809

occupy a relatively large area in the optic nerve. With E

regard to the symptoms of retro-ocular neuritis, in one case there was subjective sensation of colour of a violet or t

reddish pink tint, with slight peripheral contraction of the 1field and a diminution there of perception for green, which (

assumed a bronze appearance. The movement of the eye-ball was painful in one or other direction corresponding with ithe portion of nerve affected. The degree of amblyopia varied greatly. Acuity of vision was diminished in a ]bright light or after prolonged use, general fatigue, or ex- haustion from want of food. In some cases objects appeared as if seen through a moving haze. These phenomena might be explained by the breaking up of the nerve-sheath, leaving the axis cylinders incompletely insulated, or by the ]alternating activity of exhausted fibres. In support of this ilast suggestion it has been found that the colours red and blue are distasteful to the subjects of retro-ocular neuritis.The liability to injury appears to be more marked at the i

periphery and extreme centre of the nerve. The causation ! of the neuritis may be traced locally to the spread of thechange to the nerve from neighbouring orbital cellulitis, dueto erysipelas, cold, or septicæmia; or to periostitis extendingto the optic foramen from the adjacent sphenoidal sinuses, inwhich case both nerves are affected ; or the neuritis may bea local manifestation of a general disease, such as syphilis,gout, or rheumatism, the latter having a tendency to recur- rence ; and, finally, the optic tracts and nerves are liable tosuffer as part of the central nervous system, as in insularsclerosis.

Dr. BUZZARD spoke on the medical group of cases

exhibiting the features of retro-ocular neuritis. In insularsclerosis disorders of vision were frequently associated withatrophy of the optic disc, a condition referable to neuritis ofthe retro-ocular portion of the nerve; 50 per cent. of casesof this disease presented pallor of one or both discs, or inplace of this a red-grey injection and amblyopia lasting fordays or months. Post mortem there were found isletsof gelatinous tissue of a warm grey colour, having adiameter of an inch or more in the brain, and varying greatlyin number. Microscopically, they were found to exhibitnaked axis cylinders, increase of the fibrous elements and aprimary vascular change, but a certain proportion of thefibres were degenerated independently of the other changes.Dr. Buzzard attributed these appearances to interstitialinflammation occurring in local patches capable of resolu-tion, but causing temporary paralysis, and he assumed thesame condition to be present in the optic nerve. Secondarydegeneration did not take place, the lesions were localised,and the pallor of the disc was due to interference with blood-supply, not to atrophy. The local diagnostic features werethe pallor or greyish-white colour of the disc, chiefly in thetemporal half, the edges being sharp, the physiological cupdeep, and the lamina cribrosa distinct, these changes beingbilateral and associated with preceding or immediate impair-ment of vision ; whereas in the intra-ocular form of opticneuritis the changes were much more obvious and attendedat first with little or no alteration in vision and no centralscotoma, the loss of vision being slowly progressive. In theretro-ocular form the central scotoma was general and theperipheral amblyopia a characteristic feature, but both weretransitory, and there was no progressive deterioration ofvision. Concentric contraction ot the visual fields some-times occurred in diphtheria, and the speaker referred to aninstance in a man, aged fifty-eight years, with paresis ofarms, legs, and palate after sore throat, to whom the floorappeared concave at the point of sight. There was no

scotoma, the fields of vision were small, and the left discwas pallid. The fields had since enlarged.

Dr. GOWERS drew attention to the modern established factthat an axis cylinder contained as many flbrils as there werefibres in a nervs, and the important bearing this had on thecomprehension of pathological changes. In connexion withthe rheumatic origin of neuritis he quoted an instance of ayoung man who, after a bath, suffered from paralysis of theocular nerves with proptosis and tenderness of the left eyeassociated with convulsions, and followed by a similarcondition on the right side. He attributed the symptoms toacute cellulitis of the orbit extending to the membranes ofthe brain. Referring to ten cases of insular sclerosis inwhich the optic nerve was affected there were none, hethought, in which the nature of the changes suggested anislet in the optic nerve. In many of the cases the state ofthe vision and appearance of the disc were identical withthose occurring in tabes dors-ili4, apparently a piimary

affection of the nerve fibres. The cases referred to by Dr.Buzzard he thought were of a similar nature. Retro-ocularneuritis was frequently a result of blood poison, especiallygout. The symptoms might simulate those of an intra-cranial tumour affecting the chiasma.

