THE LANCET,]

MR. HAMILTON ON SULPHUROUS ACID IN TYPHOID FEVER.

are but too well known to those who have studied the subject, and have witnessed an epidemic of small-pox in India. Instances are not wanting in other countries to show what a mortality accompanies small-pox where no prophylactic measures are employed to check its progress; and I would merely cite the case of the Island of Puynipet, as given in Sir James Simpson's pamphlet, entitled "Proposal to Stamp out Small-pox," and published in 1868. From a single case of small-pox left on this island, 3000 out of a population of 5000 fell victims to the disease. I may mention here that the mortality from small-pox witnessed in India, and to which I shall now allude, has reference only to those parts of Hindoostan where inoculation is not practised.

[JAN. 9, 1869. 45

with in the Himalayas, where it has been adopted since the most remote times, and whence it probably extended to Bengal, having been received primarily from Central Asia through one of the Himalayan passes. The following description is from personal observation and inquiry in villages where it was being employed or had lately been practised; while that of which I was not an eye-witness was obtained from inoculators by profession, whom I had taught vaccination and brought on the Government establishment as vaccinators.

If we take into consideration the period of the yearviz., the hot and rainy seasons-when small-pox generally rages as an epidemic, the circumstances in which it finds its victims, the utter absence of any treatment other than smearing the body with clarified butter and turmeric, together with the observance of some religious ceremony, consisting mainly in processions and offerings to the deity, we shall be prepared for a high rate of mortality, but hardly for what seems really to be the case. Judging from my own experience, in villages which small-pox had lately visited, and from the observations of the villagers-who, I may add, were inclined to view vaccination unfavourably as a European or foreign innovation, and were therefore not likely, by increasing the mortality, to make out too strong a case for its introduction, as likely ultimately to interfere with their religious prejudices,-I should consider the mortality to be as high as 80 per cent. in very young children, in those a little older, 60 per cent.; but, as far as I could learn, seldom if ever under 40 per cent.; and, as this is only met with in the case of adults, it may be omitted from the calculation, for the following reason:-In the districts I allude to, it is rare to find an adult native suffering from primary small-pox, or one who has been proof against this continu-up with sugar and flour, and, with the addition of water, made ous contagion till he has reached that age-a further proof of the prevalence of the disease. So fatal is small-pox among children, that the following has become quite a saying" among the agricultural, and indeed the wealthier, classes-viz., never to count children as permanent members of the family, nor make arrangements to leave them money, &c., until they have been attacked with and recovered from small-pox.

2nd. The various prophylactic measures adopted to check the disease when it has appeared, and prevent its spreading. This, which I consider the more important division of this paper, can be best discussed by subdividing it into two-viz.:

A. The prophylactic measures employed by the natives of India, which may be summed up in inoculation.

B. Those had recourse to by the Government of India, and which are comprehended in their schemes of vaccination.

A. The prophylactic measures adopted by the natives of India. -With the exception of the districts in which inoculation is practised-viz., the Himalayan range generally, and some portions of Lower Bengal, the natives of India adopt no measures whatever either to check the disease or to prevent it spreading; on the contrary, the numbers which collect at the religious ceremonies, conducted during these epidemics with the view of appeasing the offended deity of small-pox, must have the effect of conveying the contagion to villages which had as yet escaped it. The natives of Hindoostan consider an outbreak of small-pox to be due to the displeasure of the female deity who presides over this scourge. Hence the name for this disease, which, though it may, and does, vary with the dialects of the districts, is, nevertheless, that of the deity in that particular part of the country-for instance, "Thakooranee," or the goddess, &c. I mention this circumstance, as it will help to account for the apathy with which the natives of India view this disease, and may explain the reason of their adopting no treatment for it other than the benefits supposed to be derived from religious ceremonies, but submitting with a fatalism, always the more intense as it is a religious one, to its ravages. When I once hinted to a native, at a non-vaccinating period of the year, that he should not allow his child to play with others who were suffering from small-pox, his answer, which was most characteristic of the above, was, Never mind, the child may as well take the disease now as a year or two hence; the sooner, perhaps, the better. If it recovers, which God only knows, I can calculate on its life."

