EPIDEMIOLOGICAL SOCIETY. MONDAY, JUNE 4TH, 1855.

Ætioloyy.-In this

usual, the subject of the dis- ledge. Thus such a case as Bellingham’s, where a man was eighty-eight cases (recorded by cured of a popliteal aneurism in two days, and of a femoral Hodgson, Bellingham, Scarpa, &c.) of popliteal and femoral aneurism in forty-three days; that of Tuffnel’s, where the aneurisms, only two were females. Hunter is stated by Wil- periods of compression in the same individual for aneurisms of son never to have seen a case in the female; and John Bell’s both popliteals and his femoral were respectively six, fortywords are, that " aneurisms of the limbs are never known in two, and thirteen days; seem to point to some extraneous women." Sir A. Cooper, in an experience of forty years, had agencies of a very enigmatical description. What are we to seen but eight cases of popliteal aneurism in the female. As think of such a case as one of the latter author, where the sac regards age-of 51 cases (derived from the above sources), 5 of a large popliteal aneurism solidified in seven hours? Again, varied between 51 and 67; whilst the mean age of the other in Case 5 of Bellingham’s series, a popliteal aneurism, about 46 was 27’; no one was under 20. J. Bell offers the following three square inches, ceased to pulsate in forty-eight hours ; very pertinent reflection on this head :-‘At that period of and yet Case 9, much the same in its details, took fifty-seven life in laborious, hard-working men, the joints are not stiff, days to cease to pulsate. I have, nevertheless, endeavoured nor their muscles shrunk; in short, the defects of old age have to calculate the mean period of compression of reported cases, come upon the arteries sooner than the rest of the system-the leaving out of consideration all that took less than a week or arteries are unequal to those exertions of which the muscular more than sixty days in their cure. I then find the mean frame is still capable." Sir A. Cooper tied the femoral for period to be twenty-eight days; Tuffnel, taking all cases into popliteal aneurism in a man aged eighty; and mentions an calculation, makes it twenty-five days. But, in truth, a refeaneurism of the anterior tibial in a boy aged eleven. But the rence to reported cases shows that cases of extraordinarily earliest age I have met with is that of Mr. Syme, where he prolonged cure are much fewer in number than those of extratied the femoral for popliteal aneurism in a boy aged nine ordinarily accelerated cure. years. It is a received notion, that post-boysare especially liable to popliteal aneurism. This, I believe, to be erroneous. In a case I saw at the Middlesex Hospital, as in the present one, the patient had not been in the habit of riding much for twenty years. Out of forty-nine cases (including two of my own), only three were hostlers. Indeed, a perusal of these The cases shows occupations not calling for riding at all. previous good health of patients with popliteal aneurism is remarkable. Out of forty cases, only five were in bad health; ease was

of the male

is

case,

as

sex.

Of

of which, three suffered from heart disease. Symptomatology.-The peculiar thrill felt in this case was very much like what is sometimes felt in the subclavians of anaemic females. It is not constantly observed in aneurisms; it was not felt in the case of popliteal aneurism I saw at the Middlesex Hospital, though the sac was very large, and the pulsations very powerful; it possibly depends on a vibration of the walls of the sac, consequent on some peculiarity in their constitution, and the degree of fluidity of the blood. I now come to speak of the most important feature of the case.

Treatment.-As to the propriety of trying the compression there could be but one opinion. The general enlargement, tension, and slight oedema of the leg, with the varicosity of the superficial veins, would render gangrene not improbable in the event of ligaturing the main artery. One way in which compression guards against gangrene is, that should any tendency to it show itself, we have at once the means of getting rid of its cause by relaxing the pressure, whereas the ligature of the vessel is a thing done not to be undone. The size and utter want of consolidation are no objections to compression. Thus in Nos. 9, 10, 12, 15, &c., of Bellingham’s series the tumour filled the whole ham. By the 18th of October it is very probable that the sac would have become consolidated, but for the imprudence of the patient in taking off his instruments. A sudden accession of severe pain Ni the knee and leg not uncommonly immediately precedes the consolidation of the sac. In a case under Mr. Liston in 1843,

