METHODS AND OBJECTS OF PREVENTIVE MEDICINE.

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  • 133METHODS AND OBJECTS OF PREVENTIVE MEDICINE.

    Pharmacology and Therapeutics.BICIY, A TOXIC FERMENT CONTAINED IN CASTOR-OIL SEEDS.IT has long been known that the seeds of the castor-oil

    plant were poisonous, but the nature and properties of thetoxic principle were very imperfectly known. A good dealof light has now been thrown on the question by the pub-lication of a Dorpat graduation thesis by Dr. H. Stillmark,who has been working at the subject in Professor Kobertilaboratory. He finds that the only toxic principle con-tained in ricinus seeds is an albuminoid body, which henames "ricin," and classes amongst the so-called 11 un-formed ferments." It is unaffected by dry heat of 100 C.,but is destroyed by boiling. It acts, when administered bythe mouth or by hypodermic or intravenous injection, by pro-ducing hmorrhagic inflammation of the gastro-intestinaltract, especially and primarily affecting the small intestine,and secondarily the stomach and large intestine. It usuallyalso causes extreme fulness of the gall-bladder, probably bysetting up some obstruction of the bile-duct; frequentlyalso the bladder is found greatly distended with urine, thevesical mucous membrane being inflamed. In connexionwith these experimental results obtained by observations onanimals, it is interesting to note that jaundice and anuriahave been observed in some cases of accidental poisoning bycastor-oil seeds in the human subject. Diarrhoea is by nomeans constant, constipation having been frequently noticedboth in experimental and clinical cases. Dr. Stillmark hasnever observed the cholera stools in animals which havebeen described as occurring in cases of accidental poisoning.The drowsiness and convulsions which occurred in some ofhis experimental observations he is disposed to attribute tothrombosis of the cerebral vessels. As to the lethal dose, hefinds that for animals it is 01 milligramme per kilogramme ofbody weight when the drugisinjectedintothe veins, so thatfora man weighing 60 kilogrammes it would be 6 0 milligrammes.As drugs administered in this way are perhaps ten times asactive as when taken into the stomach, the ordinary lethaldose of ricin may probably be set down as about 60 milli-grammes, a quantity contained in ten ordinary seeds. It mustbe observed, however, that Christison once had a fatal casewhere onlv "two or three seeds had been swallowed. Thisseems to have been a very exceptional instance, as there aremany cases on record where a much larger quantity has beentaken without a fatal issue: e.g., Rapp reported a casewhere an Italian non-commissioned officer took seventeenricinus seeds, and recovered ; Bouchardat, on the otherhand, had one where a girl of eighteen ate twenty seeds,and died in five days. Experiments on the physiologicalaction of ricin showed that it possesses a peculiar effectupon blood. When this is defibrinated, ricin produces a con-glomeration of the red corpuscles, together with the forma-tion of a fibrin-like substance. When blood is freshly drawnfrom a vein ricin causes it rapidly to coagulate. Again,defibrinated blood is rendered capable of passing through afilter by ricin-that is to say, the serum passes through,leaving the red corpuscles behind ; an extremely dilutesolution is sufficient for this-1 of ricin to 60,000. Noeffect was produced by ricin on isolated nerves or onthe blood pressure, and little or none on isolated muscles oron a frogs heart prepared according to Williamss method.Other euphorbiace were examined, especially the croton-oil plant, and an identical, or at all events a similar, poisonousprinciple was found in them. It was plainly proved byDr. Stillmarks experiments that the action of castor-oil hasnothing at all to do with ricin ; also that croton-oil acid,which has been shown by Buchheim, Krich, Hirschheydt,and Kobert to exist in croton-oil seeds, is an entirely distinctbody from ricin. These seeds therefore contain two virulentout distinct poisonous principles-ricin and croton-oil acid.

    HYDRASTIS CANADENSIS.

