THE TREATMENT OF GALL-STONES: A SUGGESTION.

1011 1.9 in London and 1’7 in Edinburgh. The fatal cases of whooping-cough, which had been 2 and 7 in the preceding The 156 deaths two weeks, declined again to 4 last week. in Dublin last week included 24 of infants under one year of age and 59 of persons aged upwards of sixty years ; the deaths of infants showed a further decline from those recorded in recent weeks, while those of elderly persons showed an increase. Three deaths from violence and 5 inquest cases were registered during the week, and 43, or more than a fourth, of the deaths occurred in public institutions. The causes of 20, or nearly 13 per cent., of the deaths last week in the city were not certified.

THE SERVICES. ARMY MEDICAL STAFF. -Surgeon-Major H. Archibald Fogerty, M.D., is placed on temporary half-pay (dated April 15th, 1891). INDIAN MEDICAL SERVICE.-Brigade Surgeon Hamilton is appointed to the administrative charge of the Allahabad District in place of Deputy Surgeon-General Rudd; Brigade Surgeon Graves succeeds Deputy Surgeon-General Hinde at Poona; Deputy Surgeons-General Warren and Walsh are under orders for India, the former for Poona and the latter

for Allahabad. NAVAL MEDICAL SERVICE.—In accordance with the provisions of Her Majesty’s Order in Council of April 1st, 1881, Deputy Inspector-General of Hospitals and Fleets William Jas. Eames has been placed on the Retired List at his own request, with permission to assume the rank of InspectorGeneral of Hospitals and Fleets. VOLUNTEER CORPS. Artillery: 1st Glamorganshire: George Herbert Hopkins, Gent., to be Acting Surgeon (dated April 25th, 1891),—Rifle: 1st Volunteer Battalion, the Royal Warwickshire Regiment: Richd. Arthur Newton, Gent., to be Acting Surgeon (dated April 25th, 1891).4th Volunteer Battalion, the Cheshire Regiment : Surgeon W. E. S. Burnett is granted the rank of Surgeon-Major, -

ranking as Major (dated April 25th, 1891).-2nd Volunteer Battalion, the Cameronians (Scottish Rifles): Surgeon and Surgeon-Major (ranking as Lieutenant-Colonel) J. Loudon, M.D., resigns his commission; also is permitted to retain his rank, and to continue to wear the uniform of the Battalion on his retirement (dated April 25th, 1891).

Correspondence. I’ Audi alteram

partem."

"THE PROPOSED RECONSTITUTION OF THE LONDON UNIVERSITY." ’To the Editors of THE LANCET. make a brief comment on a statement in Dr. Hale White’s letter published in your last issue. Dr. White states that the Senate of the University of London received a letter dated March 3rd, 1891, expressing the acceptance of their last promulgated scheme by certain London medical schools (named).). I was at the epoch mentioned, and am still, a member of the Medical Council of one of these (named) hospitals and of the governing body of the medical school attached thereto. I am sure that the project of the Senate has never been considered by the one nor has it appeared on the agenda paper of the other of these bodies. I am forced to conclude that the letter in question does not afford very reliable support to the views expressed by Dr. White. I am equally sure that I am not alone among my colleagues in the belief that whilst the scheme in question will destroy the value of the degrees of the London University, it will not meet the legitimate demand of the London medical student. I am, Sirs, yours faithfully, M.D.LOND., London, April 24th, 1891. M. D. LOND., F.R.C.P.

SIRS,—Permit me to

PUBLIC HEALTH AND PROFESSIONAL COURTESY.

i

upon which you comment. In view of your not having had a copy of my report in extenso I beg to enclose you one which I will ask you to carefully peruse, and specially that. part of it relating to the outbreak of diphtheria at Brandon. This part of it is, seriatim, a copy of the special report which I presented to the Thetford Rural Sanitary Authority, under whom I act, and also to the Local Government Board" at their request in June last, 1890. Neither of these councils have asked me for an explanation of any of the paragraphs, and therefore I conclude they interpreted them in the light intended by me, but to which exception seems to have been taken by your correspondent. No one has. been more astonished than myself at the misconstruction which has been placed upon them, and I can only regret that your correspondent should have imputed to me the charges of professional discourtesy. I distinctly deny that any part of the report was intended as a reflection upon the conduct of the cases of diphtheria.. by the medical attendant, but it was rather an admonition to the public generally and a repetition of the tenets which I have repeatedly advocated in former reports, im order that early and timely medical advice should be obtained, and thus give the medical attendant a fairerprospect of conducting his case to a successful issue, and also to facilitate the work of the health officials. In the paragraph of which complaint is made, I was led to infer this (a) from the personal statement of the. medical attendant to me, and (b) his admission by letter, which I possess, "that it is a great question whether sepsis, may not account for the bronchitis." Under this suggestion had I not reasonable grounds for regarding its possible origin in the illness at Leeder’s house ? And this eliminates the charge of my going behind the certificate of death. With regard to the examination of the infectious cases,, I admit having seen some of them, but at his request, as he was anxious about the serious phase the cases assumed. It must be evident there could be no particular wisdom in courting infection myself, except for some mutual or ulterior good purpose. I have endeavoured to lay before you a, bonâ-fide statement, which I feel persuaded will enable you to absolve me from the charge of which I have been accused.-I am, Sirs, yours faithfully, FREDERICK JOY. Brandon, Norfolk, April 20th, 1891.

