Pacini's Plan of Artificial Respiration.-The following plan of artificial respiration is that of Pacini, of Naples. Place the patient on his back on a table or bed, and let the operator have his abdomen against the head of the patient, and place his hands in the axillæ, on the dorsal aspect, and then pull the shoulders towards him with an upward movement at the same time. The shoulders should then be relaxed, then the former movement, and so on alternately. The air sometimes makes a loud noise when it passes the larynx. (Dr. E. P. Bain, p. 344.) DISINFECTION WITH CARBOLIC ACID VAPOUR.-The employment of carbolic acid vapour as a disinfectant is recommended in cholera or fever hospitals. The acid should be placed in a small porcelain dish which is to be floated in a larger vessel of hot water, and the heat of the latter is to be maintained by means of a gas jet, or similar means. (Dr. J. B. Russell, p. 326.)

IMPROVED SYRINGE-PIPE FOR HYPODERMIC INJECTION.-A gold syringe-pipe may with advantage be fitted with a solid steel spear-point. By this means, we avoid the liability to corrode, which is characteristic of steel needles, and at the same time are enabled to pierce the skin with ease. (Dr. T. Buzzard, p. 325.) LEAD POISONING.-Sulphates and Iodides.-The two chief remedies for lead poisoning are the sulphates and iodides. The former render the lead inert, by reducing it to its most insoluble form, and the latter eliminate it after rendering it as soluble as possible. The lead is eliminated as an iodide of lead and potassium, which is very soluble. The sulphates are most suitable for the treatment of acute cases, the iodides for chronic. As good a formula as any for the administration of sulphates is the following: Magnesiæ sulphatis Zij., acidi sulphurici diluti Mx., tinctura hyoscyami Mxx., aquæ mentha piperitæ 3j., ter die. (Dr. E. Clapton, p. 347.) SNAKE-BITES. Dr. Halford's Remedy.- Professor Halford's remedy for snake-bites is attracting a good deal of attention in Australia. A solution of ammonia is made of the strength of one part of strongest liquor ammonia to two parts of distilled water, and of this an ordinary hypodermic syringeful is injected into a vein. For this purpose an incision must be made through the skin, and the superficial radial vein exposed. The point of the syringe must be introduced through the coats of the vein. This has been tried upon animals, with great success, and once in the human subject. “The beneficial effect was immediate. From an almost pulseless state, and from a. stupor verging on death the patient speedily became con-scious." (p. 353.)

OCT 21 1907

LIEK

PRACTICAL MEDICINE.

DISEASES AFFECTING THE SYSTEM GENERALLY,

1.-ON THE LIMITS OF ALCOHOLIC STIMULATION IN ACUTE DISEASE.

By Dr. W. T. GAIRDNER, Professor of Practice of Medicine in the University of Glasgow.

[Dr. Gairdner considers that the assumption has been made unduly, without proof, to the effect that alcohol not only is a food in the ordinary sense of the term, but that it is the only food that can be relied on to support the system in many states of disease.]

The root of error, as I believe the opinion mainly responsible for the extreme lengths to which Dr. Todd and others have carried alcoholic stimulation-is to be found in the undue assumption that alcohol is not only a real food (which, hypothetically, I at least do not deny), but that it is the food, of all others, which is to be chiefly relied upon for supplying the material of repair in fevers; thus compensating the waste, and averting the functional exhaustion, characteristic of most acute diseases.

This doctrine I firmly believe to be erroneous; and if erroneous, it must not, in the great interests of humanity, be allowed indefinitely to shelter itself under the authority of great names, or to take refuge in the theoretical confusion which may be raised around it, in the present unsettled state of the physiological question. I shall venture, therefore, here to state the opposite doctrine in as precise terms as the nature of the case admits, viz.: that alcohol, per se (that is, apart from the other ingredients present in some stimulating liquors), is not in any sense a fitting material to be chiefly relied on for the repair of the textures in fever; that even admitting the doubtful hypothesis that alcohol may under certain circumstances act as a true reparative material, its practical utility in this direction is very strictly and even narrowly circumscribed by the stimulating or medicinal, narcotic, and ultimately poisonous, action which it always exerts upon the nervous system when given in

sufficiently high doses; that in ordinary medical practice we cannot, as a rule, secure any considerable amount of the supposed feeding action of alcohol without a certain amount of this medicinal and poisonous action; and that the proper use of the stronger alcoholic liquors in acute disease is, therefore, therapeutic, and not properly dietetic.

Now, in order to bring the issue in the matter before us into the clearest possible shape, I shall maintain, as a doctrine based upon experience, that "alcoholic food," so called, is not only a bad and defective form of nourishment in most cases of fever, but (when used in quantity and continuously) a very positively injurious and disastrous one, inasmuch as it tends invariably, in the high doses prescribed by Dr. Todd and others, to destroy the susceptibility of the system for other and more natural food, to disturb the power of assimilation, to retard the elimination of effete matters from the blood, and by poisoning the nervous system, to render the patient more or less insensible to the natural wants of the exhausted body.