    Dr. Schatz of Rostock recommended five years ago, atthe meeting of German naturalists at Freiburg, hydrastiscanadensis as a remedy for hypermia and chronicinflammation of the internal genital organs. Since thenthis remedy has been very frequently employed, andprivate as well as public reports testify to the certainty ofits action within reasonable limits. The want of successwhich has been observed by some medical men is, according

    to Schatz, partly due to the fact that the drug was extractedin Germany, and consequently not from the fresh plant.He has repeatedly obtained remarkably good results whenthe preparation used was the one recommended, which ismade from the fresh American plant. In cases of uterinemyoma the menses became not only less in quantity andmore regular, but lie has even seen a case where thetumour, which had previously extended up to the umbilicus,had, after the constant use of the fluid extract for abouttwo years, almost disappeared in the pelvic cavity.Schatz also confirms his former communications as to thefact that hydrastis causes no pains, but produces onlydilatation of the vessels. He does not, however, wish tosay that the drug makes all, or even most, operations formyoma unnecessary. The drug is also recommended in thetoo frequent or excessive menstruation of young girls. Thehydrastis canadensis has, however, generally to be takenfor a long time and with great regularity. Another remedywhich has also come from America is, according to Schatz,most valuable in some cases, because we have no substi-tute for it, although it cannot be nearly so often em-ployed as hydrastis. It is viburnum prunifolium, whichwas obtained from the United States. This arrests thepains that some women, who have previously aborted,are apt to have during pregnancy, and which only toooften lead to the premature expulsion of the ovum. Thisdrug also has to be taken very regularly and for a longtime, in doses of from 40 to 60 grains of the inspissatedextract. Under these circumstances, however, it cannotbe replaced by opiates or by bromide of potassium. True,the opiates cannot be entirely replaced by viburnum,especially in all cases where strong labour has actually com-menced and requires to be arrested as promptly as possible.It will be impossible in such cases to do without rest andthe recumbent position, at least for some time; and successis of course only possible if the ovum is still living, andfurther interference with it warded off. But Schatz hasseen some cases in which at the first consultation the deathof the ovum could not be assumed, and where it was retainedfor months in the uterus by means of viburnum, while itactually had been dead all the time, as was shown by itsappearance when abortion subsequently took place. Theviburnum does not set quickly or powerfully enough tobe applicable to cases of normal birth or labour comingon suddenly. Schatz cannot as yet tell how the drugacts-whether by stimulating the inhibitory nervous centreof the uterus or by paralysing its motor nerves. He thinksthe former the more probable.

    METHODS AND OBJECTS OF PREVENTIVEMEDICINE.

    THE following is an abridged report of the Presidentialaddress delivered by Dr. John C. MVail, at the fourteenthannual meeting of the Sanitary Association of Scotlandon the 4th inst. :The means for disease prevention which lie at the dis-

    posal of the modern sanitarian are both numerous and varied,and the value itself of the whole object of preventivemedicine is but seldom called in question. Broadly speak-ing, we may take it that there are three great lines ofdefence, three groups of measures belonging to preventivemedicine. These are sanitation, inoculation, and isolation.Sanitation is the first line. The word is often used to coverboth inoculation and isolation, but I wish to apply it herein a more restricted sense. Assuming the theory to becorrect that zymotic diseases are due to specific organisms,we may say that the object of sanitation in this narrowedmeaning is to produce such conditions of air, soil, andwater as shall not be consonant with the existence of theseorganisms. Such environment as is most suited to a humanbeing is least suited to his microscopic foes. The first lineof defence, in fact, is simply cleanliness - cleanliness inbreathing, eating, and drinking ; cleanliness, personal,domestic, and national. It includes many measures. Itmeans that the soil on which we construct streets and housesshall be unpolluted, that the houses themselves shall beroomy and well ventilated, and that the air which ventila-tion provides shall itself be pure. It means that the waterwe drink shall contain no germs of cholera or enteric fever,and that our food shall be clean and wholesome. It means