* We are glad to receive Mr. Joy’s letter, which unfortunately crowded out of our last issue. Our comments were largely based on such expressions as that " the element of fatality in every case, save one, which attended the outbreak was mainly due to imperfect medical supervision," and the assurance of our correspondent that.

was

the medical officer of health " never saw, either ante mortem or post mortem, the children Leeder and Dyer."’ But it would seem clear that such wording of the report as appeared to imply slight were never so intended, and we feel confident that Mr. Joy’s assurance to that effect will be accepted in full.-ED. L.

THE TREATMENT OF GALL-STONES: A

SUGGESTION. To the Editors of THE LANCET. "

SIRS,—Mr. Walker’s case of Removal of Gall-stones by Ether Solution," which was publisbed in your issue of the 18th inst., has been specially interesting to me. For some or six years ago, when a student in the class of physiology and pupil to a surgeon, under whose care I had seen a case of biliary colic, the idea struck me that if ether were to be injected with a hollow needle direct into the gallbladder gall-stones might be dissolved in situ. And’

five

since then I have been very anxious to test this have mentioned it to several friends with the hope of meeting with a suitable case, but so far I have not been successful. The few cases of biliary colic which I have had the opportunity of seeing have yielded quickly to opiates and general treatment. Of course, in a case such as Mr. Walker reports, where there is a sinus leading into the gall-bladder, the treatment he adopted was as simple as. it was ingenious and rational. But, on the other hand, grave difficulties surround the injection of solvent fluids direct into the gall-bladder by the "hypodermic’p method. In the first place, we must have a case in which

ever

method, and

To the Editors of THE LANCET. SIRS,—IN your impression of April 4th, 1891, and amongst the annotations, is to be found the above, and the gall-bladder

can

be localised against the abdominal

1012

wall; secondly, we should have the facilities for immediately performing the operation of cholecystotomy should threaten. any symptoms of general peritionitis &e. Next, as to the dangers of intra-cystic injections : (1) Inflammation and suppuration of the gall-bladder and its sequelae ; (2) the needle prick might possibly (the obstruction not yielding) lead to extravasation within the peritoneal cavity, though probably adhesions would ere this have been contracted or lymph have closed the aperture. How might these dangers be obviated? (1) By being careful not to inject too irritating a solvent; (2) by, if possible, removing some of the fluid from the gall-bladder previously to injecting the solution. I have always intended injecting a mixture of ether in olive oil with the hope that the oil would do away with the risk of causing inflammation &e. I should feel To this a little chloroform might be added.

’inclined always to employ a solution containing some alcohol in addition to the above. For when bile stagnates for any length of time the bilirubin is transformed into biliverdin, which is only slightly soluble in ether and not at all in chloroform. But biliverdin is soluble in alcohol, whereas cholesterin is soluble in either ether, chloroform, or warm alcohol, and bilirubin is soluble in chloroform.l And the composition of gall-stones is well known to be either pigment or cholesterin separately; or both these combined. I feel that the method of treatment which I have thus endeavoured to explain may be at least worthy of a trial ; and I cannot but think that had Mr. Walker’s patient been subjected to intra-eystic injections of such a solvent as I have suggested it might have so lessened the obstructing stone as to have allowed it to pass into the intestine; and that even possibly under repeated injections the remaining calculi might have gradually been dispersed; and thus the operation of cholecystotomy not been required. (Of course, experience only can show whether or not intra-cystic injection would not be more dangerous than cholecystotomy.) The fact that there is no reference whatever to intra cystic injections for gall-stones in the standard works of medicine, or in Dr. Neale’s Digest," may be a sufficient apology for the above suggestions which I offer for the consideration of your readers. I am, Sirs, yours faithfully, MARCUS M. BOWLAN. Workhouse Hospital, Newcastle-on-Tyne, April 22nd, 1891.

painful to witness. At her urgent request I administered emetine in full dose, with a draught of warm water. Upon the first copious emesis the pulse reappeared in fall beats, giving five or six impulses at a rate of 48, then, within a half minute, falling into a rhvthm of 80, which continued during my observation. All difficulty of respiration passed away with this recovery of the pulse, and in a very short time the patient expressed herself as being " perfectly comfortable." Careful examination detected no evidence of organic disease of the heart, and no other diagnosis now appears so appropriate as that of " reflex tachycardia." I am, Sirs, yours truly, H. WEBSTER JONES, M.D., Yale University. , La.nghsLm-street, W., April 27th, 1891. CONGRESS OF HYGIENE AND DEMOGRAPHY.