The whole drift of the argument of Dr. Todd's book is, that without such doses of alcohol as he describes it is impossible to pass safely through a fever of considerable intensity. Hence the alcohol (as he remarks elsewhere) must on no account be stopped, even though its use should appear to lead to flushing, or to increased delirium, or to coma; for it is more likely that the dose is too small than too large, and in any case, he remarks, "it is much better to err on the side of over-stimulation than not to give enough" (p. 130). Hence, also, the repeated cautions "against the morbid fear of over-stimulation, which leads many to adopt an opposite or vacillating course, and to allow their patients to die from exhaustion. "I must tell you, in limine," he writes, "that is far more dangerous to diminish or withdraw alcohol than to give too much" (p. 484). Again-"I cannot too strongly impress upon you that, to do good with stimulants, you must use them early, with care and watchfulness, in very definite quantities, and not in a vacillating or timid manner. The harm which they do (in disease) is grossly and unfairly exaggerated, and always due to the slovenly administration of them" (p. 270).

But

These statements are certainly entitled to the credit of being the fruit of a very strong and undoubting conviction. are they well founded in fact? Is the large use of the stronger alcoholic liquors in acute disease so necessary? Are the dangers of their injudicious use to be found always, and alone, on the side of under-stimulation?

To both these inquiries I am led by experience to give a negative answer; and as, even apart from all theory, the statement of the facts is important, I shall ask your permission

to place some of them before you in an extremely condensed form, referring to previous communications for the details of evidence.

As regards epidemic fever in the first place, I believe I have unassailably demonstrated that its treatment may be successfully conducted with allowances, even in the very worst cases, of stimulants far less in quantity, and far less continuously given, than those on which Dr. Todd was accustomed to insist from day to day (as above shown), in the face of quite apparent symptoms of alcoholic coma, under the mistaken idea that life could not be preserved without going to the very verge of "over-stimulation." In a rather minutely detailed narrative of two months' experience in the Glasgow Fever Hospital, I have accurately recorded 68 cases of febrile disease (chiefly typhus fever) in males, and 58 cases in females, in the precise order in which they occurred, omitting no single case (even when sent to the hospital actually moribund) that crossed the threshold of the ward; and yet I have calculated that the whole of the 68 male cases consumed only 328 ounces of wine and 401 ounces of whiskey, being, in all probability, a less quantity of alcohol than was administered to the one young girl Copstock, whose case is mentioned above. The mortality of these 68 cases was only 6-i.e., less than one in eleven, one of the deaths being in a case of pneumonia, one in enteric fever, the rest in typhus. The number of these cases is of course quite too small for a statistical analysis of any value, and it is not my intention to insist upon this at present, further than to say that all the available evidence goes to show that the mortality was, as compared with almost any similarly and equally exactly observed series of cases, remarkably small, and that Dr. Todd's results, so far as they are known, were in fact very inferior to mine in respect of numerical success.

It must be stated that in 49 out of the 68 males, and 34 out of the 58 females, there were absolutely no stimulants administered; and in many of the remaining instances the quantities given were so small as to be purely experimental, but at the same time such as to show that I did not, from any preconceived theory, or to carry out a dogma, willingly omit any reasonable opportunity of observing if stimulation appeared to do good. The details of the fatal cases leave it, of course, open to be argued that some of them might possibly have been saved by a larger administration of stimulants; but, on the other hand, I was quite satisfied at the time, and am equally satisfied now, that if on this side there was a possible error, there was also, to a certain amount, an unnecessary, perhaps even injurious, administration of them to some of the patients who recovered. To those who recoil distrustfully from numerical arguments, I

would recommend the study of these cases in detail. I believe that such a study of them will lead to the conviction that, under a habitual practice of high stimulation, the general result could scarcely have been better on the whole, while there is a good deal of reason to suppose that it might have been very much worse. Yet I should be sorry if any one drew the inference that I consider these cases as examples of a perfected or model treatment in all respects, or even that I look upon them as entirely conclusive with regard to the exact quantities of alcohol that may be most beneficially administered in fever. The only conclusion I wish to draw from them is, that the habitual, or continuous, or alimentary use of alcohol in fever is to be deprecated as at least unnecessary, and even to be suspected as possibly injurious.

On commencing hospital practice in Glasgow in the end of 1862, I found another great epidemic of fever already in progress. Four physicians were very soon at work in the fever wards; and I became aware, through various suggestive hints, that the ratio of stimulation I had insensibly adopted, after so many years of varied experience, was considered unusual, and even doubtfully orthodox, by some of the most respected of my senior colleagues. On one occasion it was pointed out to me, from the wine and spirit rolls of the house, that in the other wards of the fever hospital, at a particular date, fully six times as much wine and whisky were administered per patient as in mine; or rather, to state the matter more exactly, the wards might be considered as equally divided between two physicians who adopted a system of pretty high stimulation, and two others who followed a practice of very great moderation in this respect. Under these circumstances it became a simple duty to inquire into results, and to secure, in so far as it could be done without invidious personal reflections, that the lessons of experience should be made as plain as the nature of the facts permitted. I accordingly gave the necessary instructions to my assistants, and I had the satisfaction of having them followed out with the most minute accuracy and faithfulness in detail. The result was a triple series of cases, amounting to 595 in all, which were analysed and commented on in the Lancet, March 12, 1864.

It is difficult to state here in a condensed form what I believe to be the just conclusions from this experiment, without laying them open to some more or less plausible objections; but the following facts are, I believe, unquestionable, and will serve to to give an idea of the inferences fairly deducible from the whole.

In the year 1861 (commencement of the epidemic), before I had left Edinburgh, the recorded mortality of typhus over the whole of the Fever wards of the Glasgow Royal Infirmary was