosphere. It 4 50 Pulmonary Consumption is foolish to expect that antiseptic agents can act, so to speak, retrospectively. Water may extinguish fire and stay its ravages, but it cannot rebuild what the fire has destroyed. So antiseptic agents may arrest the activity of septic influences, but they cannot undo the mischief that is already done. When I read of hospital physicians vigor- ously plying, with so-called antiseptic sprays, patients in the very last stages of phthisis, with lungs riddled with cavities, and then reporting that they have arrived at " decisive negative results,'^ I am amazed to think that they ever imagined it possible that they could arrive at any other. When I read that such a plan of treatment was attempted in nine patients during the last three weeks of their lives, and then read that after death " nothing was found in the patho- logical condition of the lungs which in any way indicated the commencement of a healing pro- cess; there was an extensive phthisical decay, with cavities filled with fluid pus ; in one case of left- sided pneumothorax there was a per- forated cavern — '' I feel constrained to say, that if ignorant charlatans wrote in this way, we should find no lano^uac^e too severe to con- Its Antisejotic Treatment 51 demn their imbecility. Grentlemen, this kind of thing is foolish trifling. When you are called to a case, as it is often my lot to be, and find a patient in the last stage of phthisis, with physical evidence of extensive phthisical infiltration and breaking-down of large tracts of lung- tissue and signs of excavation in various parts of both lungs, you should honestly confess that you are absolutely powerless before such a state of things, and never bring discredit on any method of treatment by attempting with it what, from your experience and pathological knowledge, you must be aware is absolutely impossible. Nor should we fall into the error, as some writers seem to have done, of regarding the antiseptic treatment of pulmonary phthisis as closely analogous, or a strict parallel, to the anti- j septic method as adopted in surgical procedures. The surgeon's object is to prevent the access u of infective organisms from without; our object is to destroy or arrest the activity of a specific organism which is at work within — a very different end to keep in view; and I fail to see any practical or logical a priori argument against the conclusion, that it may be possible to impose conditions on an organism which is 52 Pulmonary Consumption spreading througli tlie pulmonary tissues which shall prove inimical to its growth and repro- duction, and that is what is meant by the anti- septic treatment of phthisis. But a complete antiseptic treatment, though it may be possible, no doubt requires minute care in carrying it out in detail. It is not a little instructive in connection with the history of this subject to find Dr Copland, many years ago, recording the fact tbat a young man who had repeatedly come under his observation in an advanced stage of phthisis, completely recovered bis health after he had been for a considerable period employed in the manufacture of creasote ; and at the end of his ' Historical Sketch of the Treatment of Pulmonary Consumption ' he observes : " The inhalation of the fumes of tar or of creasote, or of the terebinthinates, very weakly diffused in the atmosphere breathed by the patient, is in some cases beneficial in impeding the advance of tubercles or the formation of cavities, and in healing the surfaces of cavities which have been formed. ^■' Valuable testimony has been given by Dr Lemaire and Dr Sansom as to the eflBciency of the inhalation of " carbolised air '^ in phthisis. Its Antiseptic Treatment 58 Dr Lemaire gave carbolic acid also internally in aqueous solution. He found very remarkablo effects follow its use. There was diminution of cough after twenty-four hours, and in some cases almost a complete disappearance after a few days. The expectoration was diminished or almost suppressed^ and if the sputa were offensive, their foetor disappeared. In many, the physical condition of the respiratory organs was ameliorated. Some were cured, in others there was a subsidence or disappearance of rales, and parts became pervious to air which had previously been impervious. In other cases he had noticed increase of strength, return of appetite and sleep, increased freedom of breath- ing, and general exhilaration. Dr. Jaccoud, the eminent Professor of Medi- cine in the Faculty of Paris, in a treatise which he published last year on the ' Curability and Treatment of Pulmonary Phthisis,' thus testifies to the good effect of creasote given internally. The '' pure creasote of the beech-tree '^ is the preparation used by preference in Paris. " This remedy,^' he says, ^^ more rapidly and more surely than any other diminishes the expectora- tion and limits the extent of the catarrhal lesions, and thus reduces considerably the area 54 Pulmonary Consicmjjfion of tlie pulmonary changes. But that is not all j and I am induced to believe that creasote may act on the fundamental lesions themselves, the tuherculoiis lesions, and promote indurative changes, which, as you know, is the method of cure/' He mentions the case of a young girl, twenty-two years of age, who was in the hos- pital three months with infiltration and softening at the left apex ; and, after the creasote treat- ment, she became greatly benefited, and was discharged fifteen pounds heavier. The signs of " peritubercular catarrh *' had disappeared, the dulness had greatly diminished, and breath- sounds had to some extent reappeared. She remained in good health for two years, when she was readmitted with an attack of broncho- pneumonia from exposure to severe cold. She was very ill, but recovered to some extent ; and, when convalescent, she was obliged to leave the hospital, and was lost sight of. In another case quoted by Jaccoud, of a young Russian thirty years of age, he observed the area of infiltration and softening at the apex of one lung diminish one half under the creasote treatment. " This amelioration has lasted two years, and is still maintained j and the state of the patient's general health is par- Its Antiseptic Treatment 65 ticularly good/' He considers creasote a '^ precious medicine/' and it now forms a ''^fun- damental part '' of his treatment. His method of giving it is to begin with a very small dose, to increase it very slowly, and to maintain its administration for a very long period. He never gives at the commencement more than three minims in the day, often less, increasing by one minim every ten days, rarely exceeding ^YG minims, and never exceeding six. He wisely objects to its being taken pure in cap- sules, on account of its irritating effect, in this concentrated form, on the gastric mucous membrane. He prefers that it should be added to the cod-liver oil, if the patient take this ; if not, that it should be given in glycerine. He has found that the addition of creasote to cod- liver oil has often had the effect of enabling patients to take the latter, who were unable to do so previously, adding to the dose one drop of essence of peppermint. His formula for creasote in glycerine is as follows : — Glycerine, 10 drachms ; brandy or rum, 2 drachms ; crea- sote 3 to 6 minims ; a third of this to be taken three times in the day. Besides the internal use of creasote Dr Jaccoud is in the habit of recommending the 56 Pulmonary Consumption inhalation of a spray of carbolic acid in cases wliere the disease has advanced to the formation of vomicae^ chiefly with the object of preventing the absorption of putrid secretions and debris. But it seems practicable to obtain the good effects of antiseptic agents without the necessity of using a spray, which entails a certain amount of trouble, and can only be applied occasionally ; whereas, with the plan I am going to advocate, you have the decided gain of being able to apply the antiseptic inhalation almost continu- ously, and of almost any degree of strength. Several instruments have been devised for the purpose of diffusing an antiseptic vapour through the atmosphere the patient breathes. I have found none answer better than the simple con- trivance I am now going to describe to you. It has the great advantage that it practically costs nothing. A dozen such inhalation-respi- rators as those you see on the table before you cost less than a shilling ; and, with a little instruction, a nurse can make one in a few minutes. My patients in this hospital have long used them. You take a piece of paper about six inches long and four wide ; you fold it along the middle, and cut it with a pair of scissors into Its Antiseptic Treatment 57 this form. This is your pattern. You place thisj as I now do^ on a piece of perforated zinc^ whicli costs about sixpence a square foot^ and thenj with a pair of stout scissors^ you cut out a piece of zinc of the same size and form as the paper. You see I have cut out a piece of per- forated zinc of the size and shape of the piece of paper I showed you. Now you see by a little manipulation^ for this zinc is very pliable, I can bring the two outer ends (a and b) together^ so as to slightly overlap ; and then_, fixing them together with a twist of fine wire passed through the holes of the zinc, I get a suitable mouth-piece, or rather nose and mouth- ] 58 Fulmonary Consumption piece, for it is important, I consider, to cover botli nose and moutli. This can be bent to fit comfortably any face. The two middle pieces (c, d,) now stick out behind, and, by gradually bending first one of these down, and then the other over it, you construct a little cage behind the mouth-piece which will hold a small bit of sponge, or a bit of tow or cotton wool, or any suitable material for retaining the antiseptic vaporisable fluid. It is desirable to cover the rough edge of the mouth and nose-piece with some projecting material, it matters not what ; I have, as you see, used tinfoil ; a loop of elastic on each side serves to attach it behind the ears. It can be covered with black silk or any other material* according to taste, but no covering is really necessary. You see nothing can be easier than the construction of an inh alation-respirator of this kind; and it costs so little that it can be ^given, without hesitation, to hospital and dis- pensary patients. It is light and comfortable to wear, much more so than some other more expensive contrivances, and patients find no difiiculty in sleeping with it on. Now, there are many antiseptic substances the vapour of which may thus be continuously. Its Antiseptic Treatment 69 or almost continuously^ diffused into the air that is breathed. Your choice may depend somewhat on the taste of the patient^ or you may change the applications^ from time to j • time, until you find out, in each case, which .' , is most useful, and best supported by the patient. Some simply keep the sponge (or tow) moist- | / ened with carbolic acid ; others prefer creasote, j and others use spirits of turpentine. I have used all these alone, as well as in combination. I have also used eucalyptol, thymol, terebene, i camphor, fir- wool oil (oleum pini sylvestris), jj solution of tar in rectified spirit, tincture of benzoin, tincture of iodine, &c. Specimens of Ij these substances are on the table before you, and I hand round to you inhalers charged with several of them. Of all these, I prefer creasote ; (( ( but I also frequently use carbolic acid and euca- lyptol, with which I sometimes mix a little camphor. Turpentine is a useful addition as an astringent where there is profuse secretion or a tendency to hgemorrhage. Camphor has been said to be a very powerful antiseptic, but it has the objection of diffusing itself very rapidly, and is unpleasantly pungent and pene- trating. I have also found it a* very convenient '/ 60 Puhnonary Consumi^tion plan to mix these substances^ such as creasote, carbolic acid, eucalyptol, or turpentine, with equal parts of spirits of chloroform. It helps to diffuse and vaporise these substances, and it is itself somewhat of an antiseptic ; and it has also a soothing effect on the often irritable bronchial mucous membrane. I have often seen a patient tormented with cough at night, so much so as to be unable to get any sound sleep, obtain perfect relief from this distressing symptom by using at bedtime one of these inhalations in an instrument of this kind. The quantity required for this purpose is often quite inconsiderable ; it is rarely necessary to use more than twenty minims of a mixture of equal parts of creasote and spirits of chloroform dropped on the sponge at a time, and renewed occasionally as it becomes exhausted ; and it is often desirable to begin with very small quan- tities, until the patient gets used to the vapour. Five drops of the mixture may be dropped on the sponge at a time, and gradually increased to fifteen or twenty. One of the advantages of the little inhaler I have described to you is that, being perforated all over, the access of air is unimpeded, while the vapour diffuses itself freely into the immediately surrounding Its Antiseptic Treatment 61 atmosphere. Witli more solid inhalers, patients will often say they feel '^ stifled '^ and refuse to use them. The substances I have named are, I believe, the best for continuous, or almost continuous, inhalation ; for occasional inhalation, you will find a weak iodised vapour often very useful; and even a very dilute chlorine vapour is well borne by some patients. But in these matters, as I have already said, you must consult in some measure the tastes of your patients. Iodine vapour may be diffused through a room or small chamber by throwing fragments of iodine on a heated plate, as I now do ; or it may be inhaled from the surface of hot water, by pouring a few drops of tincture of iodine on the top of hot water contained in a suitable vessel, and holding the mouth and nose over the vapour, with some light covering over the mouth and nose and vessel. The vapour of tar may be inhaled in the same manner. A sleeping apartment may be impregnated with, tar vapour by putting some tar on a heated metal plate, or stirring a vessel containing tar with a piece of heated metal of any kind. Other antiseptic substances which are not volatile or are vaporised with difficulty may be 62 Fulmonary Consumption inhaled in solution in the form of spray. A Siegers spray-producer is the instrument usually employed for this purpose. A substance which has been given in Ger- many, and recommended as an antiseptic in cases of tuberculosis by Dr Max Schiiller of Griefswald and Dr Rokitansky of Innsbruck, is the benzoate of soda. This they give in the form of spray, i.e. the two to five per cent, solution in distilled water. But the great objection to this mode of treatment was the amount of fluid it was necessary to inhale (twenty ounces of a five per cent, solution daily) in order to take in the minimum dose. The patient would have, as indeed Dr Max Schiiller says, to devote his life to his cure ; for you cannot inhale a spray and do anything else at the same time, whereas the inhalation of an antiseptic vapour by the method I adopt can be continued at the same time with almost any other occupation. I have adopted this plan of treatment in a number of cases, and in nearly all of them it has been attended with conspicuous benefit. Even in somewhat advanced cases, it allays the cough, lessens the amount of expectoration, and diminishes the fever. Its Antisejotic Treatment 63 There is a young girl^ twelve years of age ,in the hospital now, an orphan with no obtainable family history, who was admitted three months ago in a wretched general condition, and ap- parently sinking from rapid phthisis. There was dulness all over the left side, with co- extensive moist crepitant and course rales ; there was diminished resonance over the upper half on the right side, with diffused bronchial rales. The temperature was high and fluctuat- ing, constant cough, much dyspnoea, loss of appetite, and great emaciation. She has been kept inhaling a mixture of equal parts of eucalyptol and spirits of chloroform ; and, con- sidering the miserable state