1065 operation, and thought that each case should be judged of but why was the separate indication of their cause so diffiindividually. With regard t...

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operation, and thought that each case should be judged of but why was the separate indication of their cause so diffiindividually. With regard to how far operative treatment cult ? No power had yet succeeded in making this generally might be attempted in acute cases, he believed it was impos- possible, nor was it likely that any power ever would, owing sible to arrive at any conclusion until we had obtained a large to the very nature of the cases themselves. They might be amount of accurate information as to the results of treatment, classed under the following heads :-(1) The cases where and he would therefore not attempt to indicate under what symptoms of intestinal obstruction attended acute pericircumstances abdominal section should be resorted to. tonitis, due to gradual escape of faecal matter following perDr. BARR highly approved of the papers read by Dr. Greves foration of intestine, frequently of the vermiform appendix. and Mr. Pughe, and was much pleased with the bold and In these cases the patient died of septic poisoning, though successful line of treatment which they adopted in the very the symptoms were those of obstructed intestine. Treatinteresting case which they brought before the Society. Dr. ment was hopeless from the first, but we did not know that Barr was of opinion that if surgeons were called in at an until afterwards, because the obstruction symptoms were early stage of the case and operative interference more fre- similar to those arising from other causes, and might even quently practised, many valuable lives would be saved, be palliated by appropriate treatment; but in vain, for all and that the operation would not be attended by such a these symptoms were subsequently overshadowed by the fatal fearful mortality as follows it when merely used as a dernier virulence of the poisonous absorption. (2) The cases of pure ressort; or like a drowning’ man catching a straw. He con- functional obstruction, a numerous class, the symptoms of fined his remarks to cases of acute intestinal obstruction, the which were found, as in other classes, presenting every degree symptoms of which are well-marked in pronounced cases; of acuteness orchronicity, severity or mildness, but which under but he thought that different practitioners attached different the palliative treatment that we now all profess to approve values to symptoms in any given case, and hence we find were capable of recovery in a majority of instances. (3) An that the disease seems to be very common in some men’s intermediate class of cases of internal strangulation, inpractice, while with others of equal, if not greater, ex- cluding intussusception, volvulus, band, and the like, not. perience it is comparatively rare. If you look upon all necessarily fatal, yet largely so, though a small minority recover spontaneously, under varying and even conflicting - cases where you have got severe pain in the abdomen, constipation, and vomiting, with, perhaps, more or less shock, treatment, or after abdominal section. Among these cases there were no certain methods of distinguishing the varieties as cases of intestinal obstruction, then, no matter what line of palliative treatment you adopt, you ought to have a very at first, and under operative treatment the successes were not good percentage of recoveries; but if you belong to a more more numerous than without. Even to open the abdomen exclusive school, and in your anxiety for accurate diagnosis, was to run the risk of meeting with one out of the class just referred to, and operating both unnecessarily and harmfully. eliminate all cases of colic, constipation, enteralgia, &c, then you will find that you have a terrible disease left, which The careful adoption of expectant and palliative treatment tends more frequently towards a fatal issue than to recovery. would here enable us to save cases in which recovery was No doubt many very severe cases, under jjudicious treatment- occasionally possible without sacrificing some in which that rest, starvation, opium, hypodermic injections of morphia or result would otherwise be attained with facility. He agreed combined with a small quantity of atropia (which prevents with Mr. Davidson that there was no comparison between the sickness and depression which morphia often occasions abdominal section undertaken for ovarian or other tumours when administered alone),-undergo spontaneous recovery ; and that practised for intestinal occlusion. Whilethealvances. the bowel gets out of its knot or twist, or frees itself from in operative method, dressing, and af ter-treatment were shared its constricting band, or the impacted faeces soften, and the by both sets of cases, the patients in obstruction cases did not inflamed and paralysed portion of the bowel recovers its tone, seem equally capable of recovery, whether that were due to the previous state of the bowels or to some other cause. or in cases of intussusception the invaginated portion sloughs away. But these are exceptional cases rather than the rule. In the first class of cases to which he had referred all treatDr. Barr did not advocate indiscriminate operation, in fact ment was futile, in the third a small minority might be he was strongly adverse to operation unless there were assisted by palliative treatment to undergo spontaneous reasonable grounds to suppose that the patient could not recovery, but the second consisted of cases of which a The physician should arrive at as majority were capable of easy recovery if not improperly otherwise recover. accurate a diagnosis as possible ; the surgeon should be treated, and often if let alone. Upon these his hopes were called in early, and then if an operation were deemed based, and it was in the interest of these that he recomnecessary, there was no use delaying it until the bowels mended the assiduous adoption of palliative measures were all glued together by peritonitis, or the patient dying uniformly in all case9, after the plan laid down by Sydenharn He was puzzled to know why acute in- and fully elaborated by Mr. Thomas. of septicaemia. testinal obstruction occurring within the abdominal cavity (2Q be concluded.) should receive <1ifferent treatment from that which it receives when arising at some of the abdominal rings. Why should an internal abdominal hernia be treated by palliatives while THE BRIGHTON WATER-SUPPLY. In an external receives powerful operative interference ? the latter case, if you fail to reduce the hernia you promptly ON the 6th inst. a representative body of the water incut down and divide any constricting band. Why not, then, in suitable cases of acute occlusion adopt a similar terest visited the waterworks at Brighton, the extension of course, even though the operation be more grave ?1 The the works being now completed after engaging the attention cases are desperate, and justify a heroic remedy. Mr. of the Town Council for some time past. Previously to 1853 Banks had spoken in a very guarded manner about operafrom a well sunk in the obtained its water-supply Brighton tive interference, but Dr. Barr was pleased to think he In that year, was a more bold operator than his remarks would seem chalk and from private wells in the town. to imply, as last winter Dr. Barr sent a case of strangulated however, Mr. James Easton advised the sinking of other hernia into the Royal Infirmary, under the care of Mr. wells and the cutting of tunnels at right angles to the Banks, who in the operation cut away about twelve or four- fissures in the chalk, by means of which the surplus water teen inches of gangrenous bowel, stitched the edges of the had made its way to the sea, so as to intercept the water and two portions of sound intestine together, and the patient carry it to the pumping station. This was done, and the made a perfect recovery. Dr. Barr hoped that in future tunnels were extended from time to time as more water was such excellent surgery would extend more deeply into the needed. From this source the whole town was supplied until 1865, when, owing to the rapid increase of population, abdominal cavity. Mr. RUSHTON PARKER considered the present discussion a greater demand for water arose, and it was determined to construct another pumping station. A well was accordingly an advance on those of past years, and also thought that Dr. Greves and Mr. Pughe were to be congratulated sunk to the west of the town, where a naturally formed upon their case, which they had so skilfully managed basin occurs, and tunnels were driven to the extent of about throughout. Their treatment was justified by the result, a quarter of a mile across the valley parallel to the sea and though he agreed that good luck as well as good manage- intersecting the fissures in the chalk. From these sources a. ment were on their side. The discrepant opinions that copious and constant supply of the purest water is obtained. resulted from the study of restricted varieties of case, the It is found that the fluctuations are very slight, the differdifferences in cause, and the similarity in symptoms, alike ence of quantity of water being felt rather by the impossipointed to the difficulties of diagnosis for differential purposes. bility of the pumps lowering its level than in its rising higher. The recogniti(n of symptoms of obstruction was easy enough, The area of the district supplied is considerable, being about