  • 134 METHODS AND OBJECTS OF PREVENTIVE MEDICINE.

    many Acts of Parliament-Acts relating to pollution of :river:?, to adulteration of food, to water supply, to bake-houses, to smoke abatement, to cattle diseases, to dairiesand cowsheds, to factories and workshops, to open spaces,and to public health matters of many other kinds. This,then, is our first line of defence, and the question arises,Is it not in itself sufficient ? Are all these laws and is allthis cleanliness not enough, in our own country atleast, to exterminate zymotic diseases? Unfortunatelyexperience answers No, for there are germs and germs.A few feet of pure air are enough to destroy thepoison of typhus fever, while, if Dr. Hubert Airy beright, that of diphtheria may retain its vitality for severalmiles. Typhus fever, enteric fever, and cholera may betaken as the best examples of enemies which are unable topass our first line of defence. The question as to whetherthis line will ever be rendered capable of eradicating sucha disease as small-pox is hardly a practical one. I do notsay that cleanliness has no power over it. The germs ofsmall-pox will thrive better in a dirty house than in a cleanone. But in the case of a disease whose living causeappears to retain its vitality through a mile or more ofLondon air, it is clear that in this country, with itsenormous population, such air space as can be given in thebest of model dwellings will be of little avail against thisscourge. Whether a mans head, or his heart, or his liverbe his weak part, he is strengthened and benefited bythose sanitary measures which constitute our first line ofdefence. And be it noted that, valuable as are thesecond and third lines of which I am about to speak,it cannot be said of them that they directly protectagainst attack by any other than those diseases in specialview of which they are undertaken.The second line I have named inoculation, and I have done

    so advisedly, as indicating a theory rather than an actuality.If we describe the group of measures classed under the firstline as consisting of means for preventing disease germs fromspreading and multiplying, we may describe the secondgroup as a protection against germs which have succeededin breaking through the first line. The second line is evenless complete than the first. We have no inoculation toprotect against scarlatina, measles, or whooping-cough.Against hydrophobia the line is in active formation.Against cholera it was tried with very doubtful effect inSpain two or three years ago. In fact, it is against only onedisease that in past years this method of protection hasbeen found capable of being made efficient. Fortunately,the disease in question-small-pox-is one against whichthere is very special need for protection, for there is noneover which the first group of measures has less power.The third and last line of defence is isolation, the separa-

    tion of the sick from the healthy. It has been said that theuse of the knife is the opprobrium of surgery. In the sameway isolation is the opprobrium of preventive medicine.Our first aim, as we have seen, is to prevent the existenceof disease germs. Our second aim, which assumes that thefirst has been unsuccessful, consists in efforts to make thehuman body proof against the germs, to provide a coat ofmail against an enemy that has broken through ourdefences. Our third aim assumes that the enemy has gotsome of us by the throat, that part of our forces is in hisgrasp. I say, therefore, that isolation is the opprobrium ofpreventive medicine, and in all our work it is necessary tokeep this in mind, that our main object should be to makeisolation unnecessary by preventing any section of the popu-lation from being seized by disease, just as the main objectof the surgeon should be to make operation unnecessary bythe use of other and better means. But while it is truethat the knife is the opprobrium of surgery, it is also true,paradoxical as it may appear, that some of the greatesttriumphs of surgery are due to the use of operativemeasures. So also with us, some of the greatest triumphs ofpreventive medicine are due to timely isolation, isolation,that is to say, of the disease poison. For it is to be remem-bered that the isolation of the patient is simply a meanstowards the isolation of the poison. All methods of dis-infection belong to this third line of defence-the burningof bedding, the fumigation of rooms, and so on, have fortheir object the destruction of a living germ whose exist-ence we have failed to prevent.