in which she was on her admission, she has mended wonderfully. She coughs now very little; her appetite is good ; she has gained flesh, and become quite cheerful. The moist sounds have completely disappeared from the right side, where the resonance is now good; and on the left side the catarrhal sounds have, to a great extent, disappeared, and the dulness is now limited to the upper lobe. She continues, however, to manifest a subfebrile fluctuating temperature. I could enumerate a great many cases which have come under my care during the past five li 64 Fuhnonary Consumption or six years in which remarkable results have followed this method of treatment when it has been honestly and faithfully carried out ; but I must not weary you with these details. I can- not, however, forbear to call your attention to the particulars of a case I have quite recently had under my care, and in which, I must say, I have never seen better immediate results from this or from any other kind of treatment. I first saw the case on the Gth of May. The patient was a married lady, twenty-eight years of age, living in a low damp locality, who had lost two brothers from consumption, one at nineteen the other at twenty-three years of age. She had had a cough for two years, and had been losing flesh. She was confined last Christmas, since which time she had been worse. Night sweats were constant ; the cough was troublesome, and expectoration abundant. Her voice began to be hoarse a fortnight ago, and was now nearly lost. Her appetite was bad. Pulse 112 ; respirations 20; temperature 101° Fahr. She was considerably emaciated. There was sorcie dulness over the left apex in front and behind, with moist clicks at the end of inspiration, and some diffused largish crepi- tations on coughing. On the right side, sub- Its Antise^ptic Treatment 65 crepitant rales were heard over a spot just below the angle of the scapula, where there was also a patch of dulness. She was ordered to wear as constantly as possible one of my inha- lation respirators, charged with from five to twenty drops at a time of a mixture of equal parts of creasote and spirits of chloroform, so as to breathe an atmosphere only as strongly impregnated with the antiseptic as was quite j comfortable to her. She was also to rub into the chest a mixture of turpentine and iodine liniment, and to take three times a day a mixture, each dose of which contained three grains of hypophosphate of lime, two grains of quinine, twenty drops of the syrup of phosphate of iron, and half a drachm of glycerine, and to continue the cod-liver oil she had been taking. She was also ordered to leave the place in which she was liviug, and go to some dry, bracing locality. It was agreed that she should go to an isolated farm-house built on a hill three hundred feet above the sea, between thirty and forty miles from London, on the borders of Hampshire and Surrey, where there were pine woods and open heather country. She came to see me again after about three weeks, and she had improved immensely. The temperature 66 Pulmonary Consumption "had become normal ; the night sweats entirely disappeared after a week of the treatment ; her voice had returned after ten days ; the cough and expectoration were greatlj lessened. The dulness of the left apex was much less evident, but respiration there was feeble^ and there was a distinct pleuritic creak in the left supra- spinous fossa, a notable sign of past mischief in that region ; all the moist sounds had dis- appeared. Her general condition had com- pletely altered. I have never seen a more striking improve- ment in so short a time, under any plan of treatment or in any locality. But this patient had been unusually obedient to the instructions that had been given her. She had devoted herself at once and unhesitatingly to all the details of the treatment. She had removed immediately to an aseptic if not an antiseptic , atmosphere ; she had passed a great part of \ her time in a hammock, suspended between fir trees, in the situation I have mentioned, and she had perseveringly worn her inhaler as I had directed. But there is another antiseptic method of ! treatment which has come into general reputa- I tion within the last ten or twelve years, and of Its Antiseptic Treatment 67 tlie advantage of wtiicli in certain cases tliere can be no kind of doubt. I allude to the removal of consumptive patients to the dry, pure, cold air of elevated regions. The low temperature of these regions may have much. to do with limiting the vitality and propagation jj of the tubercle organisms. But I have gone into this question fully elsewhere,* and I need not go over that ground again here. I will, however, refer to a reuiarkable passage in a letter from a well-known resident in one of the chief of these resorts, Davos Platz, which seems to me to have great significance with regard to the question of the contagiousness of consump- tion. Speaking of the overcrowding that has taken place in that locality, he says : ^' The tendency at Davos has been .... to pack the patients together in as small a place as possible, and to build new inns at the doors of the old ones. All this is done in a climate where winter renders double windows and stove-heated buildings indispensable. All this is done for a society where the dying pass their days and nights in closest contiguity with those who have some chance of living. Within the last few weeks, two cases have come under my * ' Health Eesorts and their Uses,' chap. iii. i — ■ 68 Fulmonarij Consumption notice : one, that of a native of Davos attached to the service of the visitors; another, that of an English girl, who had both contracted lung disease in the place itself, owing, as I believe, to the conditions of life as thej have recently been developed here ^^ (Mr J. A. Symonds, in the ^Pall Mall Gazette 0- Now, if the infective character of tubercu- losis were generally recognised, and the tuber- culous nature of pulmonary consumption gene- rally admitted, mistakes of this kind would hardly be committed. So, again, the antiseptic influence of sea voyages is greatly interfered with by the unavoidable occurrence of bad weather necessitating the continement of the in- valids in close overcrowded cabins, in which the atmosphere they may have to breathe, for days and days together, is anything but antiseptic. In conclusion, let me again remind you that you will fall into a serious error if you carry away with you the idea that the treatment of phthisis is to be altogether comprehended in the inhalation of an antiseptic vapour. It is a part, and only a part, of the rational treatment of phthisis. I know of no disease in which so many and various indications for treatment arise during Its Antiseptic Treatment 69 its progress. But^ if pulmonary plifcliisis be palmonary tuberculosis, and if tuberculosis depend on tbe presence of an infective organism in the tissues, a rational treatment of pbtbisis must include the administration of antiseptic agents, or the surrounding our patients with antiseptic conditions. NOTE I On the Antiseptic Teeatment op Phthisis Since the delivery of the preceding Lecture my attention has been directed to some very recent reports, published in Germany, bearing on the antiseptic treatment of phthisis. Dr Frank el (' Centralblatt/ June 10th) has been making ex- perimental injections of antiseptics into the pul- monary tissues of animal — such as carbolic acid, boracic acid, iodoform, tartrate of alumina, &c. These injections were not attended with any constitutional disturbance; and the post-mortem examinations showed the existence of extrava- sations and simple inflammatory changes in the lungs ; and, in later stages, the formation of cicatricial tissue. On the strength of these results, he proposes that similar injections should be made into the foci of disease and their neigh- bourhood, with the view of modifying the morbid process and of limiting its extension by cicatricial barriers. In a patient with fetid expectoration he administered six injections, each of fifty minims of 70 Fidmonary Consumption a 5 per-cent solution of carbolic acid. It excited no reaction and no coiigh^ but bad no effect on tbe expectoration. I mention tbese experiments witbout, for tbe present, offering any opinion as to tbeir value, merely to sbow tbe activity witb wbicb tbis subject is being investigated in Germany. XOTE II On the Inhalation of Sulphuretted hydrogen in Tuberculosis. Experiments on tbe inbalation of sulpburetted bydrogen in tuberculosis bave been made by Professor Amaldo Cantani, of Naples; be bad observed, in conjunction witb two of bis colleagues, tbe good effects resulting from tbe employment of tbe waters of tbe solfatara of Pozznoli. Tbese contain sulpburetted bydrogen, as well as some sulpburic acid. Tbey administered tbe concen- trated waters internally and also submitted tbe patients to tbe action of tbe vapour in specially constructed cbambers. Tbey report tbe following results : 1. Altbougbtbe patients objected at first ; tbey subsequently became quite tolerant of tbe sul- pburetted bydrogen vapour, and no bad effects followed. 2. Tbe patients so treated became quite free from fever in a few days. '6. Tbe progress of tbe local disease was arrested during tbe treatment and tbe expectora- tion was diminisbed. Professor Cantani is continuing bis obser- vations. Its,Antise;ptiG Treatment 71 NOTE III On Benzoate of Soda m Phthisis The history of the attempt to treat phthisis antiseptically by the inhalation, in spray, of solution of benzoate of soda is related in the following extracts. In the ''Brit. Med. Jonrn.' of December 20th, 1879, I made this communi- cation : ^^ I have now before me a private letter from Dr , Max S chillier, of Grriefswald, and a copy of a / short article by him, on the " Treatment of Tuber- culosis," extracted from the ^Berliner Klinische Wochenschrift.^ They both refer to a question of so much interest and importance that they merit something more than a passing notice. ^^ The substance of Dr Max Schiiller's letter is as follows : — Some months ago, he published a paper describing experiments he had made on tuberculous or scrofulous rabbits, in order to study the effects of a treatment based on the theory of the bacteric origin of this disease, or rather of the artificial disease in his animals. These animals were infected by the throat with tuberculous matters, and so made tuberculous. Then he derived from the tubercular matters a small form of round bacterium or coccus by a process of Professor Klebs, of Prague, which he names " fractionirte Gultus ;'' and with these he made the same experiments, and with the same results — viz. tuberculosis of the internal organs and a tuberculous inflammation of an injured knee-joint. He was thus convinced that tuber- culosis in his animals was a disease caused by living elements or special organisms (Monas tuberculos of Klebs). He then tried certain 72 Pulmonary Consumption drugs wliicli lie believed would have an inimical effect on tlie said organisms, and he found that, of the similarly infected animals, those that were not treated all died in variable times; while those submitted to treatment not only remained alive, but recovered their health and increased in weight. He thought the results of his experi- ments justified him in appealing to medical practitioners to give a trial to what might prove a causally indicated treatment for a disease hitherto without any remedy. Professor Roki- tansky, of Innsbruck, was one of the first to acce])t this invitation to make observations on man, and he is stated to have obtained good results. Dr. Max vSchiiller regrets that the newspapers should have published paragraphs with such sensational titles as *' No more Tuber- culosis :'^ and he believes that the application of this mode of treatment to human subjects is attended with many more difficulties than in the case of animals, and that it requires to be con- tinued for several months. "The drug he especially recommends is the benzoate of soda: this is inhaled in solution (2 to 5 per cent.) in distilled water, and by means of a spray-producer. For a man of average weight (sixty kilogrammes), the daily dose is from thirty to sixty grammes. If the stronger inhalation be not well borne, the drug can be given internally for several months, five to ten times a day, in gramme doses, in milk, and then weaker inhalations may be used. He considers it most important that the inhalations should be persisted in as often and as regularly as possible, through weeks and perhaps months ; and the patient must 'devote his life to his cure.' ''As, in order to give the smaller daily dose. Its Antiseptic Treatment 73 viz. thirty grammes, it would be necessary for the patient to inhale the spray of twenty ounces of a 5 per cent, solution in the twenty-four hours, an ordinary Siegle's spray-producer would prove quite inadequate, and it would be necessary to employ one of those used for surgical antiseptic dressings. '' In private practice, two to four times a day will be often enough for the inhalations of the spray, and such inhalations should be prolonged for half an hour. The patient should, at first, be recommended to make as little effort as possible in inhaling, and only by degrees should he be allowed to make deeper inhalations. A period of rest should follow each inhalation. ^' Benzoate of soda (as obtained from Messrs. Bell and Co., Oxford Street), is a white granular powder, with a faint odour of benzoin, and a sweetish not unpleasant taste. It is freely soluble in water. It is sold at one shilling and sixpence the ounce, and therefore is not very expensive, as has been stated." The above is a condensed account of Dr Max Schiiller's recommendations and directions. The excellent results at first reported by Pro- fessor Rokitansky, of Innsbruck^ were soon called in question by several physicians in some of the principal towns in Germany, and their reports were thus summarised in the ''Brit. Med. Journ.' of January 3rd, 1880 : '"'Dr. Guttmann, of Berlin, treated over thirty- one phthisical patients, of whom twenty-four were men and seven were women, from seventeen to fifty-six years of age. The phthisis was in the majority of the cases very extensive, often having proceeded to the formation of consider- able cavities ; in a smaller number of cases, the 74 Pulmonary Consumption disease was relatively lighter — cases "wliicli were at times either altogether free from fever, or which were ranning their course with only slight fever. Those patients were purposely chosen for this observation whose temperature showed a well-marked hectic type, that is to say, low morning temperatures, high evening tempera- tures, and moreover who, during the latest part of their stay in the hospital, had shown a certain steadiness in their temperature-curves. Any influence of the treatment by inhalation could, therefore, be very easily observed in the tempe- rature-curves of such patients. The temperature was taken three times a day at the same periods — morning, midday, and evening. The inhala- tions took place twice daily — morning and even- ing. The solution of benzoate of soda w^as a 5 per cent, solution in water. At first, Dr. Gutt- mann prescribed only five grammes of benzoate of soda daily, that is to sny, the inhalation of one hundred grammes of solution ; later, he rose, in the case of five patients, to ten grammes of the substance, that is to say, two hundred grammes of the inhaled solution a day. When ]U)kitan- sky's communication appeared, in which he inti- mated that his patients had daily inhaled the one-thousandth part of their body-weight of benzoate of soda in substance, that is to say, fifty grammes of benzoate of soda in substance per fifty kilogrammes of body-weight, and therefore a thousand grammes of the solution, then Dr. Guttmann also raised the prescriptions of the patients to these large quantities. Of the thirty-one patients, fifteen inhaled during three weeks ; one for two days (the latter had during this time consumed seven hundred and ten grammes of benzoate of soda in substance) ; six Its Antiseptic Treatment 75 patients inlialed during from fourteen to nineteen days. Of