1066 i into the rural sanitary district, instead of having miles in length by five miles in breadth, the ground merged surface being of an undulating character. It has therefore iindependent sanitary existence. been divided into four zones or services, each fed by its Diphtheria at Huntingdon, b,,y Dr. P ARSONs.-Huntingdon, I Each like own reservoir with its own system of main pipes. Godmanchester, was visited by Dr. Parsons in 1880, and j a consequence some action was taken reservoir is placed at a proper level relatively to the zone it as New sewer i were constructed for ventilation purposes, housesupplies, so that, while a high pressure is given, over- shafts 4 were disconnected, and pan-closets have replaced pressure is avoided. The various services, however, form, drains old and offensive midden-privies. But some of the I together with the pumping stations, one complete system,some 1 still remain in unwholesome proximity to houses and each being only disconnected from the rest by valves and latter stopcocks. The reservoirs are covered, and the water is inwells, and the arrangements for the removal of house refuse i no way exposed to any contaminating influence before it are unsatisfactory. There has been an extension of the runs from the taps. town water in the place of local wells, and the old pest Up to within a few months ago the length of the main house has been adapted to certain isolation purposes. Ten tunnel was about 2000 ft., but it has now been lengthened deaths occurred from diphtheria in 1883, but not much information could, at the date of the inquiry, be elicited as some 600 ft. more, besides being deepened, thus giving more than half a mile of intercepting galleries ; these additions to them. Some of the houses in which they were situated have been effected in eighteen weeks. The total available were in confined situations shut in by other buildings ; some were in close proximity to offensive privies, and others had daily supply of water is now five and a half million gallons, such means of drainage as to a,dmit of their pollution by but of this two million gallons are daily pumped into the On the whole Huntingdon had made some sea, the present demand only reaching three and a half drain air. substantial that sanitary progress since the first inspection, but a the have million gallons. Considering company power to widely extend their workings if necessary, it would seem further extension of the town water to houses still resorting the substitution of cleanly closets for the filthy that, increase as it may, Brighton can never fail in its to wells,that remain, and a better system of scavenging, are privies water-supply. measures still needing to be carried out.