Dr. BERRY thought the disease was a very obscure one, andthat the diagnosis was made too frequently with little pre-cision. The condition was distinct from papillitis of cerebro-pathological origin. Pallor and atrophy of the disc heconsidered were doubtful signs of retro-ocular neuritis.Symptoms very similar to those attributed to this diseaseoccurred in connexion with irritation in the teeth aud also inmigraine where nothing could be found in the fundus. Toxin

poisoning, he thought, was unlikely to produce changesin one eye only. He classilied the forms of defective visiondue to retro-ocular causes as (1) those connected withcerebral tumour ; (2) those due to chill and for the most partunilateral; and (3) toxic amblyopia, which was bilateral and,he thought, not neuritis. Many cases diagnosed as hysteriawere more serious cases of nerve or cerebral disease whichmanifested itself later.

Dr. HILL GRIFFITH said that, excluding tobaccoamblyopia, he had met with twenty-seven of the cases underdiscussion, eight of which had been bilateral. The casesoccurred between the ages of fourteen and fifty-seven years.There was a central scotoma in nearly all, and no contractionof the field of vision. A direct light reflex was present,though in three cases there was no perception of light. Thevision and pupil reflex was ultimately restored in all thecases. Pain occurred early only. and was at its worst aboutthe second day. The disc at this period was pale or un-altered. All the cases were treated with potassium iodide,salicylate of soda, and blisters, and recovery took place inall, though in some vision was not as good as before theattack. Dr. Griffith agreed with the suggestion of Thorburn,that the symptoms were due to rheumatic axial neuritis.

Mr. RICHARDSON CROSS, referring to the literature of thesubject, said that central scotoma and slight pallor of theoptic disc appeared to be the most widely observed features.Out of fifty-seven cases of retro-ocular neuritis he hadselected from 154 instances of optic nerve disease the dis-order was attributed to toxic causes in two-thirds, which wasmore common than in his own observations. Uhtoff in 400alcoholic subjects observed pallor of the disc in seventy ;half he attributed to alcohol and one-sixth to tobacco, thechoice of these among the remaining third being uncertain.He considered alcohol was an important factor in the causa-tion of the condition, though it was asserted by some thatthe occurrence of tobacco amblyopia was prevented by itsuse. In his own five cases there was slight papillitis in oneeye with a central scotoma, but no affection of the peripheryand no other ocular changes.

Mr. LITTLE, speaking of these cases apart from toxic causes,dwelt upon the occurrence of pain, central scotoma, anddiminution of visual acuity as characteristic of the affectionin the absence of definite fundus change. Though thescotoma was large and in one case there was absolute blind-ness, all the cases recovered rapidly.The discussion was adjourned till Wednesday, March 24th.

EPIDEMIOLOGICAL SOCIETY.

Review of the Statement of the Dissentient Members of theRoyal Commission on Vaccination

A MEETING 01 tnis society was held on lfeb. lutn, Mr.SHIRLEY F. MURPHY being in the chair.

Dr. J. C. McVAiL read portions of a paper (printed copiesof a proof of which were supplied to all present) reviewingthe Statement of the Dissentient Members of the RoyalCommission on Vaccination. He inferred from theiruse of such expressions as "more effective, more prac-ticable, and less objectionable modes of protecting thecommunity from small-pox than by vaccination," " approach-ing the subject too exclusively from the standpointof vaccination," and "according too little importanceto other measures," that when they did not by theirsilence imply agreement they differed from the conclusionsof their colleagues more in degree than in fact. Theirtreatment of the early history of small pox, their estimatesof the extent and influence of the practice of inocalation,and their arbitrary choice of authorities, though notmatters of much Dractica.1 importance, were in the