tliese^ one took six hundred and fifty grammes of benzoate of soda in substance. Tlie remaining nine patients inlialed during from three to twelve days. In four of these who did not tolerate inhalation^ the benzoate of soda was given internally^ in the quantity of from twenty grammes of benzoate of soda to two hundred of water (one tablespoonful every two hours). Of these thirty-one patients, nine died — seven men and two women ; two were allowed at their own wish to leave the hospital; and the rest were still there. The result obtained was as follows : — In not one case — not even, therefore, in the patients who inhaled daily a thousand grammes of the solution — was the temperature in any observable manner lowered by the benzoate of soda, nor was any influence exercised on the temperature-curves. Dr. Gruttmann adds that the internal use of the benzoate of soda, during a considerable time in which a daily quantity of about eight grammes in substance was taken, was equally without influence on the febrile ►temperature. On the second notable factor in the progress of phthisical patients, improvement or falling off in weight, the treatment with ben- zoate of soda was equally without influence. In most cases the weight of the body fell off pro- gressively, in proportion to the amount of pyrexia and exactly in the same manner as though the patients had not been undergoing treatment during this time. Only in one or two patients, in whom the fever was throughout and from the first slight, did the body -weight remain stationary or slightly increased. Neither did the local symptoms of the phthisis undergo any change during the course of the treatment^ in the sense 76 Fuhnonary Consumption of improYement. Dr. Guttmanu observed, indeed, that the catarrh and bleeding diminished shortly after the inhalations ; that is to say, that the patients coughed and expectorated less for about an hour after the inhalations were over. This, however, he attributes to the fact that the inha- lation, and the continuous deep inspiration required while it was going on, excited during the time a much more considerable amount of coughing by irritation; and thus, during the period of inhalation, a much more considei-able amount of expectoration was induced — thus clear- ing the cavities and tubes, and giving rise to less expectoration for a short time after the inhala- tions had ceased. There was no permanent improvement either of cough or of expectoration after the inhalations, nor were the nocturnal sweats, when these were present, at all lessened by the benzoate of soda. While in not one case was any symptom of phthisis observed to be improved by inhalation ; on the other hand, an occasionally unpleasant incidental action of the benzoate of soda was observed. A good many patients complained of nausea and some of vomit-. ing, symptoms which, partly at least, were excited by the continuous stretching forward of the tongue during inhalation, on which Rokitan- sky lays considerable stress, in order that the inhaled substance might reach the air-passages. It appeared to be partly due to the fact that the benzoate of soda acts as an excitant on the mucous membrane of the stomach, in so far as it reaches it by the inhalations through the oeso- phagus, and so onwards. Guttmann has observed in one case, on post-mortem examination of a phthisical patient who had inhaled benzoate of soda quite up to the end of his life, a recent and Its Antisejotic Treatment 77 general capillary congestion of tlie mucous membrane of the stomacli. In tlie post-mortem examination of nine phthisical patients, who had inhaled benzo ate of soda, nothing was found in the pathological condition of the lungs which in any way indicated the commencement of a healing process. There was generally an extensive phthisical change, with cavities filled with fluid pus. In one case of left-sided pneumothorax there was a perforated cavern. Two phthisical patients, who had for several years shown no symptoms of haemoptysis, were attacked freely with hasmoptysis after inhalations. These re- searches, therefore, carried on during the same period, in the same manner as those which were published from Eokitansky's clinique, are in absolute and complete opposition to them.''^ Similar results to those of Dr. Guttmann, of Berlin, were obtained by Dr. Wenzel, as well by Professor Drasche, of Vienna. As I have remarked in the text, it was simply waste of time to attempt to test any method of treatment by applying it to cases so advanced and hopeless as were these which are here mentioned. More- over, Professor Oertel, of Munich, in a volume he has just published on the 'Therapeutics of the Organs of Respiration,' in which he devotes about 350 pages to the subject of "Inhalations," speaks highly of the use of a 5 per cent, solution of benzoate of soda, atomised — i.e. inhaled in the form of fine spray. He has observed a very cleansing effect to follow its use in the ulcerative lesions of laryngeal phthisis ; and he infers from this that a similar favorable action may be exercised on the lesions of more deeply seated parts, on the bronchial ulcerations and soften- ings, and on the walls of cavities. The expecto- 78 Puhnonary Consnmittion ration is facilitated — increased at first, and sub- sequently diminished. Mycotic processes and decomposition of the secretions are arrested; and the absorption of secretions is thus favorably modified, and is less likely to be pyrogenic or specifically infective. He also points to the im- portance of thorough cleansing of the mouth and fauces ; the appetite is thereby improved, and the stomach is spared the infliction of decom- posing oral secretions. The swallowing of a certain amount of the solution he considers of great value, as he believes it operates in diminish- ing the fever. He duly discredits the marvellous results claimed for this plan of treatment by Eokitansky, but sees no reason to deny the correctness of Schiiller's impressions, as to the results of his experiments on aninuils, performed under conditions very difierent from those obtain- ing in the subjects of advanced phthisis. He, moreover, expresses a confident belief that, by this and other antiseptic modes of inhalation, very good effects will be attainable. APPENDIX Opinions and Experience of the Antiseptic Treatment of Phthisis Tn the present state of the discussion of the subject with which the foregoing lecture deals the testimony of independent observers is of great value. I have therefore collected in this appendix extracts from the published opinions of several practitioners of experience and repute bearing on the antiseptic treatment of phthisis. Its Antiseptic Treatment 79 The following remarks on " Pulmonary Phthisis treated Antiseptically/^ are from a paper by Dr W. Williams^ Physician to the Royal Southern Hospital^ Liverpool,, published in the ' British Medical Journal/ July 23rd, 1881. " The use of inhalations^ and even of anti- septic inhalations, in the treatment of lung- dis- ease, dates from no recent period. My object to-day is to lay before this meeting certain clinical facts which I have gathered while making an endeavour — with what success you will be able to judge — to bring the principles of Professor Lister^s antiseptic method to bear upon the treatment of cavity or abscess of the lung. It is not so much, then, to the impregnation of the inspired air with vapour as its puritication that I wish to draw attention. ^''An abscess once established, systematic infection, with rigors, fevers, sweats, rapid wasting, and, what is of far greater importance, the setting up, by means of emboli disseminated by parts already affected, of foci of similar dis- ease at a distance in the same, or in the opposite lung, are liable to take place. This is a mode of ingravescence which undoubtedly prevails, and, indeed, forms the principal features of most, if not all, cases of advanced phthisis ; and that the study of it forms the surest guide to successful treatment is, I think, no isolated opinion. The patient, although he may have every possible attention, cannot possibly derive the benefit which would, under more favorable circum- stances, be secured him so long as suppurating cavities containing septic pus are allowed to exist in the lungs, constantly exercising their perni- cious influence on the blood. ^' The surgeon^ with the resources at present 80 Puhnonarj/ Consumption under his command, lias no difficulty in obviating the occurrence of the above untoward contingen- cies ; and it will be my endeavour to show with what success I have been able to employ in the treatment of cavities in the lungs the means all but infallible in their application to external wounds. " It is a principle of treatment now universally recognised, that an abscess must be freed of its contents, kept empty by free drainage, and insu- lated or protected by antiseptic media from the septic influence of the surrounding atmosphere. These conditions being duly fulfilled, experience amply proves that any constitutional disturbance which has already appeared may very well be allowed to take care of itself, as under these cir- cumstances the local lesion will quickly cease to be anything more than a local lesion. " Free drainages from abscesses or cavities in the lungs is undoubtedly in by far the majority of instances not to be secured ; we know that they owe their most characteristic features of being rife sources of systemic infection, or septi- caemia, to the fact of their contents being re- tained while exposed to the septic influence of the air breathed ; and the partial discharge that does take place is but periodically produced by the compression which the lung experiences during coughing — a method of evacuation that suggests to one^s mind an attempt being made to cure the abscess by squeezing out the contents instead of providing, in addition to antiseptic protection, an efficient opening for a spontaneous and thorough drainage. For this reason, it will appear that all the conditions favorable to the complete carrying out of the Listerian method do not ordinarily exist here. One essential to the system — free drainage — we have seen to be Its Antisej)tic Treatment 81 frequently absent ; but while admitting tlie full significance of this fact we are, I think, bound to confess that the condition which is applicable is scarcely the least important of the two. No one, for instance, would deny antiseptic protection to a suppurating cavity because he was unable to empty it ; and simply for that reason would not a suppuration cavity in such a state, and with the risk of septicemia which especially attaches to such a state, rather call for this guard against by far the worst accident that can arise ? / ^'^ From the time when, more than two years / ago, I first attempted to bring the antiseptic > system to bear upon chronic phthisis, I have be- come more and more convinced that it is the only treatment which promises to fulfil all the requirements of these cases. "In the ordinary application of Professor Lister^s system the fact is recognised that carbolic acid, except to rid the wound in the first instance of septic germs, is not a good applica- tion. So far as the raw surface is concerned, it is irritating ; and to counteract this drawback a piece of prepared oiled silk as a protective is in- variably placed underneath the carboHsed pad. To a certain extent, air circulates through the covering of gauze ; and air purified by the filtra- tion which necessarily takes place is, therefore, in constant contact with the surface of the wound, and with the discharge which lubricates that surface. Have we not, I will ask, an exact parallel to this in the application of the same principle to the lungs ? I believe we have, even to the preliminary cleansing of the foul surface alluded to. Eespiration ensures the circulation of air to perfection; while^. as it passes through the re- 82 Pulmonary Consumption spirator^ it is not only purified, but it also becomes impregnated with a certain amount of the car- bolic vapour given off by the gauze. The quan- tity inhaled of this vapour may, for any single inspiration, be quite insignificant ; but when multiplied by the number of inspirations made in only a few hours, it does not seem difficult to believe that the amount would soon be sufficient to accomplish the disinfection of all the purulent cavities already in communication with bronchial tubes. That this end is actually gained, and even rapidly gained, my experience certainly tends to prove ; and I find moreover that, on the disap- pearance of odour, it requires subsequently the presence of very little carbolic acid on the gauze to keep the expectoration permanently free from fcetor, as though the ulcerated surfaces having been rendered aseptic, all that remained to be done was to ensure against their reinfection by the inspiration of only pure air, and also to obviate the risk of creating irritation l)y breath- ing that which contains but a minimum quantity of suspended carbolic vapour. " So far as my observations go, they also tend to show that fetid pus from the lungs is not so rich in bacteria as putrid matter from some other regions ; and this may be the explanation of the facility with which odour disappears under this mode of treatment : there being but few organ- isms to kill, the work is soon completed. ^^ Three of the six slides which I show to-day have been prepared from patients before, and the remainder after, treatment. You will observe that while they all contain micrococci, only tlie former show rod-hacteria. I have only been able to get these few specimens ready in time : that they must not be allowed to lend any support to Its Antiseptic Treatment 83 the clinical facts must be evident. The matter in eacli case was taken from recent expectora- tion, which was immediately dried, stained with methyl-aniline violet, and mounted in Canada balsam. Although the power employed — an eighth objective — is a comparatively low one for the purpose, yet with the aid of Abbess condenser the micro-organisms are very fairly shown. " With regard to the mechanism adopted, the following is a description of the kind of respi- rator I find to answer best. Over a wire frame- work, shaped like a respirator, made to cover both the mouth and nose, two or more layers of ordinary antiseptic gauze are stretched; along the concavity inside a narrow strip of sponge is placed, and, finally, the whole is fitted accurately to the face by a circumferential pad made of gutta-percha tissue, stuffed with cotton wool, or folded lint, which is more manageable. Anti- septic gauze in the dry state gives off a vapour of carbolic acid. Bearing in mind, however, the large amount of air that would in ordinary breathing pass to and fro, it will be very evident that this comparatively small piece of gauze must soon become exhausted, and require re- charging ; this is secured by the whole being dipped every half hour or so at first, afterwards less frequently, into a watery solution of carbolic acid of the strength of 1 in 40 ; the gauze is, besides, renewed every two or three days. These respirators or dressings are worn as constantly as possible ; in fact, the only occasions on which their temporary removal is permitted are during a meal, for the purpose of expectorating, and for that of dipping. Taking into account the apparent inconvenience, it is a little surprising 84 Fuhnonary Consumjyfion vrith. what readiness even hospital patients fall into the way of wearing these appliances with the greatest constancy both day and night. It is quite the exception to hear complaints of any kind. " The following cases present a fair example of the results I have met with : '' Case 1.— April 3rd, 1879. J. 0—, sailor, ret. 19, had three months' illness, originating in exposure. There was consolidation and a cavity affecting the left apex. He had purulent bron- chitis throughout both lungs, very great emaci- ation, rigors, sweating, and dian-lioea. The tem})erature was 10-1° at night, and 99° in the morning. Expectoration amounted to thirty ounces in the twenty-four hours — purulent, and very offensive. On the seventh day from the commencement of the treatment, the cough and symptoms were generally mucli improved; ex- pectoration ten ounces, and free from smell. At the end of four months he left the hospital for his native country (Norway) in much improved health ; expectoration two to three ounces, mucoid. "Case 9.