I will now briefly allude to the practice of inoculation as met

There is no separate profession of inoculators; the practice is in the hands of the priests, and seems to be hereditary, and is taken up by them as a means not only of adding to their income, but of enabling them to spend four or five months every year, not unpleasantly, and at the expense of the villages in which they operate. On the first appearance of a case of small-pox in the Himalayas, imported probably from the plains, the inoculators hurry to the spot, and, from ignorance, allowing the vesicular stage to pass, wait for the pustular, or generally for that of desiccation. During both these latter stages the inoculators collect as much pus and as many crusts as they can, the former on cotton or wool, and the latter as they fall off; though when in a hurry, by a small present, they can easily remove them prematurely. Supplied with this variola virus, they hasten to their districts, and commence operations in a village as follows. Having collected all the cases which have neither had smallpox nor been inoculated, they operate by scratching, with an instrument composed of a bundle of seven needles tied together, at the base of the thumb in the right arm in males, and the left in females; and having got a raw bleeding surface, they bind on some of the cotton or wool charged with variola pus with a blue thread; this they leave till an advanced stage of ulceration sets in, when it is removed. Should the supply of variola crusts be sufficient, they are powdered into a ball, which is swallowed or eaten by each of the patients. To prevent the small-pox resulting from these operations spreading to the neighbouring villages, all the cases requiring inoculation are operated on in the same day if possible, as the period of quarantine, strictly enforced, is limited to a month after the last case inoculated. No means being used to prevent the contagion spreading, by disinfecting the clothes &c., this quarantine of a month generally proves of little ultimate benefit. All communication with this village is closed, producing a complete stagnation of the little trade they enjoy, and often preventing the villagers obtaining their annual supply of salt, rice, &c., at cheap rates from the plains and the interior, as no passing merchant will open barter with a village under the flag, so to speak, of inoculation. During this month the inoculator lives at the expense of the villagers; and, what with fees for the treatment of any serious case resulting from his operations, and the perquisites of feasts and religious ceremonies, his time is pleasantly and not unprofitably spent. (To be concluded.)

SULPHUROUS ACID IN TYPHOID FEVER.
BY ROBERT HAMILTON, F.R.C.S.,

SURGEON TO THE SOUTHERN HOSPITAL, LIVERPOOL.

IN the late epidemic fever at Bootle, notices of which appeared at the time in the pages of THE LANCET, I employed in the last eight cases which came under my care sulphurous acid, and was so much impressed with the mild form the attack assumed, and the apparent cutting short of the progress of the disease, that I am induced now, when fever of the same description is prevailing in other parts of England, to ask those readers of THE LANCET who have much to do with it, to give the remedy a more extended trial, and thus confirm or otherwise the report here given.

The cases were all typical ones of typhoid fever occurring in the district infected, and, in some instances, in houses where previous cases had been. Five were children under ten years of age; three were grown-up young people. The

Mr. Mason said that he had purposely commenced the operation by paring the edges of the fissure, because dividing the muscles was a painful process, and was sometimes attended with smart hæmorrhage, which would probably have alarmed so young a patient. The process of paring the edges was comparatively painless. He had taken great care to dissect each side off in one continuous piece, so that there might be no doubt as to the whole surface being raw. The little patient had behaved remarkably well up to this point; but, on an attempt being made to introduce the needles carrying the sutures, he closed his mouth resolutely, and it was necessary to use a screw-gag to keep it open. This was easily effected, and the operation completed without further difficulty. The parts came together so well that it was thought unnecessary to divide the muscles.

Mr. Mason believes that this patient is the youngest ever operated upon successfully without chloroform. He objects to chloroform on account of its frequently causing vomiting, which is a matter of some importance to be avoided after the operation of cleft palate. He thought that an attempt should be made to close the fissure as early in life as possible, so that the patient might have a better chance of losing by education the peculiar nasal twang always more or less associated with cleft palate.

CHARING-CROSS HOSPITAL.

THE USE OF CARBOLIC ACID.