810 T

highest degree unsatisfactory from the bias they dis- z

played. Mead, for example, was not, as they suggested, a

prepared to apply to what he expressly described as " the z

moie common contagion of small-pox" the strict quarantine and isolation that he advised as precautions against future re-introduction of the plague, the two diseases being looked on in his days somewhat as cholera and c

measles are now; and (to say nothing of their protestsagainst compulsion as applied to vaccination) it was unfair to iitalicise in a quotation from Haygarth his reference to the tbenefits ‘ which might reasonably be expected from the tunited, systematic, and concerted regulations of the whole island, aided and strengthened by legal premiums and i

punishments, without a hint of his belief that the infection could not be conveyed by clothing or otherwise than by c

actual contact, on which the feasibility of his schemedepended. It was even more unfair to represent Sir James c

Simpson as a supporter of isolation as a substitute for vac- icination on the strength of selected passages from an essay which contained a glowing eulogy of Jenner and vaccination. They seized every opportunity of emphasising the influence of sanitary improvements in reducing the mortality from I fevers," though the figures they quoted from Sir John Simon showed that between two periods 1746-55 and 1846-55 selected by them " fevers had declined in the proportion of 100 to 71 only, but small-pox of 100 to 17, and that in recentyears the reduction had been confined to typhus fever and typhoid fever, measles having been unaffected, and ithere was no falling off in scarlet fever until 1880.Their speculations as to the numbers cf susceptiblepersons and the influence of inoculation and vaccinationat different periods were based largely on conjectureand assumption. Their account of the labours of Jenner,of his controversy with Woodville and Pearson, of theirconversion to his views as to the non-eruptive natureof cow-pox and of their employment of the "varioloustest," was misleading. They seemed to desire to

charge Jenner with deliberate fraud, as using for his testsclear variolous lymph instead of pus in order to court

failure ; when, in fact, with the instinct of a bacteriologist,he did so that he might have the virus free from extraneouscontamination. When it suited their purpose they describedas vaccinations operations which they had previouslydeclared to be almost certainly variolations, and endeavouredto extricate themselves from the dilemma by saying thatthey employed the word vaccination in a colloquial sense.They took the statistics of the Highgate Hospital-which formany years had been a small-pox hospital in name only,admitting none but paying patients, and refusing allunder seven years of age-as fairly representing theextent of vaccination and the prevalence and age in-cidence of small-pox in London generally, wholly ignoringthe evidence before them derived from the free hos-

pitals of the Asylums Board at Homerton and Fulham,where of 2540 children admitted under ten years of age47 per cent. were unvaccinated, though the proportion of un-vaccinated children in London must have been incomparablyless. When they came to the question of the recentepidemics at Sheffield, Leicester, Dewsbury, Warrington, andGloucester there was the same effort to explain away positivefacts and figures by arbitrary conjectures, and they refusedto recognise differences in the type and severity of thedisease, although they had argued that when vaccination wasunknown the fatality varied from 2’5 to 33 per cent. Theycompared the death-rate of 9’9 per cent. among the vac-cinated at Gloucester with that of 12 per cent. among theunvaccinated at Leicester, ignoring the fact that at theformer town the disease was of the severest and at the latterof the mildest type, the fatality among the vaccinated andunvaccinated respectively having maintained the same

relative proportions-viz., at Leicester, 1 and 12 ; in London,2-2 and 24-2; at Dewsbury, 2-6 and 25-1; at Sheffield, 4-8and 49-6; at Warrington, 6-4 and 353 ; and at Gloucester,9-9 and 40-9. In the whole of the six towns the fatalityamong the vaccinated under ten years was 2 7 per cent.and of those above about 5 per cent. Among theunvaccinated under ten it was 36 per cent. and over ten 34-3.As to severity of type of small-pox, they affected to discreditDr. Barry’s classification of the cases into varioloid, and dis-,crete, coherent, and confluent variola, which gave attack per-centages among the vaccinated of 355, 500, 13-0, and 15,and among the unvaccinated of 0 0, 17-9 62’5, and 19-6, onthe ground that no two observers would exactly agree ; butignored the simple grouping by different men into milder