— December 8th, 1879. J. P— , joiner, a3t. 43, had had four months' illness, commencing with cough and repeated attacks of lia3moptysis; emaciation followed, with rigors and night sweats. Percussion over the right apex showed dulness to exist as far down as the fourth rib ; a large cavity was also present here ; coarse crepitation, with increased vocal resonance at the right base. The left lung was fairly healthy. The expectoration was five ounces in the twenty-four hours, nummular. The bowels were mostly loose; temperature 100°. He had frequent attacks of pain in the right chest. Its Antiseptic Treatment 85 ^^ December 1 8 th.— Weight 9 st. U^ lb. He tad slig'lit haemoptysis during the night. ^^ January 8th.— Weight, 10 st. 6 lb. '' 16th.— 10 St. 7 lb. " 33rd.— 10 St. 91b. '' March 6th.— Weight, 11 st. 6 lb. ; so far as I could gather, his normal weight. '' This patient was discharged cured on March 8th, 1880. I have seen him up to the last three weeks ; he continues free from relapse^ though the cavity still exists, and he follows his employ- ment. '' Case 3.— November 7th, 1880. W. C— , a labourer, set. 19 j height 6 ft. 2 in., weight 8 st. 11 lb., slight build; five months' illness. He first had a cough and pain in the chest ; after- wards thick expectoration, occasional attacks of hemoptysis, great wasting, sweating, &c. The thorax was flattened on the left side above; respiration here was cavernous, and accompanied by gurgling ; pectoriloquy and cracked-pot per- cussion note were marked ; dulness extended all over the left front and upper third behind. The left lung contained several cavities. The heart was displaced upwards and to the left. There was puerile breathing on the right side. Expectoration amounted to about six ounces, nummular, and occasionally very offensive. Tem- perature 104° at night, and sometimes a little higher. He was ordered a carbolised respirator. " He left the hospital, after four months' treat- ment, for the Convalescent Institution at Wool- ton. Expectoration was mucoid, a few drachms only j cavities dry. He had not had haemoptysis for a month, and then only a slight tinge ; weight 2 st. 6 lb. He was able to go about as usual. One day, a month ago, this patient called upon 86 Pulmonary Consumption me, when I learnt that lie had remained pretty- free from cough, and was still improving. The condition of his chest seemed to be precisely what it was on his first leaving us." Mr Eobert Hamilton, Senior Surgeon to the Royal Southern Hospital, Liverpool, referring to Dr W. Williams's communication, observes : — '^ The inhalation of carbolic acid vapour, in the continuous mode suggested by my colleague, meets a difficulty which I have always felt has stood in the way of all previous methods of con- veying drugs to the lungs. He utilises the car- bolic gauze of Lister, and merely saturates it occasionally with an aqueous solution of the acid. " The old forms of inhalers, as well as the modern spray producers, necessitate a quantity of aqueous vapour being introduced into the bronchial tubes and into the air colls, much in excess of what is ever naturally taken in. There is a positive evil in this, such vapour condensing, and being then deposited on the delicate epithelial lining of air tubes and cells, interferes with the osmic movements which respiration induces. That respiration is practically impeded is sho-svQ by the coughing and the suffocating sensation produced, so that a very few minutes' use, at one time, of inhalers and vaporisers is all that is possible. The suspension put to natural pro- cessess is apt to be overlooked in our eagerness to get the drug brought into actual contact vnih diseased lung tissue ; and the evil produced by the water is far more than commensurate with the good that the drug can do. " The mode of conveyance of the minute par- ticles of carbolic acid by Dr Williams's respirator is not open to the above objection : and as the Its Antiseptic Treatment 87 drug itself has been tested in surgical practice, and found to be of invaluable service in the treatment of all suppurating surfaces wbich are accessible, it is fair to infer that, if it can be applied per se to the lungs, it may be equally- efficacious in checking the growth and develop- ment of morbific germs in them, and thus allow tissue to be reconstructed. " I have treated several cases of phthisis in the way suggested by Dr Williams with good results. The almost constant wearing of the respirator whilst under treatment may be an obstacle to the rapid adoption of the method ; but it is, as he says, astonishing how soon the patients become accustomed to the wearing of them. They are only one degree more unsightly that the respirators which many people wear out of doors without hesitation. Further improve- ment in their shape and appearance is sure to follow if their value be established.^' And in a further communication which ap- peared in the same number of the ' Brit. Med. Journ.' as my lecture, Mr Hamilton makes the following interesting remarks : — " In consump- tion we have a predisposing condition of the lungs, which may be more precisely described as a state of lung development, that is, of cell- growth, defective in one or more points, either inherited or the result of insufficient surrounding sanitary conditions, and thus not fully commen- surate for the work they are called to maintain, or to contend against the malign influences which at times are brought to bear upon them. Now what are these malign influences ? They come to the lungs directly through the medium of the atmosphere. '^ Griving these malign influences another name 8S Pulmonary Consumption and calling tliem germs, and surely we may do so with the knowledge we have acquired on the subject_, we are brought at once to reason on their modus ojjerandi, when they impinge upon a soil prepared for them, in other words in a receptive condition, whether in the lungs or elsewhere, and our reason is founded on analogy. How do another set of germs act when they alight upon a surface freely exposed to them, where formative material on a large scale is being elaborated, as on the stump of a recently amputated limb, or the raw surface of a burn. The action of these germs is to arrest the vital processes of repair, not in its earliest stage, but somewhere along the line just where cell-gi'owth is passing from the general to the particular to become a special form of tissue, and the blood-corpuscle, which was about to be — or had recently been — laid down as an atom in the building up of cellular tissue or connective tissue, is turned aside into the pus- corpuscle, which is, in other words, but a blood- corpuscle deprived of its own \4tality and breaking np after it had undergone certain trans- formations through the action of the sporule of a fungus upon it. " Before applying this reasoning to what takes place in the lungs in phthisis, we must allow the truth of another of the theories which is now pretty well established as a fact vriih regard to germs, that is, the specific qualities which so many of them possess. It would take up too much space to give all the reasons in favour of this view, but if it is granted, and how we can account for diphtheria, typhoid, or cholera, on any other supposition it is difiicult to see, then the resemblance of the action of germs in the lungs to the action of germs on the fauces^ in Its Antiseptic Treatment 89 dipMheria^ for instance^ may be thus traced. The air cells of the lungs and the finer twigs of the bronchial tubes weakened by long exposure to a vitiated atmosphere^ or not originally in all parts well developed from hereditary causes^ receive at some time an air charged with specific germs, and these latter alight on the cell-walls, and put a stop to the progressive changes taking place in those blood- corpuscles with which they there come in contact, and thus arrest to a large extent is put to the perfecting of new material, whilst yet the old and effete continue to disintegrate and pass away. Healthy formative material becomes for a time the nidus out of which the sporules of a vegetable organism multiply. " (The terms " blood-corpuscles " and '"'' forma- tive material '^ are here used indifferently, for it is impossible to define at what stage, from the moment of the blood-corpuscles escaping the vessels to their changed condition as germinal matter, the micrococci of a fungus act upon them.) • " But it is not the ordinary non-specific germ such as we meet with in every suppurating sur- face, but the particular one which has character- istic properties of its own which is the producer of phthisis. When it finds an entrance and a feeding ground prepared for it, and above all certain atmospheric conditions of temperature and moisture, it rapidly converts to its own growth and material development the formative material which the blood has brought to the walls of the air cells. The development of the tubercular germ proceeds in this way to the stage of reproduction and there stops. The parent germ then loses its vitality and disinte- grates, and it is this disintegrated germinal 90 Pulmonary Consumption matter that constitutes the purulent expectora- tion of phtliisical patients. It has, however, left its seed behind it, to go through the like stages at the expense of normal tissue. " (That certain conditions of temperature and moisture are necessary for the development of germ-life has been long known ; but it is only lately that we have arrived at the conclusion that each of the specific germs has a temperature and moisture of its own, without which it cannot burst into active life. This holds true of the phthisis germ, as well as of the diphtheria and cholera germ.) '^ Looking at the origin and course of phthisis from the above point of view, how should we plan our treatment ? Firstly, we want a weapon which shall be quickly fatal to our enemy ; and, secondly, we must bring it into direct contact with the foe. These are the two problems we have to solve, and they are surrounded with great difficulties. May we say at least that we are in the right track at last ? We are experimenting on the best method of reaching the lungs directly through the trachea, and we are casting about to find the best germi- cides. These are the specific weapons of our warfare. " Most medicines can be triturated or in some way reduced into particles lighter than air, and thus become capable of inhalation if brought into close proximity with the entrances to the air passages. I firmly believe that the continuous inhalation of an air moderately impregnated with some, perhaps yet unknown, vegetable or mineral product will ultimately prove the cure for phthisis.^' Dr J. G. Sinclair Coghill, Physician to the Royal National Hospital for Consumption, Vent- Its Antiseptic Treatment 91 nor, writes tlius ('Brit. Med. Journ.') on ''Anti- septic Inhalation in Pulmonary Affections. ^^ " Antiseptic inhalation is evidently and deser- vedly coming into notice as a valuable aid in the treatment of a large and important class of dis- eases ; and I believe that it is capable of much greater development and extension, and that it will ultimately play a distinguished role in the pulmonary therapeutics of the future. It must, however, be admitted that it has not been adopted as rapidly or as generally as the undoubted indi- cations for its employment would seem to justify. It is somewhat difficult to account for this tardy recognition of means that have been found so valuable in the hands of those physicians who have put it to the test of long and extensive trial. ''The propriety of attacking disease in the looal seats of its activity, in addition to treating the constitutional conditions which accompany not necessarily in the relation of cause and effect — the local lesion, is one which, in the present state of pathological knowledge, hardly admits of ques- tion. If this be accepted as a leading principle in the therapeutics of disease in general, how much more readily should its application be recognised in the treatment of affections like those included in the common term of phthisis, where the relation of the tissue-lesion to the constitutional morbid state is not accidental or variable, as it is in many other maladies, but essential and continuous ; and where, conse- quently, their reactions on each other are of primary importance. In the advanced progressive forms of tubercular phthisis, the fever which accompanies the breaking down of the infiltrated and disintegrated pulmonary tissue has long been recognised as an infectious pyrexia, directly 92 Fuhnonary Consumption resulting from tlie absorption of the septic materials from the seat of this retrogacle meta- morphosis. In pneumonic or secondary phthisis, also^ we have a suppm-ative process set up as a retrogade sequel to the original inflammation of the lung-tissue, ending in an excavation, which is in all essential conditions analogous to a sur- gical abscess. The natural progi-ess of the two local states — the excavation in the lung and the external abscess, as well as their influence on the general condition — are identical. In both, we have a localised suppurative process, continually invading and breaking down the adjacent sound tissues, exhausting the patient in proportion to the amount of pus thus secreted, forming active centres of disseminating infection, and lowering the powers of the patient by the resulting febrile movement, thus still further diminishing his chances of recovery. But this morbid process is capable of arrest — nay, as the great Laennec first pointed out, and as all our post-mortem experience amply corroljorates — nature herself is equal to the task ; but it is none the less the duty of the physician to come to her aid with all the means in his power. Why, then, should we, as physicians, not recognise that, in all suppurative processes in the lungs, as evidenced by purulent expectora- tion, we have local conditions presented, calling as loudly for direct antiseptic medication as the wounds, abscesses, and ulcerations which belong to the produce of our surgical brethren ? But, while the external or surgical employment of antiseptics is an easy and simple process, and its results more immediately apparent, it is very different when we have to introduce our remedies into the interior of the body through an intricate Its Antiseptic Treatment 93 and jealously guarded portal^ as we liave in tlie case of tlie lungs. That the comparative accessi- bility^ however^ of the lungs^ through the glottis_, should have^ even in the earliest times_, suggested direct medication^ is not surprising; but it is^ indeed_, strange that inhalation^ or taking advan- tage of the respiratory act for this purpose_, which dates from the days of the Father of Medicine himself^ should only have received^ until com- paratively recent times^ but occasional and rare employment. That its importance was from time to time recognised there is abundant evidence in the works of the older physicians ; and that this importance was even occasionally exaggerated by them is shown by the statement of the celebrated Italian physician, Mascagni, who says : ^ If ever a specific should be devised against con sumption, it would be such as to be introduced into the organism through the windpipe.' A succession of celebrated names in more modern times, too numerous to mention, is associated with the subject of pulmonary medication by inhaling; and a great variety of apparatus, more or less elaborate, have been introduced from time to time for the purpose. There are, however, great objections, apart from the almost impossibility of their penetrating deeply enough into the tissue of the lungs, to the inhalation of dry powders, however finely divided, on account of their mechanically irritating eif ect on the often already morbidly sensitive laryngeal and bronchial surfaces. Non- volatile fluids, again, can only be very partial