treatment,

large

"great pain was felt in the knee, extending down the leg," the evening before the cure. Case No. 22 of Bellingham is very remarkable in this respect. Compression had been discontinued, the sac having solidified, but not lost its pulsation; the patient then returned to the country. Thirty-eight days after discontinuance of the pressure the man was riding a spirited horse, made a sudden exertion, and felt great pain in the knee; the pain increased towards night; he took a full opiate, and slept; the next morning the pulsation was gone. Another most interesting case is reported by Hodgson. A woman, aged sixty, had a subclavian aneurism, which gradually extended half way up the neck and some distance below the clavicle. The pulsations became at last very violent, and the pain in the shoulder intense ; the pulse was small and hurried, and death by suffocation seemed impending; when of a sudden the pain became much aggravated for forty-eight hours, and from this time for-

wards all the symptoms abated, and the woman was cured. The period of compression in Hale’s case was six weeks. In order to appreciate the time occupied in effecting the cure in this case, we should compare it with cases similar to it-1st, in the disposition and general health of the patient; 2nd, in the size and amount of previous consolidation of the sac; 3rd, in the medical and dietetic treatment simultaneously employed. Now, a reference to recorded cases shows that in many instances these particulars are not given, besides which we meet with such startling anomalies every now and then, that other influences must be at work in addition to those mentioned Suprâ-influences inexplicable in our present state of know-

10

In the Hunterian operation, it has been shown by dissection that the artery is obliterated, and converted into a ligamentous cord at two points-first, at the seat of ligature; secondly, where the aneurism existed; and further, that a double collateral circulation becomes established---one connecting the vessel above the seat of ligature with the pervious portion of the artery, between the two points of obliteration; and a second connecting this latter with the arteries below the obliteration of the popliteal. Now, in three cases of cure by compression that Bellingham dissected, the femoral artery was found pervious throughout, the obliteration being confined to the popliteal, where the aneurism had pre-existed. The fact of the pulsation ceasing (as in our case) whilst the tumour still exists in the ham, goes to prove that this obliteration of the bore of the artery nearly invariably occurs, for if the aneurismal sac were merely filled with fibrine, it would be in the position of any other tumour placed over the tract of a large artery. The fact above noticed, that in the compression treatment the femoral artery remains pervious, has an important practical bearing-that we should not discontinue pressure till some days have elapsed after the consolidation of the sac and the cessation of pulsation, in order to allow time for the deposition of fibrine to extend into the bore of the artery, since the heart’s impulse is not, as in the treatment by ligature, in great measure removed, but remains in all its force, as soon as the compression is withdrawn. Mr. JEFFREYS narrated a case of a young woman, from different parts of the surface of whose body he had, in about six months, removed a hundred needles-a great many from the mammae. She had previously had a great many extracted at the Bath Hospital. None had ever been found in the mucous passages. She gave no account whatever of how the needles had entered her body.

EPIDEMIOLOGICAL SOCIETY. MONDAY, JUNE 4TH, 1855. DR. BABINGTON, PRESIDENT. DR. SNOW read

a

paper

ON THE COMMUNICATION OF CHOLERA THROUGH THE MEDIUM OF WATER.

The author said that he had on a former occasion explained the circumstances connected with the pathology of cholera, and with its history as an epidemic, which led him to the conclusion

that the disease is propagated by the morbid poison which produces it being accidentally swallowed; and that the morbid matter increases in the interior of the alimentary canal by a process of reproduction, and passes off, to cause the disease in other persons who may take it into the stomach. He (Dr. Snow) had endeavoured to show that there were ample opportunities for the evacuations of cholera patients to be swallowed in the crowded habitations of the poor, where a number of persons lived, cooked, ate, and slept in the same apartment, as the dejections, which often flowed into the bed, were almost devoid of colour and odour, and could not fail to soil the hands of those about the sick person. It was amongst the poor and uncleanly that the cholera frequently spread from person to person, whilst this rarely happened in the better class of houses, where the rooms for eating and sleeping were distinct, and wherethe hand-basin and towel were in constant use. The great prevalence of cholera in the mining districts of this country, during each epidemic, was owing, in the author’s opinion, to the constant practice of the workmen of taking food into the pits, which they ate with unwashed hands, and without knife and fork, whilst the pits were like huge, dark privies, so dirty were they. He had in his former paper related a number of instances, which occurred in the epidemics of 1832, 1848, and 1849, to show that the evacuations of cholera patients would reproduce the disease, after being mixed with the drinking water of the community, by getting into pump wells, either through accidental opening, or by permeating the ground, and also by passing down the sewers into the rivers from which the water supply of many towns was obtained. In this way, the malady often became more extensively diffused than it otherwise would be, and reached classes of the community which it would not reach by its more ordinary mode of propagation. He (Dr. Snow) had become acquainted with many striking instances, also, in the epidemics of 1853 and 1854, of the communication of cholera through the medium of water, but would confine his remarks, on the present occasion, chiefly to a single example on a large scale, which took place in the south district of London, the chief part of the Lambeth Company, and the Southwark and Vauxhall Company; and throughout the greater part of the area which these companies supplied, their pipes were intimately mixed, a few houses being supplied here and there by one company, and a few by another, and very often a single house had a supply different from that on either side. There was no difference in the class of persons supplied by the two water companies; each company supplied both rich and poor alike. In 1849, the water supplied by the twocompanies was almost equally impure, that of the