MR. R. BARWELL tells us that he has gradually adopted carbolic acid for a larger and larger class of cases, including wounds (recent and old), burns, syphilitic sores (primary and secondary), certain skin diseases, and sundry other maladies. Of the forms wherein he has used the acid, it need only be said that the lotion (from ten to fifteen minims of carbolic acid glycerine to the ounce of water) is that which he finds most readily applicable; a sort of thick ointment or putty, made of the acid mixed with oil and whitening, he also occasionally uses. The multiform plasters described by Mr. Lister require much time in their application, and his slight experience of them does not encourage him to expend such time on them.

Recent wounds (surgical).In two cases in which Mr. Barwell opened the palm widely, the lotion was applied to the whole wound, deep and superficial, which was also covered with the putty, spread thickly on lint. One case healed without suppuration; in the other that action was but slight. In one case of excision of the shoulder-joint, the external wound tended to heal even too rapidly, and the opening necessary for the escape of deep pus had to be kept artificially pervious.

[JAN. 9, 1869. 47

Provincial Hospital Reports.

LEEDS GENERAL INFIRMARY.

REMOVAL OF THE ENTIRE TONGUE.

(Under the care of Mr. NUNNELEY.)

In addition to the five cases of removal of the entire tongue described in a paper published in the British Medical Journal for Nov. 5th, 1866, Mr. Nunneley has since that time had seven others, all of which have recovered. Mr. J. A. Nunneley, M.B., has given us this note respecting them. The operation has been somewhat simplified, but is substantially the same as described in the paper referred to. The eye in the broad end of the blade, which carries the wire rope of the écraseur, is now made open, so as to allow the latter to be attached without tying, and to be readily removed when necessary.

In order to ensure the removal of the whole tongue, some plan was necessary to prevent the wire rope from slipping forwards after it was placed in the desired position, and before the screw of the écraseur was tightened; in the earlier operations, hare-lip pins were thrust through the tongue, as far back as necessary, and the loop of rope put over these, which were removed when the rope was so far tightened as to be fixed. This same purpose is now effected commodate itself to the tongue, and having two branches, much more easily by an instrument slightly curved to acat the end of each of which is a notch to receive and push backwards the rope, by which means the latter is kept in position, and may be fixed to any part of the tongue, even to its extreme base.

Nunneley now performs it:-A sharp-pointed blade, curved The following are the details of the operation as Mr. on the edge, about four inches long, and having in the broad end an open eye carrying the wire rope of the écraseur, is passed about midway between the jaw and the os hyoides, but rather nearer the former, and exactly in the median line, into the mouth, and is brought out at the frænum linguæ, and as near the tongue as possible, and the blade removed. The loop of the rope is passed over the tongue, which is drawn out of the mouth as far as possible by Lüer's tongue forceps, and is pushed as far back as necessary by the instrument mentioned above, and held until the screw of the écraseur has been tightened so as gently to fix the rope. Up to this point there has been but little pain, and the voluntary efforts of the patient have materially assisted. He may now be put fully under chloroform. The screw of the instrument is steadily and deliberately tightened, and the tongue gradually cut through.

Twice only has there been any hæmorrhage, and in both cases the tongue was unusually soft, and had been cut through too quickly. It was in each case arrested without difficulty by a ligature.

Recent wounds (accidental).-Of these we may select two men severely wounded with glass during the burning of Her Majesty's Theatre. The wounds healed, not by first intention, but rapidly by a sort of dry, or nearly dry, The whole operation is perfectly easy and simple, leaves granulation. The same means produced the rapid healing jaw heals at once,-is attended by but very little pain, is no deformity afterwards-for the small wound under the of a deep and very jagged wound received in the boiler explosion in Charles-street. This wound closed in twenty-occupies but a short time in its performance. Each of the usually almost bloodless, requires but few instruments, and four days. last three cases has left the hospital about the tenth day.