in their distribution; and, if inhaled at high temperature, must further render the upper reaches of the respiratory tract sodden, and increasingly sensitive to changes of temperature. Careful observation of the action and effects of 94 Pulmonary Consumption this steaming process in affections of tlie lungs has convinced me that it is not only inefficient, but, in every respect, positively injurious. It relaxes the tissues with which the vapom' comes into contact ; it encoui'ages suppuration where the ulcerative process has begun, and it tends, therefore, to increase expectoration and cough, and consequently the distress and exhaustion of I the patient. The inhalation of hot moist vapour, / indeed, is so repugnant to the respiratory tract ■ that but a small quantity of the medicated material can penetrate sufficiently into the pul- monary tissue to be of use. The immediately subsequent effects are also not unattended with risk, from the exposure of the air passages to air of a lower temperature after hot inhalation. However beneficial, then, in laryngeal affections (and we are all familiar enough with its value in such) the inhalation of dry powders or of pul- verised fluids in the form of spray, either cold or hot, may be, they cannot be regarded seriously in connection with the treatment of suppurative processes within the lung itself. " It is now more than five years since I became strongly impressed with the important bearings of Lister's teaching on the local treatment of phthisis; and, in working out the idea of anti- septic inhalation, the considerations above referred to suggested the plan of adopting the principle of the old-fashioned, and now happily almost obsolete, respirator for the purpose — selecting a volatile medium for the antiseptic materials, and employing the breath in the alternate acts of inspiration and expiration as their vehicle. These so-called antiseptic inhalers or respirators were first made to my order by a local tradesman in common tin, of the exact shape and size of the Its Antiseptic Treatment 95 ordinary metal respirator. These were, however, somewhat primitive in style ; and they have since been extensively made by Messrs. Maw and Son in a more elaborate and convenient fashion/^ The respirator inhaler Dr. Ooghill describes does not cover the nose but only the mouth ; this I do not think advisable, as the majority of persons breathe through the nose, and indeed, it is desirable they should do so; and especially, when worn during sleep, it is better that the nose should be covered as well as the mouth. He considers the best times for inhalation an hour or so before going to sleep at night and after the morning expectorations — which leaves the suppurating surface or cavity dry to be acted upon — disinfected, so to speak, by the antiseptic vapour. Many of his patients, however, have worn the respirator almost continuously day and night. He lays great stress on inspiring through the mouth and expiring through the nose in order to secure a complete circulation of the medicated air. But this process would prove very tiring if attempted continuously. Occasionally carried out for a few minutes at a time it is a good plan. He goes on to say : ^' After many trials of the now formidable list of antiseptics, I find that carboHc acid, creasote, and iodine, in combination with sulphuric ether and rectified spirits of wine, are the most effi- cacious and satisfactory. Of the three antiseptic agents I chiefly use I find iodine most useful in the second stage of phthisis, when the expecto- ration is passing from the glairy into purulent character. I use a tincture, for inhaling pur- poses, made with sulphuric ether instead of spirits of wine ; and this ethereal solution has a singularly soothing effect on the cough and 96 Pulmonary Consumption pulmonary irritation. In combination also witH carbolic acid, as carbolised iodine or iodide phenol, it is extremely useful in tlie pm-ulent expectoration accompanying the resolution of pneumonia, both catarrhal and croupous. In the stage of excavation, whether tubercular or pneu- monic, the combination of iodine with carbolic acid and creasote is most potent. The acid seems to have the greater influence in checking the amount and purulent nature of the sputa ; while creasote acts mure as a sedative in the cough, ap])arently by reducing the irritability of the pulmonary tissues. The addition, also, of varying propor- tions of sulphuric ether and cliloroform greatly Mssists in soothing and allaying irritation. These combinations also act frequently like a charm in the profuse expectoration of ])uru]ent bronchitis, as also in bronchial asthma. I have also noticed that patients, while using this form of inhalation, frequently experience great relief from the aches and ilying muscular pains which often occasion much distress in the advanced stages of phthisis." The following is a formula which he suggests : — Tincturas lodi Etherealis, Acidi Carbolici aa 5ij ; Creasoti vel Thymoli 53 ; Spiritus Vini Rect. ad 5J ; to which he adds chloroform or sulphuric ether if the cough or breathing is troublesome. After quoting several cases in which great improvement followed the use of antiseptic inhalations, he concludes thus : — " These cases have been taken at random, and are by no means those in which we have seen the best results from antiseptic inhalation on the amount of sputa. " To be able also by this means to dispense, to a great extent, with cough mixtures, ct hoc genus ovine, is in itself no small advantage in the treat- ment of a class of diseases in which it is so Its Antiseptic Treatment 97 necessary to preserve,, if possible^ the appetite^ with the digestive and assimilative processes undisturbed and intact. If there be sputa col- lected in the lungs there must be cough; the rationale of treatment then is to prevent, if possible, the material from being- secreted which demands cough for its expulsion. To attempt to stifle a cough under such conditions by sedatives is erroneous in theory and most dangerous in practice, apart from the other mischievous effects of preparations to which I have already referred. ^^I may say here, that my later and wider experience of this form of antiseptic inhalation in phthisis laryngea, if such a disease exists j^^r se, of which 1 have grave doubts, or, as I would prefer putting it, in phthisis complicated with affection of the larynx, has not been so favorable as my earlier cases led me to expect. It seems to have too drying or astringent an effect ; and, in all such cases, a warm moist vehicle is pre- ferable for the antiseptic material, if such be indicated. '^ I have now, for nearly five years, employed antiseptic inhalation as a regular part of the treatment in all lung affections characterised by purulent expectoration, both in my private prac- tice and in the Royal National Hospital for Consumption. I find that all patients take to it very readily, become very speedily impressed with the amount of relief it affords, and inclined to continue it on their own account, without the encouragement and suggestion which many other details of treatment often require. Any difficulty on the score of odour is easily met in the great variety of antiseptic materials from which to choose. I have received a great many communi- cations from members of the profession, many 7 98 Pulmonary Consumption of tliem in large practice among jxi/frnm^^T."?, expressing tlieir high opinion of its vahie. I am sure the results of this auxiliary to general treatment, in appropriate cases, will be found most encouraorinor." The following note on the " Antiseptic Treat- ment of Lung Diseases'' is by Dr J. Carrick Murray, Physician to the Northern Counties Hospital for Diseases of the Chest, and appeared in the ' British Medical Journal,' July 23rd, 1881. " On May 31st, the medical officers of the Northern Counties Hospital for Diseases of the Chest received, per order, a number of Dr Coghill's inhalers, made by Messrs. Maw, Son, and Thompson ; also some of the inhaling mixtm^e recommended by Dr Coghill. The inlialors have been in diligent use since, with satisfactory results, the amount of sputa having in each case lessened. Patients who commenced to cough and spit at four o'clock in the morning can already lie until rising time without coughing. Some of them complain that they do not get the phlegm up so easily as before ; but I am of opinion that the sufferers continue to cough more from long habit than from real necessity. I find that our inhaling patients observe the strong smell of the antiseptic in their sputa, and that half an hour twice a day appears sufficient to use the inhaler ; also that twenty minims dropped on at once are enough for two days' use. More has been found too irritating to the glottis in the cases in which we have used it. "I prefer surgecn's lint doubled to cotton wool or tow, and had n^ade for me an inhaler more elegant, a little, that Dr Coghill's. It fastens by a broad india-rubber band at the back of the neck ; this does not hurt th(.« ears. The outer Its Antiseptic Treatment 99 perforated plate is Mnged, and therefore more easily manipulated. The makers are Messrs. Henry Aitken and Co., Bisliopliill_, York; the price five shillings each. "My conviction is that medicated inhalation might be used with benefit in more diseases than Dr Coghill enumerates; e.g. in hay fever_, in- fluenza_, incipient phthisis, or where a husband sleeps with a consumptive wife, or vice versa, haemoptysis between attacks ; chronic bronchitis with profuse, inspissated, or difficult expectora- tion; asthma from loss of lung tissue; so-called laryngeal phthisis ; circumscribed gangrene of lung, &c.^^ Dr Battersbury of Wimborne, Minster, con- tributes the following testimony {' Brit. Med. Journ.,^ October 21 nd, 1881) in favour of the " Antiseptic Treatment of Lung Diseases : '^ " I do not know whether it is generally known that the treatment of phthisis and other lung diseases by the inhalation of antiseptic solutions is not confined to England. My attention was first called to this method of treatment last autumn by a patient of mine suffering from phthisis, who had found great relief from the inhalation of a solution of carbolic acid through an inhaler, recommended to him by Dr von Messing, of Meran, in the Southern Tyrol. The inhaler is made of German silver, and is shaped like an ordinary respirator, but has a cavity enclosed between the outer surface and an inner plate ; both plates are perforated, and the outer one can be raised at pleasure for the pur- pose of placing in the cavity cotton wool saturated with the drug required for inhalation. The instrument is called inhalations-respirator, and is made by W. von Pernwerth of Meran ; it 100 Pulmonary Consumption appears to resemble almost exactly tlie respirator recommended by Dr Cogliill^ and figured in the journal of May 28tli. My patient wrote, asking hoTv these inhalers could be obtained, to Dr von Messing, and he very kindly sent me one ; and in his letter to me, dated September 6th, 1880, says : — ' I have heard of your desire to try the inhaler I am using for my patients, and I have ordered one to be sent to you. The value is a trifle and I beg you to accept it from me. I have been using it for about five years, and I am perfectly satisfied with the results. I generally use a mixture of twenty parts of carbolic acid to 100 of water, to be well shaken, and twenty to thirty drops poured out on the cotton. I advise my patients to inhale through the ajiparatus, and exhale through the nose, three to four times a day, for ten minutes at first and then for an hour ; in this last case wetting the cotton two or three times. In cases of bronchitis it affords great relief and shortens the process ; also in cases of whooping-cough. In consumption it lessens the fever by absorption of the carbolic acid, and faci- litates the expectoration. In chronic bronchitis with bronchiectasiae, it does away with the smeU and disinfects the air passages. Violent spas- modic cough, above all at night, is immediately checked by the addition of fifteen to twenty di-ops of chloroform.' " Since receiving this letter I have tried the inhaler with very satisfactory results. In my last case, a case of phthisical consolidation in- volving a considerable portion of the left lung, and attended with a hectic and purulent expecto- ration, the weight increased in one month from 7 St. 1 lb. to 8 st. 1 lb., during the use of the antiseptic inhalation ; the fever entirely disap- Its Antiseptic Treatment 101 peared^ and the cough and expectoration almost entirely. Now, unfortunately, a fresh patch of inflammation has occurred, which has brought back the fever and cough, but the temporary benefit was well worth having. ''In one case I substituted the oil of Pinus syl- vestris for the carbolic acid with very good result, and should be inclined to try it again in cases of obstinate chronic bronchitis. ^^ Dr McAldowie contributes a note {' Brit. Med. Journ.,' October 22nd, 1881) on ''The Inhalation of Terebene in Phthisis. ^^ " The antiseptic treatment of phthisis has been so prominently brought before the profession of late, and is a subject of so much importance, that no excuse is necessary for the present brief com- munication. ^ " For upwards of four years, antiseptic inhala- tion has been one of the principal remedies em- ployed by me in the treatment of phthisis and certain other lung diseases. The vapours of creasote, carbolic acid, iodine, and other anti- septics, have been used in more than 400 cases, occurring both in hos'^ital and in private practice. During the past two and a half years I have adopted terebene as a remedy in preference to the antiseptics mentioned above. I have used it in upwards of 200 cases of consumption, bron- chiectasis, chronic bronchitis, and other pulmo- nary complaints characterised by profuse purulent expectoration. It is very valuable, and its vapour possesses antiseptic qualities equal to any of the others. It has also a sedative action, allaying the cough and irritation, and is almost invariably preferred by the patients themselves to any of the other antiseptic inhalations, on account of its agreeable and fragrant pine-wood f ] 02 Fu hnonary Consume t Ion odour. In cases where tlie expectoration is copious and fetid it is advisable to administer it internally in addition to tlie inhalation of its vapour. Given in doses of five minims, either in emulsion or with carbonate of magnesia^ it acts as an aromatic expectorant. "The researches of Cohnheim and others have shown how liable the lymph-folHcles of the intes- tine are to tubercular infection during the pro- gress of pulmonary consumption, in consequence of the sputa being swallowed by the patient. Administered internally, terebine destroys the virus and lessens the risk of intestinal infection." Mr Wilson Hope, of Petworth, recommends the following simple method {' Brit. Med. Journ./ July l(3th, 1881) of inhalation in phthisis. " Cut from an ordinary roll of wadding two pieces large enough to cover the nose and mouth. A diamond-shape answers very well. Now, remove the skin-like substance which coats the pieces ; put them together, and ft)ld them in a piece of thin muslin, to the ends of which ribbons may be sewn, and your inhaler is made. I have used it for a couple of years, directing the patient to drop five or ten drops of creasote between the layers of wadding, fold it in the muslin, and to wear it for half an hour two or three times a day, or sometimes through the night. It is well to tell the patient to have two or three of them, as the moisture from the breath spoils the inhaler after a time. There are cases where, merely as a filter, it may be useful; and using it with creasote, I am convinced, is useful in many cases of phthisis, in some cases of chronic bronchitis, and in some cases of diffuse capillary bronchitis in young people." i)r Robert Saundby, Assistant Physician to Its Antisejotic Treatment 103 to the General Hospital, Birmingliam, writing in tlie 'Brit. Med. Journ' for December 28tli, 1881, and giving the preference, as I do, to tlie naso- oral form of respirator, observes : '"''As the use of antiseptic inhalations has proved useful in phthisis in my own practice, and is supported by those who, like my friend. Dr. Sinclair Coghill, have special opportunities of estimating the value of treatment in this malady, I think it is important that we should try to im- prove the necessary apparatus as far as possible. I have been using for the last year an inhalation- respirator made for me by Mr Best, instrument- maker to the Greneral Hospital, of Sumner Lane, Birmingham. The naso-oral form which I have employed almost exclusively is very well shaped, is light, comfortable, well ventilated, and worn by patients without complaint of inconvenience or fatigue. The antiseptic I have found most suitable is the oil of eucalyptus, in doses of five to ten drops pom-ed on the flax twice daily. ^'I do not claim, nor do I think we can rationally expect, to cure any cases by them ; but many of my patients have found great relief from their use, mainly in checking purulent secretion and allaying cough.