Lambeth

the entire number of houses supplied by each company, as indicated in their returns to Parliament, he (Dr. Snow) had obtained the assistance of a medical man, and had extended his inquiries to all the districts and sub-districts to which the supply of either company extended. In stating the result, he should divide the time of the inquiry into two periods. In the first four weeks of the epidemic there were 334 deaths in the districts to which the supply of the two companies extended. In 286 cases the supply of water was that of the Southwark and Vauxhall Company; in only 14 cases it was that of the Lambeth Company; and in the remaining instances it was from other sources. When the number of houses supplied by each company respectively was taken into account, it was found that the cholera was fourteen times as fatal at this period in the houses supplied by the former company as in those supplied by the latter. In the next three weeks of the epidemic, as the number of cases greatly increased, the mortality was eight times as great in the houses supplied by the one company as in those supplied by the other. During the remaining ten weeks of the epidemic the Registrar-General caused an inquiry to be made, through the district registrars, of the water supply of the houses in which fatal attacks of cholera took place in the south districts of London, and the result was, that at this period the cholera was five times as fatal in the houses having the impure water of the Southwark and Vauxhall Company as in those having the improved water of the Lambeth Company. The cholera increased during the progress of the epidemic amongst the customers of the latter company as it increased amongst the population of London at large; but they enjoyed throughout the epidemic an immunity from cholera greater than that of the average of the metropolis, or even the average of the districts situated on the north of the Thames. The following, amongst other reasons, proved that the water conveyed the specific cause of cholera, and did not act as a

predisposing cause :Many persons had been fatally attacked with cholera within forty-eight hours after arriving from healthy parts of mere

1.

the country, and drinking water which had received the evacuations of cholera patients. 2. Great numbers of persons drank very impure water from pump-wells and neglected cisterns throughout the epidemic, but did not suffer so long as the water was not liable to be contaminated with what came from cholera patients. 3. When a pump-well, or other limited supply of water, became accidentally contaminated with the evacuations of a cholera patient, as in Wandsworth-road, Horsleydown, Broadstreet, Golden-square, and other places, a great number of persons using the water were attacked altogether, showing that the water contained the real determining cause of the

Company being obtained from the Thames, near Hungerford Suspension-bridge, and that of the Southwark and Vauxhall Company being obtained, as at present, malady. from Battersea-fields; and the cholera was almost equally It was an error to suppose that cholera was always, or even severe in the districts supplied exclusively by one company; generally, associated with impurity of the air; the comparaand in those in which the ever,

by

an

the

supply was mixed. important change was made in the Lambeth Company, who ceased

water in the middle of

London,

In 1854, howwater supplied to obtain the and removed their works to

Thames Ditton, some distance beyond the influence of the tide, and quite out of reach of the sewage of London. When the cholera returned in the latter part of 1853, it was observed by Dr. Farr that it was less fatal in the districts partly supplied by the Lambeth Company than in those entirely supplied by the Southwark and Vauxhall Company. On the recurrence of cholera in 1854 the same circumstance was observable, and he (Dr. Snow) resolved to call at the houses in which deaths from cholera took place in the districts where the supply of the two water companies was intermingled in the way mentioned above, in order to ascertain whether the diminished mortality was really due to the improved quality of the water. Being kindly furnished with the addresses at the General Register Office, he made a personal inquiry respecting every death which took place in the first seven weeks of the epidemic, in all the sub-districts in which the supply of the two companies is mixed. The deaths were 652 in number. Of these he ascertained that in 525 instances the water supply of the house in which the attack took place was that of the Southwark and Vauxhall Company; in 94 instances it was that of the Lam beth Company; and in the remaining 33 instances it was from pump-wells and other miscellaneous sources. As the Lambeth Company supply considerably more than half the houses in the sub-districts in which the water supply is mixed, it was evident that the people having the new supply of water from Thames Ditton enjoyed a very great immunity from cholera as compared with those receiving the water from Battersea-fields. In order to get an exact result, by comparing the number of deaths amongst the customers of each water company, with