Burns. When the blistered cuticle separates, the lotion appears to produce more rapid healing, Mr. Barwell thinks, than any other application. There is less pain and less suppuration, therefore less exhaustion, than with other modes of dressing,

TAUNTON AND SOMERSET HOSPITAL. CASE OF AMPUTATION AT THE HIP-JOINT; RECOVERY. (Under the care of Mr. HENRY J. ALFORD.) THE following case is an addition to the list of recoveries after amputation at the hip-joint for disease, and it also bears testimony to the great value of Lister's aorta compressor in an operation of this kind. Hardly a drop of arterial blood was lost, and no ill effects arose in any way from the application of the instrument. Thus one of the great dangers which used formerly to be dreaded in this operation

Syphilis. Among a large number of patients with primary sores, those who had used carbolic acid lotion properly have been freer from buboes. The sores have healed, and induration disappeared more rapidly than with those who had not the lotion. He has strong reason to believe that the occurrence of secondary symptoms is less frequent, cæteris paribus, among those using the lotion; but the time has been insufficient for arriving at any absolute conclusion; and the proverbial uncertainty belonging to out-patient practice also precludes his speaking positively on this point. Two cases of favus, and three of porrigo, were success--namely, hæmorrhage-is entirely removed. fully treated by this lotion. A patient with scabies thus treated was rapidly getting better, when he disappeared from the clinique.

Thomas H, aged forty-two, a labourer, was admitted on June 2nd, 1866. About two years ago he first perceived a swelling, about the size and shape of an egg, in the upper

part of the left popliteal space. It grew very slowly at first, and caused him no pain till a year after, when it was as big as a man's fist. He then felt pain by night, though not by day. He continued his work until September 24th, 1865. On admission, iodine was applied, and iodide of potassium given, without effect; and he left the hospital October 21st for a time, being again admitted on June 2nd, 1866. He was then found to have an enormous swelling of the left thigh, chiefly at the posterior part. Its upper limit was about four inches below the level of the trochanter major, and its lower five inches below the level of the lower margin of the patella. Anteriorly the boundaries of the tumour were by no means well defined, either above or below. The movement of the hip-joint was perfect, and there was some movement of the knee. The skin, particularly posteriorly, was red and brawny, and in some places it had given way, and small, circular, unhealthy-looking ulcers were found. The leg and foot were much enlarged from oedema, which diminished on the application of a bandage and keeping the limb raised. The patient looked pale, emaciated, and cachectic, and evidently suffered great pain.

mosis round the site of the blow, and not, therefore, due to fracture. The head was shaved, a cold lotion applied, and a dose of calomel administered. But coma persisted, and at half-past seven the following morning, about twelve hours after admission, the man died.

A post-mortem examination showed a large thick clot on the right side, between the dura mater and the cranium (the blood had evidently proceeded from the lateral sinus), producing compression of the brain. No fracture was found at the part struck; an extensive fissure was discovered over part of the right parietal, petrous portion of temporal, and involving the greater wing of sphenoid bone, but no depression or displacement whatever. At the inquest which followed the death, the exact way the blow was received was not made out, as no one saw it done. The man had been out with his dray in the morning, and on subsequently arriving at the brewery, about one o'clock in the day, where he gave in his accounts with perfect accuracy, he was observed to have blood-stains on his clothes. He accounted for them by saying that a cask fell off his dray, and, on trying to replace it, the horse started, causing the cask to On June 12th, after consultation, amputation at the hip- fall out with a jerk, and strike his head. He was able, howjoint was performed. The precaution of bandaging and ever, to put back the cask, and go on with his work. Other raising the limb prior to operating was taken, in order to witnesses had noticed the man asleep on his dray, his body drain as much blood as possible out of it. A little brandy leaning outwards, thus making a probability of his falling was given, and before the chloroform. Lister's aorta tour-off, and so receiving the blow. After settling his accounts niquet having been applied, a long anterior and short pos- at the brewery, he went to his cottage, and entered into terior flap were made, the joint being opened and the limb conversation with his friends, but afterwards, feeling faint, disarticulated as soon as the anterior flap was completed. he went to lie down, and became comatose about five o'clock The femoral artery was at once ligatured. Scarcely any in the evening. arterial blood was lost. Seven ligatures were applied in all, which controlled all hæmorrhage. Twelve silver - wire sutures were then applied, and the stump covered with strips of wet lint. The man was ordered thirty minims of Battley's solution, and beef-tea and brandy.-8 P.M.: Slightly sick. Ordered ice, champagne, and Liebig's ext. carnis, and also a draught containing laudanum, sal volatile, and chloric ether.