^' Mr. Taylor, of Guildford, in the following* interesting letter (Brit. Med. Journ.,' November 6th, 1881) questions the value of the "respirator,^' but Mr. Taylor^ s method, while excellent for diffusing an antiseptic vapour through the sick room, is useless and inapplicable in the majority of cases where a respirator can be worn. " As some of your correspondents are asserting their claims to priority in the treatment of lung disease by antiseptic inhalations, it may not be amiss to recall the fact that this treatment, in 104 Pulmonary Cons^imj^fion one form or tlie other, is really ancient. We can see tliat tlie germ of the idea was in the mind of medical wi-iters in the sixteenth and seventeenth centuries, when they directed their fumigations with various balsamics, ' which is to be done by throwing the ingredients on red coals, and receiv- ing the fumes through a proper tube directed to the windpipe/ It was further developed fifty years since by Garmul, Scudamore, and Criehton, who severally recommended the inhalation of chlorine, iodine, and tar-vapours; while two of the substances now employed, namely creasote and the terebinthinates, were specially mentioned by Dr. Copland in his ' Medical Dictionary ' as valuable remedies in phthisis and chronic bron- chitis. " The only novelty in the modern procedure is the use of a respirator as a medium instead of an inlialer, and I (piestion if it be so great an improvement. My own experience leads me to prefer having the vapour of the tbnigs in cpiestion diffused in the air of the room by means of a bronchitis-kettle, the solution being dropped from time to time on a small piece of sponge placed within the mouth of the steam-pipe. The vapour being thus constantly inhaled, and in a state of greater dilution than when a respirator is used, aifords equal benefit, and is more agree- able to the patient. It was precisely this form of inhalation that Dr. Copland recommended in his article on ' Tubercular Consumption,' pub- lished more than twenty years ago. But, setting aside the claim of originality, it is only fair to admit that those who have revived the use of antiseptic inhalations deserve great credit for calling attention anew to a remedy of unquestion- able value." Its Antiseptic Treatment 105 Dr Snow^ of Bournemoutli (^ Brit. Med. Jonrn.'' Feb. 18, 1882), testifies to the value of tlie ^^ Antiseptic Treatment of Lung-Disease.'^ ^' For several years I have largely employed dry antiseptic inlialation in phtliisis, as an adjunct to general constitutional measures. The treat- ' ment I believe to be useful, but every case of improvement must not be attributed to the inbala- / tion. The most suitable cases are those attended / with profuse expectoration, especially when soft- / / ening has commenced or cavities formed. / / " The effect is sedative ; in a large proportion of cases the expectoration diminishes in quantity and improves in quality, cough becomes less frequent and severe, and sounder sleep is enjoyed, enabling the patient to dispense with objection- able cough medicines. The same effects may be noted when the general progress of the lung- / affection is not arrested. I have never seen / haemoptysis produced by its use. As a respirator, I prefer a simple tin-box, perforated and shaped to the mouth, introduced by Dr Roberts, of Man- [ Chester. The patient is directed to place a few drops of the carbolic solution on the tow in the box, and to use the respirator for ten minutes after the morning cough, and at intervals during the day. Many habitually use it for hours while reading. If dryness arid irritation of the mouth aud throat be caused by the carbolic inhalation, other remedies may be substituted — such as terebene and eucalyptus oil. ^^ To produce an aseptic atmosphere the constant use of the vapour of carbolic acid in the sick room has been recommended; few can be induced to submit to this treatment, which I cannot recommend." Dr Hunter Mackenzie, Lecturer on Diseases of 106 Pulmonary Consumption tlie Tliroat, School of Medicine, Edinbnrgli, who has devised an excellent naso-oral respirator- inhaler writes as follows {' Brit. Med. Journ.' Jan. 3, 1880), "On the Antiseptic Treatment of Phthisis Pulmonalis. " Ha^anof some months aofo found bacteric . . . organisms in the sputum of a phthisical patient, it occurred to me whether their presence might be associated with a process of blood-poisoning from the decomposition and putrefaction of the pro- ducts of iutlammation in the pulmonary bron- chi and air-cells. I accordingly experimented with various antiseptic inhalations of different strengths, and latterly have been using pure carbolic acid or creasote. I have had made, by Mr Young of this city, a respirator somewhat resembling that of Dr Roberts of Manchester, but which covers both mouth and nose, and has a double breathing-chamber f6r containing pieces of sponge saturated with a strong carbolic or creasote solution. The sponge is covered 'vvith a light layer of cotton wool, to act as an additional filter and prevent the outward evaporation of the antiseptic. The respirator is worn as con- tinuouf^bj as j^ossihle both by night and day. By this means, not only is the respired air purified, but the volatile antiseptic is dra^^^l in with each inspiration and thoroughly permeates the lungs. A renewed application of the fluid is made night and morning by means of a camel-hair brush. I have had no difficulty in inducing even young children to wear the respirator for lengthened periods, the only drawback having been a ten- dency to chafing of the skin by the continuous pressure of the borders of the instrument. This, however, has been overcome by having the instrument bordered with soft sponge^ which Its Antiseptic Treatment 107 answers admirably. My experience of tliis method of treatment lias as yet been limited^ and confined to cases in tlieir first stage. Tbe results obtained^ however^ liave been so satisfactory as to justify me in discarding tlie internal adminis- tration of tbe various specifics and continuing tbe inhalations alone. It is_, of course, impossible for me to say that cases of phthisis are absolutely cured by this system of treatment ; but the dis- tressing symptoms of phthisis — the night sweats, cough, and impaired appetite — have been so ameliorated as to justify me in publishing this pre- liminary note, reserving for a future communica- tion further details of the method and notes of the cases tried by it." NOTES ON" SOME VAPOEISABLE ANTISEPTIC SUBSTANCES APPLICABLE TO THE TREATMENT OF PHTHISIS Sulphur and Sulphurous Acid The use of sulphur vapour and of a spray of sulphurous acid as an antiseptic in phthisis and certain other diseases^ was warmly commended some years ago by Dr Dewar, of Kirkculdy. One of his methods was to sprinkle flour of sulphur on a few red cinders on a kitchen shovel, in successive small quantities, until the atmosphere was filled, but not disagreeably, with the fumes. The process could be at once interrupted by putting the shovel under the grate, or modified by opening a window. The operation could be repeated as often as neces- sary, but he preferred that the sick-room should never be free from a certain amount of the vapour. Dr Dewar devised a spray-producing 110 Vai:)orisahle Antiseptic Substances apparatus for applying sulphurous acid^ diluted with one or two parts of water, to the air passages ; but now a Siegle^s steam-spray producer is the most convenient apparatus to use. Dr Dewar quotes several cases of phthisis in which this ^' sulphur medication '' proved of great value. It has also been stated that those engaged in the manufacture of sulphuric acid are protected against phthisis. Sulphurous acid has been proved by many observers to possess remarkable disinfecting properties, and it is probably one of the most potent germicides at our disposal. Iloppe- Seyler asserts that 1 — 2 per cent, of sulphurous acid in the air of a room will destroy all the lower organisms, a condition which will be produced by burning thirty to sixty grains of sulphur for every lOO cubic feet of space. Sulphurous acid fumes may also be evolved by burning two parts of flowers of sulphur with one part of charcoal. Iodine The inhalation of iodine has been found of great value in the treatment of phthisis by VajQorisahle Antisejotic Substances 111 many physicians. A few grains at a time may be vaporised on a hot plate in the sick-room. Or the sponge of an inhalation-respirator may be wetted with a few drops of pure tincture of iodine or of a solution of iodine in ether, or in spirits of chloroform. Ten grains of iodine dissolved in an ounce of amyl hydride makes a good inhalation (Phillips). Or a spray may be used containing a few drops (10 to 20) of tincture of iodine in an ounce of water. The ^'Yapor lodi ^^ of the pharmacopoeia is produced by adding one drachm of tincture of iodine to an ounce of water, supplying heat in a suitable vessel so that the vapour that is driven off may be inhaled. Some have used with advantage, in the form of spray, a mixture of ten to twenty drops of tincture of iodine and one or two grains of carbolic acid added to an ounce of water. The warmth of the hand suflQ.ces to vaporise a mixture of carbolic acid and tincture of iodine. Others have used dry inhalations of a mixture of iodine and camphor. Sir Charles Scudamore, who had great faith in the value of iodine inhalations in phthisis, believed that the addition of a little tincture of 112 Vaporisahle Antisejjtic Substances conium subdued the irritating qualities of the iodine vapour, when inhaled with the steam of water. Piorry was a strong advocate of this mode of treatment, and he was so anxious that his patients should breathe the vapour continuously, that he used to have several saucers containing iodine placed about the patient's pillow. There exists a very strong body of evi- dence in favour of iodine inhalations in the treatment of phthisis. Iodoform The inhalation of an ethereal solution of iodoform (1 to 8 or 10) has been used with advantage in phthisis. Its unpleasant odour is an objection to its use. Its insufflation in powder has been found of considerable value in laryngeal phthisis. i^HLORINE The inhalation of diluted dry chlorine vapour as well as the spray of a weak solution of chlorine Vaporisahle Antise^ptic Substances 113 and of cUorinated soda^ have been reported as of much value in the treatment of phthisis ; but the irritating properties of chlorine^ except when very dilute, have usually led to the pre- ference of other antiseptic agents. Sir James Simpson thought well of its use and so did Dr Elliotson ; but it is probably irrespirable in sufficient quantity to affect disease germs in the living subject. Caebolic Acid This powerful antiseptic substance has been largely employed in the treatment of phthisis. It has been used in the form of dry inhalation, as a spray diluted with water, internally by the stomach, by hypodermic injections, and by in- jections through the chest walls into the lung. The most common and most convenient method of employing it is by dropping a few drops of the pure liquid acid on the sponge of an inhalation-respirator, which should be worn as continuously as possible, and the charge of acid renewed when the odour gets feeble. In this way the air that is breathed is moderately charged with the antiseptic vapour. If the car- bolic acid be mixed with an equal part of spirits 8 114 Vaporisable Antiseptic Substances of chloroform the vapour probably comes off more rapidly^ and is perhaps more efficacious when the inhalation can only be used occasion- ally. The spirits of chloroform, moreover, soothes bronchial and laryngeal irritation. The vapour of carbolic acid can readily and usefully be diffused through the atmosphere of a bed-room or other chamber occupied by the sick person, by making an iron shovel or an old earthenware plate hot over the fire, and pouring the acid upon it. This is an excellent way of diffusing an antiseptic vapour through the atmosphere. A mixture of camphor and carbolic acid has been used in France as an antiseptic under the name of Camphor phenique. It is made by adding powdered camphor to a mixture of crystallised carbolic acid nine parts and alcohol one part. This may be inhaled in the same way as the pure acid. Or a mixture of carbolic acid and iodine may be inhaled as I have already said. As a spray, a good form is made by adding forty minims of glycerine of carbolic acid and five grains of carbonate of soda to an ounce of warm water, and used in a Siegle's spray-producer. Vajporisable Antisejptic Substances 115 Carbolic acid has also been given internally, and an excellent vehicle for its administration is a mixture of bismuth, glycerine, and muci- lage. A grain or two may be given thus three times a day. Or iodine and carbolic acid may be given together internally. When they are given together " a colourless carbolate is formed when they are dropped into water.''^ Schnitzler, of Vienna, uses hypodermic in- jections of carbolic acid, one eighth to one quarter of a grain daily, or twice a day. He finds it reduces fever (a distinct relation exists between antiseptic and antipyretic properties : the power to depress temperature exists in the same ratio as the power to destroy disease fer- ments, and germs), the pulse becomes slower and stronger, and the night sweats are dimi- nished. Quite recently Dr Frank el has been injecting small quantities of a 5 per-cent. solution of carbolic acid into the lung through the chest walls. Oeeasote This antiseptic vaporisable substance is ob- tained from wood tar, the purest being that 116 Vaporisable Antiseptic Substances obtained from the wood of tlie beech tree. There are several varieties, more or less impure, in commerce. Wood says : — " Creasote is at present a rare drug, the material which is usually sold under its name in the drug stores being really a solution of carbolic acid/^ It differs from carbolic acid in being insoluble in glycerine. Its vapour is astringent and sedative as well as antiseptic. It may be inhaled dry in the same way as carbolic acid, either pure or mixed with spirits of chloroform. It may also be inhaled with the steam of hot water. MM. Bouchard and Gimbert have derived remarkable results from its internal use in phthisis. They give it in the following manner : Pure creasote of the beech tree . 27 minims. Tincture of gentian . . . GO „ Alcohol . . . . .1 ounce. Malaga wine . . . . 4 „ A quarter to half of this is taken daily. Or they give it in combination with cod-liver oil — two parts of creasote to 150 of cod-liver oil. The average daily dose being six to nine grains, but as much as twelve to fourteen grains have Yajporisahle Antiseptic Substances 117 been given. They have found its use followed by diminution of coughj expectoration^ and fever^ and an increase of appetite, strength, and weight. Tae Obtained by destructive distillation of the Pinus sylvestris and other pines. A vast amount of testimony is on record as to the value of the inhalations of tar vapour or of the spray of tar water in the treatment of phthisis. Tar water (Eau de Goudron) has also been largely used internally in this disease, and is a very popular remedy in France. Tar water is made by stirring a pint of tar with half a gallon of water for fifteen minutes and then decant- ing. It may be used in a Siegle^s spray pro- ducer. Siegle considers it an ^^ antiseptic par excellence.'