and severer, which alike at Sheffeid, Dewsbury, Leicester,and Warrington showed an almost exactly inverse proportionamong vaccinated and unvaccinated. They refused, too, to-recognise degrees of efficiency in vaccination, and took sus-ceptibility to re-vaccination as indicative of the same to

small-pox infection, although they knew that inoculationcould be repeated. They affected to ascribe much of thegreat mortality from small-pox, especially among children,in the last century to the practice of inoculation, ignoringthe Geneva statistics of a still earlier period, which showedthat of 25,349 deaths, 6792 occurred in the first, 5416 in thesecond, 4116 in the third, 2826 in the fourth, and 1928 in thefifth, or 21,078 = over 83 per cent. in the first five years oflife, and manipulated Dr. Ogle’s statistics to suit their ownends, so that, e.g., in the Contemporary Re2iew Mr. Pictonspoke of the difference between 46’7 per cent. and 30’3 percent. as 16’4 per cent. when vaccination was involved, butin the Statement of Dissent he held that the differencebetween 6’4 per cent. and 34 per cent. was 46 per cent. (bytaking the 6’4 as the centum) instead of 3 per cent. whenthe reduction could, they fancied, be ascribed to "sani-tation." The influence of sanitation was, they maintained,most evident in the early years of childhood. Well,said Dr. McVail, what could we learn from the case ofScotland, where vaccination was since 1863 compulsory at theage of six months ? In the nine years preceding the passingof the Act 139 of every 1000 deaths from small-pox occurredin the first six months of life, and in the twenty-four yearsfollowing 138. In the next six months the deaths in theformer period were 153 and in the latter 47 in the 1000. Thesaving of 106 was clearly due to vaccination, and that of1 per 1000 in the first half-year of life might be to sanitation.In Germany, again, where vaccination was not required untilsome time in the second year, 410 deaths per 1000 at all agesoccurred in the first two years of infancy, and yet opponentsof vaccination alleged that it was sanitation, not vaccination,that had reduced German small-pox. At Sheffield, which,according to the dissentients, was an insanitary thoughfairly vaccinated town, 25’6 per cent. of the deaths fromsmall-pox were those of children under ten years ; while atLeicester, unvaccinnated, but relying on its boasted sani-tation, the children constituted 71-4 per cent. of the wholemortality. The like ratio between the practice or neglect ofvaccination of late and the small-pox incidence on the childpopulation might be traced in every town for which the datawere available; and yet they could not, while justly in-

sisting on the susceptibility of childhood to the influenceof surroundings for good or ill, recognise another anddominating factor in the mortality from small-pox. As

regards the relation between variola and vaccinia thedissentients were in hopeless confusion: they failed to dis--tinguish between the attenuated variolous lymph of Walkerand Thiele and the variola-vaccine of Ceely, Voigt,Haccius, and others who had completely refuted the doctrineof the Alfort school, and they invoked Creighton and Crook-shank alike, regardless of the fact that these gentlemen wereessentially opposed to each other in their views, Dr. Creightondenying the venereal origin of vaccinal syphilis and sub-stituting for Dr. Crookshank’s bacteria a transcendentalhypothesis of "memory" in diseases. On the vexed questionof diseases communicated by or consequent on vaccinationthe Commissioners, as the result of inquiries conducted bytheir request into every alleged case during the past sevenyears, came to the conclusion that the dangers, though realas regards erysipelas and wound infection, had been greatlyexaggerated and were practically insignificant. Mr. Pictonand Dr. Collins thought otherwise, though abandoningthe position of Mr. Hopwood, who ascribed to vaccina-tion diseases that seemed to be on the increase, re-

vising his list from time to time on no other groundthan that some which had been supposed to be increasingwere really found to be decreasing. The dissentientCommissioners relied largely on syphilis and erysipelas, buthere again Dr. McVail confronted them with statistics fromScotland and the town of Leicester. In the nine yearspreceding the enforcement of vaccination in Scotlandchildren in the second half-year of life contributed 109 out ofevery 1000 deaths from syphilis, and in the subsequent periods1864-75 and 1876-87 the proportions were 118 and 109, or