June 13th.-Has passed a comfortable night; no hæmorrhage or oozing; takes his food and wine; tongue moist; passed water freely. To repeat draught at night.

14th.-Bandage and lint removed; stump looks well; has sherry instead of champagne, and chicken for his dinner. 17th.-Takes food, and sleeps well; in no pain; no bad symptoms. Some sutures were removed.

18th.-Removed the rest of the sutures, and applied strapping and wet lint. Stump looking very healthy.

July 8th.-All the stump healed, except at the upper and inner portion, where the ligature on the femoral still remains. This came away on the 14th.

15th. The last ligature was removed. The patient puts on his clothes, and sits up every day.

23rd. He goes into the garden daily; convalescent, but weak.

BUCKS GENERAL INFIRMARY, AYLESBURY. INJURY TO THE HEAD; COMPRESSION OF BRAIN; GREAT DELAY IN SYMPTOMS; DEATH.

(Under the care of Mr. HOOPER.) THE interest of the following case lies in the lapse of time between the receipt of the blow and the setting-in of coma. The blow must have been received about midday, and the man retained consciousness till five in the evening, and was in the interval quite able, not only to complete his morning's work, and give a satisfactory report of the same to his employers, but even to converse quite rationally with his friends afterwards. The lateral sinus must have been lacerated at once, and extravasation commenced, but the blood having to force its way between the dura mater and the skull, thus meeting great resistance to its progress, the subsequent compression was considerably delayed.

Medical Societies.

PATHOLOGICAL SOCIETY OF LONDON.

ANNUAL MEETING.

ON Tuesday last the annual meeting of this Society was held, Mr. Simon, F.R.S., the then President, in the chair. The Council in their report dwelt, in the first place, upon the important labours of the Committee on Morbid Growths, which would tend to make the archives of the Society of very great scientific value. They, however, drew attention to one result of the establishment of the Committee as affecting the members generally. They thought that they could trace a tendency on the part of the members to neglect making a careful examination themselves of specimens, leaving this duty, in fact, entirely to the Committee. The number of members at present is 428. The new admissions since last October were less than usual, and the Council suggested that the members who were connected with the various schools should impress upon the attention of their colleagues who have not joined the Society the advantages which it was capable of affording. The total receipts during the year were £508 6s. 104d.-the largest income on record. The sale of the "Transactions" brought in £43 13s.; subscriptions, entrance fees, &c., £418 19s. The last volume of the Transactions cost the Society £370 13s., but it was a very large one. The total expenditure was £509 14s. The report was adopted.

Dr. H. GREENHOW moved the alteration in Bye-laws 14 and 19, which we noticed last week. As regards the former, the Council proposed that instead of the non-resident members paying a composition fee of three guineas for the Transactions, they should be at liberty to buy them at cost price; the fact being that the Transactions have increased so much in size and value, that the composition fee of three guineas is now an inadequate sum.

After Dr. Greenhow had explained, in answer to a question from Dr. Seaton, that the altered law was not to be retrospective in its operation, the proposal was carried. that all resident members may pay a composition fee of The alteration in Bye-law 19 was to this effect,fifteen guineas in lieu of entrance and annual subscriptions (the sum at present being ten guineas.)

Dr. PEACOCK and Dr. Down thought that a sliding scale should be adopted as regards the composition fee, according to the duration of membership, and that the Council should consider the question in relation to this point.

A. B- a brewer's drayman, aged thirty-five, was brought to the infirmary between seven and eight o'clock in the evening of the 5th of August last, quite unconscious, and his hair matted with blood. On examination a depression was found behind the left ear, and on a plane above it, situate over the posterior part of the parietal, and abutting Dr. SCHULHOF asked whether the composition fees were on the occipital bone. This was obviously caused by ecchy-invested, or used for current expenses.