^ The vapour of tar may be readily diffused through the air of a room. Prepared tar, mixed with water till it is soft, may be poured in thin layers on plates, which are kept hot by standing over water which is maintained at a 118 Vajjorisahle Antiseptic Substa nces higli temperature by a spirit latup. The tar should not be allowed to become dry. It is soluble in its own bulk of rectified spirit, and the sponge or other absorbent sub- stance (tow, cotton wool) in an inhalation- respirator can be kept saturated with this solu- tion. The dose of tar water internally is from one to two pints daily. Oleum Pini sylvesteis (Fir Wood Oil) This is used by some physicians in preference to oil of turpentine on account of its more agreeable odour. Like it, it is antiseptic and astringent. It may be used pure or mixed with other antiseptics, and dropped on the sponge of an inhalation respirator, or it may be inhaled with the steam of hot water in a suitable apparatus. Dr Morell Mackenzie's formula is two drachms of the oil of pine with sixty grains of light carbonate of magnesium in three ounces of water. A teaspoonful of this is thrown upon a pint of water at 150° F. for each inhalation. VajQorisahle Antiseptic Suh stances 119 Oil op Turpentine The inhalation of the vapour of oil of tur- pentine in one form or another has long been a favourite remedy in pulmonary diseases. The advantages derived from the free use of tere- binthinate embrocations in lung diseases have been referred by many to the inhalations of dilute vapour of oil of turpentine necessitated thereby. The dangers which some have seen (Dr Stokes especially) from the inhalations of vapour of oil of turpentine are only to be accounted for by the circumstance that these vapours were used in too concentrated a form. No one should think of administering any form of antiseptic vapour of a strength and concen- tration capable of exciting irritation in the air passages. Turpentine vapour is not only a valuable antiseptic when properly diluted, but it is also an exceedingly useful astringent, and is especi- ally indicated in those cases of phthisis where there is profuse secretions from co- existing bronchial catarrh. A useful formula for dry inhalations is a mixture of one drachm of spirits of turpentine, 120 Vajiorisahle AntiseiAic Substances one drachm of creasote, and six drachms of spirits of chloroform. From five to ten drops at a time of this mixture should be dropped on the sponge of an inhalation respirator. An atmosphere more or less charged with turpentine vapour may be produced around the patient by rubbing the back and front of the chest freely with Stokes's liniment at bedtime. This consists of — R. Spirit. Terebinthina3 Acid. Acetici . Vitelli Ovi . . 3.SS. • 3- Ol. Limonis . Aquas Rosmarini • 5j. 3^iss A good method also is to rub up a drachm of oil of turpentine with thirty grains of carbonate of magnesia and two or three ounces of water ; a teaspoonful or two of this mixture thrown on hot water readily gives off turpentine vapour. EUCALYPTOL OE OiL OF EcCALTPTdS This is a deservedly popular antiseptic. It I has a more agreeable odour than many other ', antiseptic volatile substances, and is on that Vaporisahle Antiseptic Substances 121 account to be preferred in many cases. The oil of eucalyptus ismuch cheaper than eucalyptol, and is quite as useful for inhalation. This volatile oil is obtained from the fresh leaves of the Eucalyptus globulus. The more volatile liquid, eucalyptolj is obtained from the former by purification with caustic potash- and fused chloride of calcium. Its powerful antiseptic properties have been well ascertained, and the eucalyptus gauze is an elegant antiseptic dres- sing introduced by Mr Lister. A pleasant and useful formula for the inhalation of eucalyptol is the following : — Eucalyptol four drachms, gum camphoraB, twenty grains ; oil of gaultheria, one drachm ; spirits of chloroform to an ounce. Ten to twenty drops of this may be inhaled at a time, dropped on the sponge of an inhala- tion respirator. The Oil of Gaulthehia Mentioned in the preceding formula is an antiseptic volatile oil with a pleasant odour and consisting largely of salicylate of methyl. 122 Faporisable Antiseptic Substances Thymol This is a solid crystalline substance readily soluble in alcohol, ether, ur glacial acetic acid. It is homologous with phenol or phenyl alcohol (carbolic acid), and has been used as an anti- septic in the place of carbolic acid when the odour of the latter is found disagreeable. It has a powerful aromatic smell, resembling that of the crude oil of thyme, from which it is obtained. Its vapour has appeared to me to be rather pungent and irritating. It is a ery active deodoriser. Wood observes that it is costly and has no marked advantages in its favour. Moreover, he states that, in America, its fragrant odour has been observed to attract swarms of flics, a decided drawback to its use for continuous inhalation. It can be used dissolved in spirits of chloro- form, either alone or mixed with other vaporis- able antiseptics. Camphoe This substance has long been reputed an antiseptic, and its antiseptic properties are Vaporisahle Antiseptic Substances 123 probably considerable. One drawback to its use is that it diffuses from its solutions very rapidly, and is on that account rather pungent and overwhelming when used as a dry inhala- tion. Many persons like the odour of camphor and for such it may be added to any of the other antiseptic vaporisable substances. It is also somewhat sedative, and tends to relieve cough. It is freely soluble in chloroform, ether, rectified spirit, and in volatile oils. Three parts of camphor rubbed up with one part of crystals of carbolic acid forms a clear solution very suitable for dry inhalation. From three to ten drops at a time should be dropped on the sponge of an inhalation respirator. Teeebene This antiseptic body, which is largely used as a disinfectant and deodorant, is a modifica- tion of oil of turpentine. When oil of turpentine is repeatedly distilled with a small quantity of strong sulphuric acid, it is converted into two inactive modifications : Terehene, Cj^H^g, boiling at 160°, and Colojjhene, Cggllgg, boiling at a very high temperature. 124 FajyorisahJe Aiitisejjtic Substances Terebene has a more agreeable odour tliau turpentine or carbolic acid, and may be cou- \ veniently used in the place of either as a |vaporisable antiseptic. A mixture of equal parts of terebene and oil of eucalyptus makes a good antiseptic inha- lation. TRINTED BY J. E. ADLAJID, BABTUOLOMEW CLOSE. [Catalo&ub C] LONDON, OctoUr, 1882. J. & A. CHUECHILL'S MEDICAL CLASS BOOKS ANATOMY. BRAUNE.— An Atlas of Topographical Ana- tomy, after Plane Sections of Frozen Bodies. By "Wilhelm Bp.aune, Professor of Anatomy in the University of Leipzig-. Translated by Edward Bellamy, F.R.C.S., and Member of the Board of Examiners ; Surgeon to Charing Cross Hospital, and Lectm^er on Anatomy in its School. With 34 Photo-lithographic Plates and 48 Woodcuts. Large! imp. 8vo, 40s. i^ZOTF^i?.— Diagrams of the Nerves of the Htmian Body, exhibiting their Origin, Divisions, and Connexions, with their Distribution to the various PtCgions of the Cutaneous Surface, and to aU the Muscles. By William H. Flower, F.Pt.C.S., F.R.S., Hunterian Professor of Comparative Anatomy, and Conservator of the Museum, Eoyal College of Surgeons. Third Edition, containing 6 Plates. Royal 4to, 12s. GODLEE.—An Atlas of Human Anatomy: illustrating most of the ordinary Dissections ; and many not usually practised by the Student. By Rickman J. Godlee, M.S., F.R.C.S., Assistant-Surgeon to University College Hospital, and Senior Demonstrator of Anatomy in University College. With 48 Imp. 4t Coloured Plates, containing 112 Figures, and a Volume of Explanatory Text, with many Engravings, Svo, £4 14s. 6d. BEATH. — Practical Anatomy : a Manual of Dissections. By CnRiSTOBfiER Heath, F.R.C.S., Holme Professor of Clinical Surgery in University College and Surgeon to the Hospital, Fifth Edition. With 24 Coloured Plates and 269 Engravings. Crown Svo, 15s. NEW BURLINGTON STREET, J. 4* A. ChurchilPs Medical Class Books. ANATOMY — continued. HOLDEX.—A Manual of the Dissection of the Human Body. By Lither Holken, F.R.C.S., Consulting-Surgeon to St. Bartholomew's Hospital. Fourth Edition. Revised by the Author and John- Laxgton-, F.R.C.S., Surgeon and Lecturer on Anatomy at St. Bartholomew's Hospital. With Engra\-ings. 8vo, 163. By the same Author. Human Osteology : comprising a Descrip- tion of the Bones, with Delineations of the Attachments of the Muscles, the General and Microscopical Structure of Bone and its Development. Sixth Edition, revised by the Author and James Shitep.. F.R.C.8., Assistant Surgeon to St. Bartholomew's Hospital. With 61 Lithographic Plates and 89 Engravings. Royal 8vo, les. Landmarks, Medical and Surgical. Third Edition. &VO, 38. t-d. MOIiRIS.— The Anatomy of the Joints of Man. By Henby Moukis, M.A., F.R.C.S., Surgeon to. and Lecturer on AnA- tomy and Practical Surgery at, the Middlose.x Hospital. With 44 Plates (19 Colourt'd) and Engra\-ing8. 8vo, l(3s. The Anatomical Remembrancer ; or, Com- plete Pocket Anatomist Eighth Edition. 32mo, 38. 6d. WAGSTAFFi:.— The Student's Guide to Human Osteology. By Wm. Wailwiok Waostafke. F.K.C.S., late Assistant- Surgeon to, and Lecturer on Anatomy at, St. Thomas's Hospital. With 23 Plates and 66 Engravings. Fcap. 8vo, lOs. 6d. WILSON — BUCHANAN — CLARK.— Wilson's Anatomist's Vade-Mecum : a System of Human Anatomy. Tenth Edition, by Gkorgb Buchanan, Profeeeor of Clinical Surgery in the University of Glasgow, and Hexkv E. Clakk. M.R.C.S., Lecturer on Anatomy in the Glasgow Royal Intirmaiy School of Medicine. With 460 Engravings, including 26 Coloured Plates. Crown 8vo, IBe. NEW BUFiLINGTON STREET. J. <§• A. ChurcUUs Medical Class Books. BOTANY. BENTLEY.—A Manual of Botany. By Robert Bentley, P.L.S., M.R.C.S., Professor of Botany in King's College and to the Pharmaceutical Society. With 1185 Engravings. Fourth Edition. Crown 8vo, 15s. BENTLEY AND TBIM EN,~-MQdicinal Plants : being descriptions, with original Figures, of the Principal Plants employed in Medicine, and an account of their Properties and Uses. By EoBEET Bentley, F.L.S., and Heney Teimen, M.B., F.L.8. In 4 Vols., lai-ge Svo, with 306 Coloured Plates, bound in half morocco, gilt edges, £11 Us. CHEMISTRY. BEBNAYS.—NotQs for Students in Chemistry; being a Syllabus of Chemistry compiled mainly from the Manuals of Fownes-Watts, Miller, Wui-z, and Schorlemmer. By Albebt J. Beenays, Ph.D., Professor of Chemistry at St. Thomas's Hospital. Sixth Edition. Fcap. Svo, 3s. 6d. By the same Author. Skeleton Notes on Analytical Chemistry, for Students in Medicine. Fcap. Svo, 2s. 6d. BLOXAM. — Chemistry, Inorganic and Organic ; with Experiments. By Chaeles L. Bloxam, Professor of Chemistry in King's College. Foui-th Edition. With nearly 300 Engravings. Svo, 16s. By the same Author. Laboratory Teaching ; or, Progressive Exercises in Practical Chemistry. Fourth Edition. With 83 Engravings, Crown Svo, 5s. 6d. NEW BURLINGTON STREET. J, 4' -^- ChurchilVs Medical Class Books. CHEMISTRY— co«^//^wt?c/. BOWMAN AND ^LO^^ J/.— Practical Chemistry, including Analysis. By Johx E. Bowmax, formerly Professor of Practical Chemistry in King's College, and Charles L. Bloxam, Professor of Chemistry in King's College. With 93 Engravings. Seventh Edition. Fcap. Sao, Gs. 6d- CZ0iri;6'.— Practical Chemistry and Qualita- tive Inorganic Analysis. An Elementary Treatise, specially adapted for use in the Laboratories of Schools and Colleges, and by Beginners. By Fra.vk Clowes, D.Sc, Professor of Chemistry in University College, Nottingham. Third Edition. "With 47 Engravings. Post 8to, 78. 6d. FOWNES AND Tl^^rJ^.— Physical and Inorganic Chemistry. Twelfth Edition. By George Fownes. F.R.S., and Hesby Watts, B.A., F.R.S. With 154 Engra^-ings, and Coloured Plate of Spectra. Crown 8vo, 8s. »id. By the same Authors. Chemistry of Carbon - Compounds, or Organic Chemi.-^tr}-. Twelfth Edition. With Engravings. Crown 8>o, lOs. LUFF.— An Introduction to the Study of Che- mistry. Specially designt-d for Medical and Pharmaceutical Students. By A. P. LiFF, F.I.C., F.C.S., Lecturer on Chemistry in the Central School of Chemistiy and Pharmacy. Crown Svo, 2s. 6d. TIDY. — A Handbook of Modern Chemistry, Inorganic and Organic By C. IIeymutt Tidy, M.B., Professor of Chemistry and Medical Jurisprudence at the Lo«doa Hospital. 8^0, 166. VACHER. — A Primer of Chemistry, including lysis. By Artuub Vacheb. ISmo, Is. NEW BURLINGTON STBE.'.T. J, (Sr A. Churchill's Medical Class Books, 0-H.-Emi^l}-EiY— continued. VALENTIN.— Introduction to Inorganic Chem- istry. By William G. Valentin, F.C.S. Third Edition. With 82 Engravings. 8vo, 6s. 6d. By the same A uihor. A Course of Qualitative Chemical Analysis. Eifth Edition. By W. E. Hodgkinson, Ph.D. (Wurzburg), Demonstrator of Practical Chemistry in the Science Training Schools. With Engravings. 8vo,7s. 6d. also, Chemical Tables for the Lecture-room and Laboratory. In Five large Sheets, 5s. 6d. CHILDREN, DISEASES OF. DAT.— A Treatise on the Diseases of Children. For Practitioners and Students. By William H. Day, M.D., Physician to the Samaritan Hospital for Women and Children. Crown 8vo 12s. 6d. ' ELLIS.— A Practical Manual of the Diseases of Children. By Edward Ellis, M.D., late Senior Physician to the Victoria Hospital for Sick Children. With a Formulary. Fourth Edition. Crown 8vo, 10s. SMITH. — ClinicBl Studies of Disease in Children. By Eustace Smith, M.D., F.R.C.P., Physician to H.M. the King of the Belgians, and to the East London Hospital for ChUdren Second Edition. Post 8vo. {In preparation. By the same Author. On the Wasting Diseases of Infants and Children. Third Edition. Post 8vo, 8s. 6d. STEINEB.— Compendium of Children's Dis- eases; a Handbook for Practitioners and Students. By Johann Steiner, M.D. Translated by Lawson Tait, F.R.C.S., Surgeon to the Birmingham Hospital for Women, &c. 8vo, 12s. 6d. NEW BURLINGTON STREET. J. 8f A. ChiirchilVs Medical Class Books. DENTISTRY. SEWILL.— The Student's Guide to Dental Anatomy and Surgery. By Henry E. Sewill, M.R.C.S., L.D.S., late Dental Surgeon to the West London Hospital. "With 77 Engravings. Fcap. 8yo, 5s. 6d. STOCKEN.— Elements of Dental Materia Medica and Therapeutics, with Pharmacopceia. By James Stocken, L.D.S.R.C.8., late Lecturer on Dental Materia Medica and Therapeutics and Dental Surgeon to the National Dental Hospital. Third Edition. Fcap. 8vo. [In the press. TAFT.—A Practical Treatise on Operative Dentistry. By Jonatha.v Taft, D.D.S., Professor of Opoiiitive Surgery in the Ohio College of Dental Surgery. Third Etlition. With 134 Engravings. 8vo, iSs. TOMES (C. >S'.).— Manual of Dental Anatomy, Human and Comparative. By Chablhb 8. Tomes, M.A., F.R.8. Second Edition. With 191 Engra^^ng8. Crown 8vo, 12s. 6d. TOMES {J. STOiV^.— Lectures on Medical Jurisprudence. By Francis Ogstox, M.D., Professor of Medical Jurisprudence and Medical Logic in the University of Aberdeen. Edited by Francis Ogston, Jun., M.D., Assistant to the Professor of Medical Jurispru- dence and Lecturer on Practical Toxicology in the University of Aberdeen. With 12 Plates. Svo, 18s. TAYLOE.—ThQ Principles and Practice of Medical Jurisprudence. By Alfred S, Taylor, M.D., F.R.S., late Professor of Medical Jurisprudence to Guy's Hospital. Second Edition. With 189 Engravings. 2 Vols. 8vo, 31s. 6d. By the same A uthor. A Manual of Medical Jurisprudence. Tenth Edition. With 55 Engravings. Crown 8vo, 148. ALSO, On Poisons, in relation to Medical Juris- prudence and Medicine. Third Edition. With 104 Engravings, Crown Svo, 16s. TIDY AND WOODMAN— A Handy-Book of Forensic Medicine and Toxicology. By C. Meymott Tidy, M.B. ; and W. Bathurst Woodman, M.D., F.K.C.P. With 8 Lithographic Plates and 116 Wood Engravings. Svo, 31s. 6&. NEW BURLINGTON STREET. J. 4' A. ChurchilVs Medical Class Books, HYGIENE. PABKES.