tively genteel and airy districts of Clapham and Kennington, which were chiefly supplied with water by the Southwark and Vauxhall Company, suffered very much more in the late epidemic than the districts of Lambeth by the river side crowded with poor people, and sprinkled over with offensive factories, but receiving chiefly the new and improved supply of water from the Lambeth Company; and, again, the sub-district of Saffron-hill, on the north side of the Thames, through which the open Fleet ditch flows and streams along, had a greater exemption from cholera than any sub-district of London, except the neighbouring one of St. George the Martyr, Holborn.

Mr. J. G. FRENCH said, that although he knew that there would be just such an outbreak of cholera in some part of London as that which occurred in his district, (after what had happened in the latter part of the previous autumn,) because that uniformly forms a part of the history of cholera, he was wholly ignorant of the cause which would produce it. This had been entirely explained by the labours of Dr. Snow and of the Rev. Mr. Whitehead, a curate of the district. This latter gentleman conceived that he possessed a sufficient knowledge of the facts to enable him to disprove that hypothesis which regarded the pump in Broad-street, Golden-square, as the cause of the evil; and he proceeded to make the most careful inquiry into the subject with the expectation rather of excluding this, as the cause of the outbreak, than of establishing its truth. This, however, was the result of his inquiries, which was conducted with the greatest care and labour, confined however wholly to one street-viz., Broad-street. It may be briefly stated (continued Mr. French) that those per sons only were attacked who drank of this water, and but few of those who really drank of it escaped the disease. Dr. ROGERS said he could not allow the evening’s discussion to terminate without stating that he was not convinced of the

11

soundness of Dr. Snow’s theory of the propagation of cholera. He (Dr. Rogers) could not too highly eulogize the perseverance, zeal, and indefatigable industry which characterized Dr. Snow’s labours to elucidate and work out his views, because in so doing, even if he did not really prove the soundness of his theory, he brought to light many violations of the laws of hygiene, and remedial and salutary measures would, he hoped, be the result. A case of one of his (Dr. Rogers’) patients having been referred to as supporting Dr. Snow’s views of the propagation of cholera, by the drinking of water into which cholera evacuations had gained admission, he would beg the Society to suspend their judgment until the whole of the facts were brought before them. He did not believe it was a case of cholera, and unless they accepted the theory enunciated by Dr. Greenhow, that during the prevalence of cholera, all cases of even simple diarrhoea must be regarded as choleraic, or incipient cholera, he did not believe that it would be found to prove all that was now imagined were direct and conclusive consequences from the case cited. The whole of the facts connected with the terrible outbreak of cholera in the neighbourhood of Broad-street requires to be known before we can arrive at any really satisfactory evidence as to the cause of it.

Reviews

and

Notices of Books.

Gout and Rheumatism, and the Curative Effects of Galvanism. By R. M. LAWRANCE, M.A., M.D., Physician to H.R.H. the Duke of Gotha.

London : Renshaw.

1855.

removing cataract, for I have succeeded in restoring this transparency to the crystalline lenses of pigs and other animals which I had previously rendered opaque by boiling, or by exposing, them to the action of acids." There is in the above passage a mixture of hardihood of assertion and desperate logic that almost defies criticism. Without’ imputing wilful misrepresentation to Dr. Lawrance, we must; in the first place, withold our belief from his statement that he has, as he expresses it, " employed" (what?) " this effect of the negative pole with success in removing opacity of the cornea," until better evidence is forthcoming. Dr. Lawrance may indeed have seen, or fancied he has seen, an opacity of the cornea; clear off in the course of time, whilst he was amusing himself and his patient with " employing this effect of the negative pole" ; but since opacities do occasionally clear off to some extent without such treatment, it is quite possible that Dr. Lawrance may have been led away by his enthusiasm. We are the more inclined to adopt this conclusion, because the same passage contains such a remarkable example of the peculiarities. of the reasoning faculty of our author, that we cannot help doubting whether it be safe to follow him in his deductions, even if we could in all cases credit his facts. Dr. Lawrance tells us-no, not M.9, but the scaly-eyed and cataractous publicthat "if an egg be boiled hard, and the solid white exposed ta a continuous current, that part in contact with the 92 egative pol6 will become perfectly transparent." That is his fact : what is: his conclusion ? Therefore "he has no doubt of its efficacy" (of this effect of the negative pole) "in REMOVING CATARACT" ! From this it would appear that Dr. Lawrance’s views as to the pathology of a cataractous lens in the living body is quite identical with that of a hard-boiled egg-i. e., that a cataract. is neither more nor less than coagulated albumen! and he even forgets his own statement, that the restored transparency of the coagulated albumen is confined to "that part in contact with the negative pole." Can Dr. Lawrance place his negative pole in contact with the crystalline lens without puncturing the eye ? He cannot, then, so much as repeat his albuminous experiment upon the cataractous lens; and yet such is the force of enthusiasm that takes the reason prisoner, that Dr. Lawrance " has no doubt that he can remove" cataract by his negative pole! He does not indeed say he has succeeded in removing cataract by galvanism, so we think we had better wait to see if experience will confirm this well-constructed-