    These, then, are the methods of preventive medicine.We come next to its aims, and to the objections thathave been urged against these aims. For in regardto our whole procedure, the question of "Cui bqno

    frequently arises. To what end, it is asked, are allour measures for disease prevention ? Are we not fightingagainst the great law of the survival of the fittest? Inolden times, it is said, the weakly went to the wall, andonly the strong lived, and became the progenitors of ahealthy race, while now the weakly are nursed and cocldledand protected against every wind that blows. The life, too,that these feeble ones live, is it worth living ? Is it notsimply one prolonged sickness, without either pleasure orusefulness ? Nor do the consequences end with the sufferers.They marry and bring fortli a degenerate race, the membersof which also marry, and so by degrees the whole life bloodof the nation is being poisoned. Thus it would appearthat our title of health officers is a misnomer, and that ourefforts after health only end in disease. In reply, it wouldbe sufficient for the sanitarian to take up the high groundof the physician; to say that human life is a holything, and that it is his duty to preserve it whereverfound. The physician may believe that the patient,whose life hangs in the balance, will, if he survive,be a curse to himself and to the world. Yet it is"his not to reason why," but to do his utmost to turn thetrembling scale towards recovery. So it is not necessaryfor the sanitarian to discuss whether it is well or ill thatthe general environment of life be made such as to causemany a consumptive or scrofulous child to live that other.wise would die. It is his work to do all lie can to makelife easy of retention by the very weakest. If the questionbe asked, Where is the proof that our preventive measures-our sanitation, vaccination, and isolation--have had theresults we speak of, the answer is at hand. It is givenby the Registrar - General in the language of figures.He points out that, according to the newest English lifetable, the children born in England in any one yearhave now divided amongst them nearly two millionyears of life" " more than would have been the casethirty-five years ago. In England and Wales the annualmortality per 1,000,000 of population has been as follows:In 1861-5, 22,595; in 1866-70, 22,436; in 1871-5, 21,975;in 1876-80, 20,817 ; and in 1881-5, 19,310. Comparing thefirst period and the last, the difference is 3285 per 1,000,000,and, taking the population at 30,000,000, the total annualsaving is about 100,000 lives. And if for every death thereare twenty cases of sickness, then we have 2,000,000 less

    ! cases of sickness than in the first period. Interesting cal-. culations have been often made on this subject, and espe-

    cially by that father of sanitation, Mr. Edwin Chadwick,who, happily, is still with us, a witness of the great.! ness of the success that has attended his lifes work.You can count the cost of each case of sickness, of lostwork, of doctors bills, and so on, and also the monetary

    ! value of each of the 100,000 lives saved. And you can put; all this as income against the interest on the money spent

    in sanitary improvements--in water works, sewerage works,! vaccination grants, officials salaries, &c. And even on this; lowest ground-on this merely commercial basis-we find; that cleanliness, which is next to godliness, resembles godli-ness itself in being " great gain." But we can take a vastlyhigher standpoint. We also are labourers in the great fieldof moral reform. In this field there are many groups em-s ployed, each pursuing its own line, and each-ay, even thesanitarian-possibly apt to attach too much importance tohis own particular department. The teetotaller holds thatif intemperance were driven out of the land, then would- follow education, cleanliness, and religion. And doubtlesstlie is right. The educationist holds that if mans intellectwere duly trained it would lead him to avoid alcohol,to avoid dirt, and to avoid immorality ! Doubtless he too,

    is right. The religionist holds that if man can be taughtt his duty to his God, he will do it also to himself and to hisfellow-man, and that education, cleanliness, and temperancef -will be the fruits of his religion. Again I say, doubtless he,

    is right. And the sanitarian holds that if a man is pro-- vided with pure air, good food, and healthy exercise, he NNills then be in a bodily condition which will produce no craving.- for the stimulus of alcohol, which will open his intellect tog all the influences of education, and which will make himr better able to receive and to appreciate the truths oji- religion. For, throughout our life, all good things are

    woven together, and thus it comes that the prosaic and oft-;. times unattractive work of the sanitarian has in it an,t abounding helpfulness that overflows into every corner ofd mans being, and makes for his intellectual and his moral"

    as well as for his physical welfare.