. about the same; whereas in the first or unvaccinated half-

year of life the number had risen from 575 to 612 and 647, sothat unvaccinated infants contributed two-thirds of the totaldeaths from syphilis at all ages. In Leicester the mortalityfrom syphilis, of course mainly infantile, had in the past

811

twenty years increased by 69.3 per cent., but in England and Wales generally by only 24 7 per cent., and from erysipelas f

by 41’5 per cent. in Leicester, as against a decrease of 16’7 t

per cent. elsewhere. The vagueness of the term sanita-tion," under which they appeared to include progress in the tcomforts and decencies of life as well as all preventive imeasures-with the exception of the greatest of all, vaccina- 4tion-enabled them to refer any improvement at any period i

back to the Middle Ages to this panacea, and by associating small-pox with typhus fever, "gaol fevers," and typhoid fever the strongly marked effects of vaccination on the small-pox mortality were merged in the more gradualimprovement in the public health properly ascribed tothe introduction of better habits and more wholesomesurroundings ; though why they should fix on the year 1800as the era of " greater sanitary activity "-a period markedby no appreciable change in the law or the habits of thepeople, except the epoch-making introduction of vaccina-tion-was by no means obvious. They quoted the belief orhope expressed by Sir E. Chadwick that improved sanitationwould tend to the extinction of all preventable diseases,including small-pox, forgetting that, however deserving ofour gratitude and respect he might be as a pioneer insanitary reform, he, was not a physician and had no right topronounce on questions of a strictly medical character.Their treatment of Hirsch was peculiar, for they professed toagree with him that small-pox as well as typhus fever " tookup its abode most readily in those places where the noxiousinfluences due to neglected hygiene made themselves mostfelt," while making no reference to his declaration that "the

"

achievement of Jenner was at once a turning point in thehistory of small-pox and a new era in the physical welfare ofmankind," ...... and that "it could be only folly or stupiditythat would seek nowadays to minimise or question theimmortal merits of Jenner." Social position as well assanitary environment had, they stated, a potent influence onthe prevalence and fatality of small-pox; but that was mainlybecause the upper classes availed themselves of the protectionafforded by vaccination, for, as Simon reminded us, severalof the royal families of Europe, as the Stuarts, the House ofOrange, and those of Austria and Germany, France andRussia, in the seventeenth and eighteenth centuries had manyvictims to this disease. The observation of Dr. Cross, that" the epidemic at Norwich in 1819 was almost exclusivelyconfined to the very lowest orders of the people," was quotedas supporting their contention, but his explanation of thisincidence-that " the indifference of the uneducated or badlyeducated was such that the number who availed themselves ofthe offer of vaccination was trifling "-was, as usual, ignored.With a strange confusion oi cause and effect they ascribedto the increased facilities for isolation the decline of small-pox in London during the last five-and-twenty years, remark-ing that in 1871-2 only 31 per cent. of the deaths took placein hospitals, while in 1893 the proportion was 87 per cent.But they did not note that the total deaths were respectively9657 and 206, and that the isolation of the 87 per cent., or179, was far easier than that of the 31 per cent., or 2994.Dr. Russell of Glasgow had written to Dr. McVail complainingbitterly of the use made by Mr. Picton and Dr. Collins of thestatistics of that city, in attributing the successful stamping-out of small-pox to isolation and sanitary reform ; whereashe had distinctly maintained that, in his opinion, hospitalscould not be looked on as more than auxiliary means,and were, perhaps, not without a certain amount of dangerto the public, but that vaccination and re-vaccination hadbeen carried out in Glasgow to an extent probably unparalleledelsewhere, so that the common lodging-houses and casualwards were for a time almost converted into vaccinationstations. The dissentients formulated their scheme for theprotection of a community, recommending early notifica-tion, ample hospital accommodation, vigilant house-to-houseinspection, prompt removal of patients, supervision andquarantine for the most part in special stations, of personsexposed to infection, the disinfection or destruction ofclothing, &c., closure jof schools, inspection of tramps,and other precautions, as well as compensation to persons fordamage sustained by quarantine, &c. Did they, he asked,realise the cost, the hostility that such interference with theliberty of the individual would evoke from the people whohad conscientious objections to compulsion of any sort, and lithe risks of evasion, of concealment, and of failure in; early diagnosis ? Perhaps they did, for in recommending theretention, "in deference to popular belief," of the entire

existing machinery for vaccination and the supply of lymph

"they seemed to have more faith in vaccination and lessfaith in isolation than they were willing to admit even tothemselves."