THE motto of this little book-venture is "Natura nihil agat frustra,." No doubt the author seeks to imitate this excellent example of Nature to do nothing in vain. We therefore conclude that Richard Moore Lawrance, M.A., M.D., Physician to H. R. H. the Duke of Gotha, had some motive in doing us the honour of presenting us with a copy of his work. What that motive may be, we are, however, at a loss to conjecture. There is nothing in it that is not very familiar to the profession, if we except two or three assertions respecting the efficacy of galvanism, unsupported by facts, and which intelligent persons will hardly be considered satisfactorily proved on the bare authority of Dr. Lawrance. The book, in short, to speak very plainly, was never designed to instruct the profession at all; it is aimed at the public, gouty and rheumatic, credulous andfee-giving. He accordinglysets out with informing this select portion of the public" that medical men generally look upon this branch of physics as one but very remotely connected, if at theory. all (!), with practice, and therefore devote but little time to its The remainder of the work, which professes to treat of the study." Dr. Lawrance is also"aware that galvanism, asbranch therapeutic effects of galvanism in gout and rheumatism, is. of medical science, has to encounter many difficulties, not from about equal to the above in the authenticity of its facts and the prejudice alone with which it is regarded, but because the the logic of its conclusions. The facts-that is, the casesthe author sometimes prefers to give in " the patient’s own application is both troublesome and tedious." The author, therefore, undertakes, " in the first place, to words." From this circumstance we are enabled to judge of give a concise detail of the general history, nature, and powers the accuracy and soundness of the descriptions of the patho-of electricity," and, in order to substantiate the accuracy of his logical states said to have been relieved. The whole matter assertion, "that medical men generally look upon galvanism and aim of this book might be expressed in the few following as but remotely, if at all, connected with practice;" and that words :-" The medical profession is prejudiced against gal it is little studied by them, he proceeds, with the free use vanism, or ignorant of its uses. Dr. Lawrance, on the other of scissors and paste and little judgment, to borrow from hand, is a profound medical philosopher, who has made the medical men on his own terms-for he has no scientific capital properties of galvanism his special study, and who is prepared or interest wherewith to repay the obligation-all that he has to employ the effects of the negative pole’ to the cure of to. say of the general history, nature, and powers of electricity! rheumatic and gouty old ladies and gentlemen." This part of Dr. Lawrance’s book, not being his own, does Having thus discharged our duty by expressing our opinion not call for criticism. We beg pardon ; we find we have of the work, we commit it to the shelf on which it is likely to, marked a passage which possibly may be his own. It is our slumber until disturbed for its final removal to the waste-paper duty to introduce it to the notice of the profession, who, being basket. very ignorant (as Dr. Lawrance intimates) of the powers of galvanism, ought not to be deprived of the opportunity of instruc- A Manual of Clinical Medicine and Physical Diagnosis. By T. H. TANNER, M. D., Physician to the Hospital for Women. tions London : Henry Renshaw. 12mo, pp. 306. " If an egg be boiled hard, and the solid white part exposed to a continuous current, that part in contact with the negative THIS little work has been written with the intention of repole will become perfectly transparent, so that writing can moving some of the difficulties which the student always-and be seen through it as distinctly as through glass. This effect of the negative pole I have employed with success in removing the practitioner frequently-must encounter while studying opacity of the cornea ; and I have no doubt of its efficacy in disease at the bed-side. It is certainly well calculated to sim-

12