Bethnal Green.-This important parish, with an estimated CHOLERA cannot yet be regarded as extinct in Paris; in- population of 128,370, had in 1883 a death-rate of 23’9 per deed, the latest weekly record which was published on the 1000, the birth-rate being 33’9, and the death-rate under one 4th inst. is to the effect that seventy-four deaths from that year 162 per 1000 births. Scarlet fever was the most fatal disease had occurred in the city during the preceding week. infectious disease, and it caused 174 deaths. From the it is evident that good work is proceeding account The announcement is, however, accompanied by an assur- under thegiven recent statute as to bakehouses. Unfortunately, From Spain as regards bakehouses occupied before June 1st, 1883, ance that the prevalence is really dying out. come continual reminders that although the disease fails to closets communicating directly with the bakehouse cannot assume an active form, yet it still lingers in that country. be dealt with apart from their having produced nuisance, Four deaths have recently occurred at Vergel in the pro. but an inspection of 137 such places is already leading to vince of Alicante, and two more are reported from Toledo. substantial improvement in Bethnal Green. The bread A recrudescence of cholera is also announced from Italy, bakeries are not the worst ; it is in the hidden recesses fifteen cases being reported as having occurred in the pro. of the pastrycooks’ and eating-house premises that the most vince of Salerno to the south of Naples; and the rumour objectionable conditions have been discovered. The cowappears to have some grounds, since, concurrently with it, we sheds are also carefully looked after, and, speaking generally, learn of the postponement of the abolition of quarantine they are now in fair condition. With regard to the housing measures in Sardinia and Sicily. of the people, Dr. Bate urges the demolition of certain courts and alleys, for, many of them being built on the vicious backto-back system, it is impossible to secure for them adequate ventilation. He also advises automatic trough closets for such localities. The report contains a special and full account of the comparative efficiency of certain disinfecting apparatus, and it concludes by advocating Lyon’s high LOCAL GOVERNMENT DEPARTMENT. pressure steam machine. All interested in this subject would do well to read what Dr. Bate says on this point. It appears from the quarterly Hastings (Urban). REPORTS OF INSPECTORS OF THE MEDICAL DEPARTMENT return of the medical officer of health for this urban OF THE LOCAL GOVERNMENT BOARD. sanitary district (Mr. C. Knox Shaw) relating to the three Diphtheria at Godmanchester, by Dr. PARSONS.-Gol- months ending September last (only just to hand) that the manchester was inspected by Dr. Parsons in 1880; the birth-rate was 23’7, and below the average for the correquarter in recent years ; while the death-rate was cottages were found to be old, dilapidated and overcrowded; and exceeded the same average. It is stated that 17’7, the sewers were of defective construction; the water was 17 per cent. of the deaths in the borough during the nearly from wells liable to pollution, and some houses had none at quarter "occurred amongst non-residents or visitors"; and all; offensive midden and cesspit privies prevailed; and it is further noted that under the heading "deaths of visitors there was much nuisance from filth and lack of scavenging. are returned all deaths of who may be "tempoAfter a lapse of three years the only improvement that has rarily sojourning in the borough." It would be well if been effected is that the worst houses are no longer further and more definite explanation of the term "visitor" were added in future returns, as "temporarily sojourning" inhabited, and that others have been supplied with is susceptible of somewhat wide interpretation. The return eavespouts. But the nrst improvement is not apparently before us has two very unsatisfactory features, although the due to the sanitary authority ; it has been brought about by gross death-rate is comparatively low. Infant mortality, a decline of population. In such a district, low-lying, damp, measured by the deaths of infants under one year of age to liable to floods, and all but absolutely neglected from a births, was equal to 19’9 per cent., which is exceedingly high sanitary point of view, diphtheria finds a foothold. The for such a population as that of Hastings. This excess is, to is just over two thousand, and there were six a considerable extent, due to the other fact that the zymotic diphtheria and two croup deaths in 1883. The recommenda- death-rate for the quarter was equal to 4’97 per 1000 of the tions urged in 1880 are again repeated in 1884, and an population. The deaths referred to the principal zymotic analysis is appended showing that the water from a well diseases included 14 from measles, 14 from whoopingwhich was deemed to be least of all liable to pollution, and cough, 2 from diphtheria, and 28 from diarrhoea. Wateringwhich the Town Councillors pronounced to be very good as places are exceptionally liable to infection from these the result of a draught which they took at one of their zymotic diseases, but a high rate of mortality from such sittings, contained so much chloride and ammonia as diseases cannot, even among watering-place populations, be strongly to indicate sewage contamination. On the whole disregarded as evidence of unsatisfactory sanitary condiwe think that Godmanchester would not lose by being tion.

Public Health


Poor Law.