  • 135THE CHAIR OF SURGERY IN THE OWENS COLLEGE.

    THE DRAINAGE OF HENLEY-ON-THAMES.

    Ix dealing with the question of the house boats and thecontamination of the Thames during the Henley Regatta,we mentioned that the Thames Conservancy had compelledthe town of Henley to adopt a general system of drainage.Some houses used to drain into the river, while the cesspoolsof others had overflows into the sewers, the contents of whichin their turn went to the river. Thus the Thames was COH-taminated by at least a portion of the sewage from the4000 or so inhabitants of Henley. On the other hand,it was no easy matter to drain a town which, by reasonof the small number of inhabitants, had but slenderfinancial resources; also the topographical position isaltogether unfavourable. Built on the banks of the Thames,there is no natural fall for the sewers, and pumping orlifting stations are indispensable. Nor is this the onlydifficulty. There is an abundance of spring water in thesubsoil, and after wet weather the spnng water rises towithin a few feet of the surface. In one place this evenrenders the road soft. It would therefore be difficult to digdeeply into such ground, and yet, to obtain any approachto a suitable fall, it would be necessary to lay at least1000ft, of the main sewer at a depth of 22 ft. to 27 ft. belowthe surface, and something like 15 ft. to 20 ft. below thesubsoil water level. These are difficulties infinitely greaterthan the substitution of earth-closets for waterclosets onboard house boats; but the Thames Conservancy insistedthat the Corporation of Henley must perform its duty,whatever the cost. This has now been accomplished,and at a special meeting of the Town Council, held a fewdays ago, it was agreed on all sides that the result wasvery satisfactory.The special obstacles to which we have just briefly alluded

    have been overcome by the application of the Shone system,and nowhere has this system been more thoroughly carriedout. At Eastbourne, for instance, it is only in part applied.Tomeet the want of level, four ejector stationshave been con-structed under the roadway at the lowest points of each ofthe four districts. These are the lifting stations. Each hastwo ejectors, one in use, the other in reserve in case ofaccident. When one of these ejectors is full (and it con-tains 150 gallons) a discharge of compressed air automa-tically takes place, and the sewage is lifted into anhermetically closed iron pipe, in which it flows to the seweroutfall. The ejectors are fed by ordinary earthenwarepipes; but as the sewers travelling to these ejectors arecomparatively short they can be laid at a good fa,ll-1 in200 at least. The longest sewer is not 1000 yards, andthe average depth in the lower part of the town is 7 feet.These sewers are all perfectly straight. The changes ofdirection are made in manholes and open channels, wherethere are all facilities for inspection and flushing. Eachejector station practically isolates the district from whichit is fed from all other districts. The whole problem ofdrainage is simplified to the necessity of reaching the nearestejector, and their number can be increased according to thetopographical difficulties that present themselves; for oncethe ejector is attained, the question of fall is no longerimportant-the sewage can be, and actually is, propelledup-hill.The first ejector is on the Reading-road, a little beyond

    the railway station. Here the sewage is lifted into a four-inch cast-iron pipe called the "sealed main." The secondejector is at the bottom of Friday-street and close to theriver, the third in New-street, and the fourth at the end ofBell-street. The sealed main, at first but four inches indiameter, and increasing an inch in diameter as it receivesthe contents of the different ejectors, now continues itscourse to the sewer outfall and sewer farm, a mile beyondthe town in the Lambridge Wood. Altogether the sewageis raised 140 feet, and this is accomplished by an air pressureequal to 40 lb. per square inch. The compressing enginehas Lancashire boilers of thirty-horse power, which supplysteamat 60 lb. pressure tothe engines, and consumeecoaltotheextent of 3lb. per horse power per hour. The cost for theworking expenses amounted to i;245 for the first half-year,and there has been no accident or miscalculation. Alreadyabout 600 out of something like 900 houses have been con-nected with this new sewer and the cesspools abolished.Active measures are now being taken to connect the