—A Manual of Practical Hygiene. EvEdml-nd a. Parkes, M.D., F.R.S. Fifth Edition by F. De CnAiMOVT, M.D., F.R.S. , Professor of Military Hygiene in the Army Medical School. "With 9 Plates and 112 Engraving¥. Sto, ISs. WILSON. — A Handbook of Hygiene and Sani- taiT Science. By Gk"I:i.k "Wilso-v, M.A.. M.D., Medic;d Officer of Health for Mid Wanrickshire, Fourth Edition. With Engravings. Crown 8\-o, lOs. Gd. MATERIA MEDICA AND THERAPEUTICS. BINZ AND SPABKS.— The Elements of Thera- peutics: a Clinical Guide to the Action of Medicines. By C. Bi.vz. ^I.D.. ProfesM)r of Pharmacology in tlie Vniversitj- of Bonn. Translated and Edited with Addition!*, in conformity with the British and American Pharmaeopceias, by Edwabd I. Spabks, M.A., M.B., F.R.C.P. Lond. Cro^vn 8vo, Ss. ed. OWEN. — Tables of Materia Medica ; com- prising the Contents, Do.'.rs, Proportional Composition, and Methoda of Manufacture of Pharmacopa-ial Preparations. By Isamh.M'.d Owe.s, M.B., M.E.C.P., Lecturer on Materia Medica at Bt. George's HospitaL Fifth Edition. Crown 8vo, 2b. 6d. BOYLE AND HABLEY.—A Manual of Materia Medica and Tlieraptutics. By J. Fokuks Ro\ i.k, M.D.. F.R.S., and John' Harley, M.D., F.R.C.P., Physician to, and Joint Lecturer on Clinical Medicine at. St. Thomas's Hospital. Sixth Edition. With 139 Engrav- ings Crown Sto, 15s. THOBOWCrOOD.—ThQ Student's Guide to Materia Medica and Therapeutics. By Joji.v C. Thorowgood, M.D., F.R.C.P., Lecturer on Materia Medica at the Middlesex Hospital. Second Edition. With EngTa\-ings. Fcap. 8vo, 79. WABING.—A Manual of Practical Therapeu- tics. By EiiWARu J. Wai.ing, C.B., M.D., F.R.C.P. Third Edition. Fcap. 6vo, 128. 6d. * NEW BURLINGTON STREET. J. (^' A. ChurcUWs Medical Class Books. MEDICINE. BARCLAY.~A Manual of Medical Diagnosis. By A. Whtte Barclay, M.D., F.E.C.P., late Physician to, and Lecturer on Medicine at, St. George's Hospital. Tliii'd Edition Fear) 8vo, 10s. 6d. ^' GHARTERIS.~ThQ Student's Guide to the Practice of Medicine. By IVIatthew Chartekis, M.D., Professor of Materia Medica, University of Glasgow; Physician to the Royal Infirm- ary. With Engravings on Copper and Wood. Third Edition. Fcap 8vo, 7s. ^' FENWICK.—ThQ Student's Guide to Medical Dia^osis. By Samuel Fexwick, M.D., F.E.C.P., Physician to the London Hospital. Fifth Edition. With 111 Engravings. Fcap. 8vo, 7s. By the same Author. The Student's Outlines of Medical Treat- ment. Second Edition. Fcap. Svo, 7s. /X/i\^r.— Clinical Medicine : a Systematic Trea- tise on the Diagnosis and Treatment of Disease. By Austin Flint, M.D., Professor of the Principles and Practice of Medicine, &c. in BeUevue Hospital Medical College. Svo, 20s. ' ^.iZZ.— Synopsis of the Diseases of the Larynx, Lxmgs, and Heart : comprising Dr. Edwards' Tables on the Examina- tion of the Chest. With Alterations and Additions. By F De Havilland Hall, M.D., F.E.C.P., Assistant-Physician to the West- minster Hospital. Eoyal Svo, 2s. 6d. >S'^iV;SOJ/.— Manual of the Physical Diagnosis of Diseases of the Heart, including the use of the Sphygmograph and Cardiograph. By A. E. Sansom, M.D., F.E.C.P., Issistant- Physician to the London Hospital. Thii-d Edition, with 47 Woodcuts Fcap. Svo, 7s. 6d. TF^i^i\^.£;i?.— Student's Guide to Medical Case- Taking. By Francis Warner, M.D., Assistant-Physician to the London Hospital. Fcap. Svo, 5s. NEW BUBLINGTON STREET. J, 8^ A. Churchiirs Medical Class Books. MEDICINE — continued. TF/f/rr^/ii:i?.— Students' Primer on the Urine. By"J. Travis "Whittakef., M.D., Clinical Demonstrator at the Royal Infirmary, Glasgow. With Illustrations, and 16 Plates etched on Copper. Post 8vo, 4s. 6d. MIDWIFERY. BARNES. — Lectures on Obstetric Operations, including the Treatment of Haemorrhage, and forming a Guide to the Management of Difficult I-ibour. By Rohkrt Barnes, M.D., F.R.C.P., Obstetric Physician to, and Lecturer on Diseases of "Women, - ; or. Short Rules of Practice in every Emergency, from the Simplest to the most formidable Operations connected with the Science of Obstetricy. By Charles Clat, M.D., late Senior Sui-geon to, and Lecturer on Midwifery at, St. Mary's Hospital, Manchester. Third Edition. With 91 Engravings. Fcap. Svo, 6s. 6d. BAMSBUTIIAM.— The Principles and Practice of Obstftric Medicine and Surgery. By Fraxus H. Ramshotham, M.D., formerly Obstetric Physician to the Ly J. J. Reynolds, M.E.C.S. Fcap. Svo, 4s. BOBEBTS.— The Student's Guide to the Practice of Midwifery. By D. Llovi. Rui.ert^. ^LD.. F.R.C.P., Physician to St. Marj-'s Hospital, Manchester. Second Edition. With 111 Engrav- ings. Fcap. Svo, 7s. SCHBOEDER.—A Manual of Midwifery ; includ- ing the I'athology of Pregnancy and the Put-rperal State. By Karl ScHROEDER, M.D., Profcssor of Midwifery in the University of Erlangen. Translated by Charles H. Carter, M.D. With EngTa\Tngs. Svo, 128. 6d. XEW BURLINGTON STREET, 10 J. i^ A. ChiirchilVs Medical Class Books. MTDWl'F'EiRY— continued. ^TT^FiV^.— Obstetric Aphorisms for the Use of students commencing Midwifery Practice. By Joseph G. Swayne, M.D., Lecturer on Midwifery at the Bristol School of Mediciiie. Seventh Edition. "With Engravings. Ecap. 8vo, 3s. 6d. MICROSCOPY. CARPENTER.— ThQ Microscope and its Revela- tions. By William B. Carpenter, C.B., M.D., F.R.S. Sixth Edition. With 26 Plates, a Coloured Frontispiece, and more than 500 Engravings. Crown 8vo, 16s. MARSH. — Microscopical Section-Cutting : a Practical Guide to the Preparation and Mountiag of Sections f . t the Microscope, special prominence being given to the subject of Animal Sections, By Dr. Sylvester Marsh. Second Edition. With 17 Engravings. Ecap. 8vo, 3s. 6d. MARTIN. — A Manual of Microscopic Mounting By John H. Martin, Member of the Society of Public Analysts, &c. Second Edition. With several Plates and 144 Engravings. 8vo, 7s. 6d. OPHTHALMOLOGY. DAGUENET.—A Manual of Ophthalmoscopy for the Use of Students. By Dr. Daguenet. Translated by C. S. Jeaffreson, Surgeon to the Newcastle-on-TjTie Eye Infirmary. Witti Engravings. Ecap. 8vo, 5s. HIGGENK— Hints on Ophthalmic Out-Patient Practice. By Charles Higgens, F.R.C.S., Ophthalmic Surgeon to, and Lecturer on OphthaLtnology at, Guy's Hospital. Second Edition. Ecap. 8vo, 3s. JONES.— A Manual of the Principles and Practice of Ophthalmic Medicine and Surgery. By T. Wharton JoneSi F.R.C.S., F.R.S., late Ophthalmic Surgeon and Professor of Ophthalmo- logy to University College Hospital, Third Edition. With 9 Coloured Plates and 173 Engravings. Ecap. Bvo, 12s. 6d. NEW BURLINGTON STREET. 11 J. 4' A. ChurchiWa Medical Class Books, OPHTHALMOLOGY— to/i^mwec/. MACNAMARA.—A Manual of the Diseases of the Eye. By Charles Macnamara, F.R.C.S., Surgeon to, and Lecturer on Surgery at, "Westminster Hospital. Fourth Edition. With 4 Coloured Plates and 66 Engra\-ings. Fcap. 8vo, 10s. 6d. iVr^Jrrzr.S'Zf/P.— The Student's Guide to Diseases of the Eye. By Edward Nettle.-hip, F.R.C.S., Ophthalmic Sui-geon to, and Lecturer on Ophthalmic Surgery at, St. Thomas's Hospital. Second Edition. With 137 Engravings, and a Set of Colourtd Tapers illustrating Colour-blindness. Fcap. 8vo, 7s. Gd. WOLFE. — On Diseases and Injuries of the Eye : a Course of Systematic and Clinical Lectiu-es to Students and Medical Practitioners. By J. R. Wolke, M.D.. F.K.C.S.E., Senior Surgeon to the Glasgow Ophthalmic Institution, Lecturer on Ophthalmic Medicine and Surgery in Anderson's College. With 10 Coloured Plates, and 120 Wood Engravings, 8vo. PATHOLOGY. JONES AND SIEVEKING.—A Manual of Patho- logical Anatomy. By C. Haxufiki.d Jonks, M.B., F.RS.. and Edward H. SiEVEKiXG, M.D.. F.R.C.P. Second Edition. Edited, with con.sider- able enlargement, by J. F. Pay.ve, M.B., Assistant-Physician and Lecturer on General Patholojry at St. Thoma.-s's Hohi.ital. With 195 Engravings. Crown Svo. 16.-'. LANCEREAUX.—AtldiS of Pathological Ana- tomy. By Dr. Lancereacx. Translated by W. S. Gkekskikld, M.D., Professor of Pathology in the University of Edinburgh. With 70 Coloured Plates. Imperial 8vo. £5 6«. F/i?C770Tr. — Post-Mortem Examinations: a Description and Explanation of tlie ^lethod of Performing them, with especial reference to iledico-Legal Practice. By Professor EcDOLPH ViRrnow, Berlin Charite Hospital. Translated by Dr. T. B. Smith. Second Edition, with 4 Plates. Fcap. 8vo, Ss. 6d. WILKS AND J/O^OiV.— Lectures on Pathologi- cal Anatomy. By Samuel Wilks, M.D., F.R.8., Physician to, and late Lecturer on Medicine at, Guy's Hospital; and Walter Moxox, M.D., F.E.C.P., Physician to, and Lectvu-er on the Practice of Medicine at, Guy's Hospital. Second Edition. With 7 Steel Plates. 8vo, 18s. NEW BURLINGTON STREET. 12 J. 8f A. ChurchUlh Medical Class Books. PSYCHOLOGY. BUCKNILL AND TUKE.—A Manual of Psycho- logical Medicine : contaimng the Lunacy Laws, Nosology, etiology, Statistics, Description, Diagnosis, Patliology, and Treatment of Insanity, ■with, an Appendix of Cases. By Johx C. Bucknill, M.D., F.E.S., and D. Hack Tuke, M.D., F.E.C.P. Fourth Edition, with 12 Plates (30 Figures). 8vo, 25s. PHYSIOLOaY. CARPENTER.— ^rincii^lQS of Human Physio- logy. By William B. Caepextee, C.B., M.D., F.E.S. Ninth Edition. Edited by Henry Power, M.B., F.E.C.S. With 3 Steel Plates and 377 Wood Engravings. 8vo, 31s. 6d. DALTON. — A Treatise on Human Physiology : designed for the use of Students and Practitioners of Medicine. By John C. Daltox, M.D., Professor of Physiology and Hygiene ia the College of Physicians and Surgeons, New York. Seventh Edition. With 252 Engravings. Eoyal 8vo, 20s. i^^^^F.— The Histology and Histo-Chemistry of Man. A Treatise on the Elements of Composition and Structure of the Human Body. By Heixeich Feey, Professor of Medicine in Zurich. Translated by Aethur E. Baekee, Assistant-Surgeon to the Uni- versity College Hospital. With 608 Engavings. 8vo, 21s. SANDERSON.— Hsindihook for the Physiological Laboratory : containing an Exposition of the fundamental facts of the Science, with explicit Directions for their demonstration. By J". Buedok Saxdeesox, M.D., F.E.S. , Jodrell Professor of Physiology ia University College; E. Klein, M.D., F.E.S., Assistant-Professor ia the Brown Listitution ; Michael Fostee, M.D., F.E.S., Pi'telector of Physiology at Trinity College, Cambridge ; andT. Laudee Beuxtox, M.D., F.E.S., Lecturer on Materia Medica at St. Bartholomew's Hospital Medical CoUege. 2 Vols., with 123 Plates. 8vo, 24s. SURGERY. BRYANT. — A Manual for the Practice of Surgery. By Thomas Beyaxt, F.E.C.S., Surgeon to, and Lecturer on >i r^ery at, Guy's Hospital. Third Edition. With 672 Engravings (nearly all original, many being coloured) . 2 vols. Crown 8vo, 28s. NEW BURLINGTON STREET, 13 J. ^- A. Churchiirs Medical Class Books. SURGERY— CO 7? «mwc(7. BELLAMY.— Th& Student's Guide to Surgical Anatomy ; a Description of the more important Surgical Regions of the Human Body, and an Introduction tu Operative Surgery. By Edwabd Bellamy, F.R.C.S., and Member of the Board of Examiners ; Surgeon to. and Lecturer on Anatomy at, Charing Cross Hospital Second Edition. With 76 Engravings. Feap. 8vo. Ts. CLARK AND WAGSTAFFE. — Outlines of Surgery and Surgical Pathology. By F. Le Gros Clark, F.R.C.S., F.R S., Consulting Surgeon to St. Thomas's Hospital. Second Edition. Revised and expanded by the Author, assisted by "W. W. Waoptaffe, F.R.C.8., Assistant-Surgeon to St. Thomas's Hospital. 8vo, lOs. 6d. DRUITT. — The Surgeon's Vade-Mecum ; a Manual of Modem Surgery. By Robebt Dklitt, F.R.C.8. Eleventh Edition. With 369 Engra\-ing8. Foap. 8vo, lis. FEBGUSSOX.—A System of Practical Surgery. By bir William Fkp...iss..s, Bart., F.H.C.S., F.R.S., late Surjrton and Professor of Clinical Surgery to Kiug'a College Hospital. With 463 Engravings. Fifth Edition. 8vi), -Jls. HEATH.— A Manual of Minor Surgery and Bandaging, for the u.se of House-Surgeons, Dre.-^sers, and Jimior Practi- tioners. ByCuRisTOPHEB Heath. F.K.C.S., Holme Profestor of Clinical Surgery in Uni^-erfity College and Surgeon to the Hospital. Sixth Edition. With 115 Engra%-ing8. Fcap. Svo. 5«. 6d. By the same Author. A Course of Operative Surgery : with Twenty Plates drawn from Nature by M. L^vbillk, and Coloured I'V hand under hia direction. Large {"Vu, 403. AL.-r., The Student's Guide to Surgical Diag- nosis. Fcap. &V0, 68. 6d. il/.A 2:'. VZ)i:/?.— Operative Surgery. By Charles F. MArxPER, F.R.C.S., late Surgeon to. and Lecturer on Purp'ery at, the London Hospital. Second Edition. With 164 EngTa%nng8. Post Svo, 69. XEW BUBLINGTON STREET. J. 4^ A. Churchiirs Medical Class Books. SJJRG^HY— continued. FinmK— The Principles and Practice of Surgery. By William Pikeie, F.R.S.E., late Professor of Surgery in the University of Aberdeen. Third Edition. With 490 Ensravina-s SOUTHAM.— Regional Surgery: including Sur- gical Diagnosis. A Manual for the use of Students. Part I the HeadandNeck. ByFEECEBiCKA. Southa:;i,]\I.A.,M.B. Oxon P R C S Assistant-Surgeon to the Eoyal Infirmary, and Assistant-Lecturer 'on Sui-gery in the OTven's College School of Medicine, Manchester Crown 8vo, 6r. 6d. TERMINOLO GY. DUJYGLISOiY.—Medical Lexicon : a Dictionary of Medical Science, containing a concise Explanation of its various Subjects and Terms, with Accentuation, Etymology, Synonymes, &c. By EOBLEY DuNGLisox, M.D. New Edition, thoroughly revised by BiCHARD J. DuNGLisox, M.D. Eoyal 8vo, 2Ss. MAYNK—A Medical Vocabulary: being an Explanation of all Terms and Phrases used in the various Depart- men s of Medical Science and Practice, giving their Derivation, Meaning, Apphcation, and Pronunciation. By Eobekt G. Mayne M D LL D and John Matne,M.D.,L.E.C.S.E. Fifth Edition. Fcap. Svo", lOs.'ed! WOMEN, DISEASES OF. BARNES.~A Clinical History of the Medical and Surgical Diseases of Women. By Eobebt Baexes M D • F E C P Obstetric Physician to, and Lecturer on Disea..es of Women, &c , at,'st' George s Hospital. Second Edition. With 18i Engravings. Svo, 28s. * aOZ7i?rr:— Practical Treatise on Diseases of the Uterus, Ovaries, and Fallopian Tubes. By Professor Cotjrty Montpellier. Translated from the Third Edition by his Pupil, Agves M'Labex, M.D., M.K.Q.C.P. With Preface by Dr. Matthews DuxcAx. With 424 Engravings. 8vo, 24s. DC/iV^a^iV^^-Clinical Lectures on the Diseases of Women, By J. Matthews Duxcax, M.D., F.E.CP., Obstetric Physician to St. Bartholomew's Hospital. Svo, 8s. NEW BUBLINOTON STREET. J. 4- A, Churchiirs Medical Class Books. WOMEN, DISEASES OF— continued . EMMET. — The Principles and Practice of Gynaecology. By Thomas Addis Emmet, M.D., Surgeon to the Woman's Hospital of the State of New York. With 130 Engravings. Royal Sto, 24s. GALABIN.— The Student's Guide to the Dis- eases of Women. By Alfred L. Galabik, M.D., F.R.C.P.. Assistant Obstetric Physician and Joint Lecturer on Obstetric Medicine at Guy's Hospital. Second Edition. With 70 EngTa%-ings. Fcap. •>vo, 7s. 6d. BEYXOLDS.— Notes on Diseases of Women. Specially designed for Students preparing for Examination. By J. J. Reynolds, M.R.C.S. Fcap. Svo, 2s. 6d. SMITH. — Practical Gynaecology : a Handbook of the Diseases of Women. By Ilf.vuo.^D Smith, M.D., rhyyician to the Hospital for Women and to the British Lying-in Hospital. With Engravings. Second Edition. Crown Svo. 'Inpr>paration. WEST AND DUNCAN.— "Lectuves on the Dis- eases of Women. By Charles West, M.D., F.R.(\P. Fourth Edition. Re%-ised and in part re-written by the Author, with numerous additions, by J. Matthews Din. ax, M.D., F.R.C.P., Obstetric Pbyaician to St. Bartholomew's Hospital. Svo, 168. ZOOLOGY. CHAUVEAU AND FLKMINt;.— The Compara- tive -\natomy of the Domesticated Animals. By A. Chai'veau, Professor at the Lyons Veterinary School ; and George Flemijjo, Veterinary Surgeon, Royal Engineers. With 450 Engravings. Svo, 31s. 6d. HUXLEY. — Manual of the Anatomy of Inverte- brated Animals. By Th.-mas II. IlrxLEY, LL.D., F.R.S. With 156 Engravings. Fcap. Svo, 163. By the same Ayfhor, Manual of the Anatomy of Vertebrated Animals. With IM EnCTa\-ing^s. Post Svo, 12s. WILSON— The Student's Guide to Zoology: a Manual of the Principles of Zoological Science. By Andrew Wilsox, Lecturer on Natural History, Edinburgh. With Engravings. Fcap. Svo, 6s. 6d. NEW BURLINGTON STREET. 16 DATE DUE Li p 9 ZOM APRS 02004 , J. "., - '-if • ' 1 1 DEMCO 38-296 COLUMBIA UNIVERSITY LIBRA^^^^^ . — .— »i^-TOO l^cr-s'cv H ^ M<^ ^^JVALlttoH A^v/ C^K<^.. . ¥^ f^t^ »^