INTERNATIONAL

To the Editors of THE LANCET. you allow us to draw the attention of the readers of THE LANCET to the forthcoming International Congress of Hygiene and Demography which will be held in London in August next under the presidency of H.R H. the Prince of Wales. The last meeting of the Congress took place in Vienna in 1887, where members from all countries were most hospitably received and entertained. Experience of former congress meetings shows that the necessary expenses of the arrangements for the reception of from 3000 to 4000 members, the printing of transactions, correspondence and postage, cannot be kept lower than E6000 or £7000. We venture to appeal therefore to all those who are interested in the progress of hygiene, the improvement of public health, and the amelioration of the conditions under which the inhabitants of towns and other groups of population exist, to aid the committee in their endeavours to make the London meeting of the International Congress not only a success, but worthy of the country which has always been distinguished not only for its hospitality, but as All donations a power in the work of practical sanitation. from members of the medical profession will be acknowledged in THE LANCET.-We are, Sirs, yours faithfully, DOUGLAS GALTON,

SIRS,—Will

Chairman of the

Organising Committee.

W. ROBT. CORNISH, Chairman of the Finance Committee.

G. V. POORE,

TACHYCARDIA.

Hon. Sec. General.

To the Editors of THE LANCET. SIRS,—IN an article appearing in the March number of the University Medical Magazine (Philadelphia) Professor H. C. Wood has effectively delineated a class of cases interesting alike by reason of rarity and obscure origin. They are the more worthy of note at the present time, when the general subject of angina, to which they are akin, has in the Medical Society of London elicited so various .opinions. Dr. Wood proposes the restriction of the name "tachycardiato those cases in which very violent heart action occurs without obvious reason, and remarks that " most of them belong to one of three classes : first, those in which there is paralysis of the pneumogastric or inhibitory nerve ; second, those in which the cardiac disturbances are reflex ; third, tho;e in which the affection may be considered Of the second variety he observes as strictly a neurosis. that he has never himself seen a case, "though Rommelaere reports one in which he asserts that an extremely rapid action of the heart was due to the irritation caused by biliary calculus." An instance of this form of tachycardia came under recent observation in the person of an American lady visiting the family of a friend in my immediate vicinity. She was an intelligent woman of middle age, of healthy configuration, but at the moment of my entrance in apparently great distress. Orthopnoea and a degree of cyanosis were present, and her account was rendered in whispers, delivered in an ejaculatory manner. This was her fourth attack, all of them occurring within a period of two years. They had come on always immediately after a hearty meal, which had included pickles or fruit, and which followed upon considerable physical fatigue. She had had skilled attendance, and a variety of treatment during the attacks, but nothing availed until the stomach was emptied medicinally. The pulse was hardly to be felt at the wrist, and was estimated under auscultation at 200. Respiration was hurried and short, and the dyspnoea was 1

Vide Landois and

Stirling,

3rd

edition, pp.

268-9.

N.B.—Full particulars and list of donations will befound on pages 63 and 64 of our advertisement columns.

CLINICAL INSTRUCTION IN INFECTIOUS DISEASES. To the Editors of THE LANCET. SIRS,-As you are drawing attention to the facilities

afforded to medical students for becoming acquainted with the symptoms and treatment of infectious diseases, I think it opportune to remind your readers and the President of the Society of Medical Officers of Health, who also has been alluding to this important subject, that no difficulties have ever attended instruction in this department of medical study so far as Edinburgh is concerned. From the first the corporation insisted on clinical instruction being given in the City Hospital. Classes have been successfully carried on during the last five years, and nearly 200 students annually take advantage of them, from six to eight separate courses being given during the session. I .am informed by Dr. Wood, the medical superintendent, that "two years ago it seemed highly probable that one student contracted scarlatina." This is the only case in which there has been any suspicion of infection having been contracted in connexion with these classes. I am,

Sirs,

Edinburgh, April 29th,

1891.

yours faithfully, D. LITTLEJOHN, HENRY D.

Medical Officer of Health.

"THE VALUE OF TUBERCULIN IN THERAPEUTICS."

allow

To the Editors

SIRS,—I should feel me to refer in

of THE LANCET.

to you if you would kindly few lines of the next issue of

obliged a