Brigade-Surgeon-Lieutenant-Colonel PRINGLE wished thatthe anti-vaccinationists could see what he had seen in Indiain epidemics of small-pox-the ground strewn with rottingcorpses, incomparably more ghastly than in the case of’cholera, when they lay calmly like Sennacherib’s hosts ; ordistricts where 90 per cent. of the population were hideouslymarked, while in others, where vaccination or the perfectedsystem of attenuated inoculation had been long practised,the faces of the people were as unmarred as in this country.

Dr. ACLAND, in his inquiries into alleged injury fromvaccination, had found none that would bear investigation.As to syphilis the disease had always been congenital,and erysipelas was invariably a post-vaccinal wound infee-,tion ; there was no evidence of the transmission of tubercle,and in the very few alleged cases of leprosy and lupus theexistence of the disease in the vaccinifer was a groundlessassumption.

Dr. COUPLA.ND remarked on the difficulty of providingsufficient accommodation for isolation, and showed someinstructive graphic representations of the age incidence andfatality of small-pox on the vaccinated and unvaccinated inLeicester, Dewsbury, and Gloucester.

Other speakers followed, and the discussion was continueduntil a late hour.

HUNTERIAN SOCIETY.

Exhibition of Specimens.AN ordinary (pathological) meeting of this society was

held at the London Institution on March 10th, Dr. G. E.HERMAN, President, being in the chair.

Dr. ARTHUR DAVIES showed a Heart taken from a girleight years of age, which exhibited a marked condition ofMalignant Endocarditis affecting the mitral valve and partof the left auricular wall. Infarcts were found in the spleenand kidneys.

Dr. SCHORSTEIN showed the Heart of a man, aged forty-one years, in which the mitral and posterior aortic valveswere affected by Malignant Endocarditis. There were infarctsin the kidneys, but no albumin or blood at any time was foundin the urine. Infarcts were found also in the left middlecerebral artery and the superior mesenteric artery, with ananeurysm which had burst into the peritoneal cavity.-Remarks were made by the PRESIDENT, Dr. SEQUiEEA, Dr.ADAMS, and Dr. F. J. SMITH.

Dr. SCHORSTEIN also showed a specimen of Acute Colitiswith Perforation in the Sigmoid Flexure. The patient hadpneumonia, with an alcoholic history. The bacillus coli wasnot found in the colon, but was present in the lung.Mr. TUBBY quoted a case of Rice-water Stools followed by

a very foul empyema.Dr. T. GLOVER LYON showed a Kidney affected with

Miliary Tubercle taken from a patient with severe heartdisease. There was no deposit in the lungs, but between thebladder and the rectum a deposit was present.-Remarkswere made on the relation between heart disease andtuberculosis by Dr. HINGSTON Fox, Dr. SCHORSTEIN, Dr. A.DAVIES, and Dr. LYON.

Dr. PEREINS showed a Stomach with Ulceration Openinginto the Splenic Artery, causing Fatal Hæmorrhage, in awoman aged sixty-six years.

Dr. F. J. SMITH showed a specimen of Tuberculous Menin-gitis taken from a girl, where there was entire absence ofsymptoms with the exception of rather severe headache atthe onset, mental dulness passing into coma, and greatactivity of the knee-jerks. He also showed a specimen ofTumour of the Brain, situated at the base and involving thecorona cerebri and the right optic tract. There was noobservable symptom till within thirty-six hours of death.

SOUTH-WEST LONDON MEDICAL SOCIETY.

Acute hzflmoanzatioo of Bone in 07ailElrejz and Young Persons.A MEETING of this society was held in Wandsworth on

March 10th, Dr. BENJAMIN DUKE being in the chair.Mr. EDMUND OWEN gave an address on a Common

and an Acute Inflammation of the Bones of Children