    remaining houses, and this will probably he com-pleted before the next regatta. Mr. Frederick Bell,formerly mayor of Henley-on-TIiamcs, in an able littlepamphlet describing what has been done, claims that theadoption of the Shone system at Henley lias resulted in thefollowing advantages:"I Small .sewer pipes, laid withgood inclinations at no great depth, watertight, and mostlyabove the subsoil water level, discharging the sewage intoan ejector, where it becomes cflcetl1ally trapped. 2. Therapid transit of the sewage into an ejector before decom-position sets in. 3. Reduced cost for flushing, when thatoperation becomes necessary, the small sewers necessarilybeing more effectually flushed with less water than largerones would be. 4. Freedom from bad smells emanating frommanholes; for, the cubic capacity of the sewers being small,the volume of air in contact with the sewage is propor-tionately small also, and, being constantly changes throughthe rapid now of the sewage the latter cannot becomestagnant and dangerous. 5. Less risk of the spreading ofcontagious diseases ; the noxious matter entering the sewersof the district not being in any way communicated toanother district. 6. The facility afforded of extending thesystem to new districts, irrespective of levels in either.7. The reduction in the cost, both in the initial outlay andin the working expenses, which thus enabled the engineerto take the outfall a mile from the outskirts of the town,with 140ft. lift; to purchase land for JE200 an acre, withoutthe slightest opposition, in a position where it is unseenand is no nuisance to the public ; and to complete thewhole of the works, including purchase of ground, subsoildrains laid in low parts of the town, and legal expenses,for 19,000."Such briefly are the results achieved at Henley. It only

    remains to add that the rain water drains by natural gravi-tation into the Thames, but all domestic waters, stabledrainage, and sewage proper are disposed of by the Shonesystem. The works will at present deal with thirty gallonsper day per head for a population of 6000, while the censusof 1881 showed that the population amounted to 4601, andhad only increased to the extent of 80 in ten years. Thesewage at the outfall is delivered in settling-tanks. The clear

    ,

    water is used to irrigate the land, while the sludge is takenout, mixed with ashes and dry refuse, and converted into

    portable manure. Thus the vexed problem of draining thelittle town of Henley appears to have been satisfactorilysolved, and the Thames saved from a very serious source ofcontamination. The local authorities are to be congratu-

    . l(tte(I on the initiative they have taken, and on the very practical and interesting experiment they have made ofi a promising method of drainage.

    THE CHAIR OF SURGERY IN THE OWENSCOLLEGE.

    ON Tuesday, July 17th, a large and enthusiastic meetingof past and present students of the Owens College MedicalSchool was held in the Free Trade Hall, Manchester,J. Sheldon Withers, Esq., M.R.C.S., L.R.C.P., in the chair.

    : There was a good attendance of practitioners, and lettersfrom others were read expressing regret at their inabilityto be present and sympathising with the object of themeeting.The Chairman, after explaining the method of procedure

    . followed in the election to professorial appointments, wenton to say that the meeting did not in the least impugn the

    f motives of the Council, which was composed of men fori whom they had the deepest regard; but it was quite open toi them to conclude that the Council had made a mistake,

    and quoted instances where such mistakes had been made1 elsewhere, and had since been acknowledged.

    The following resolution, to be forwarded to the Councilof the Owens College, was proposed and passed unani-mously: "That this meeting of past and present students

    y of the Owens College Medical School desires to approache the Council of the College with the greatest respect, and toe express to the Council its regret that the claims of its own,

    candidates for the Chair of Surgery should have been, as itthinks, so slightly regarded-a neglect for which it has failed

    - to find any sufficient justification, and one which it believes. will be injurious to the best interests of the students."e In the discussion on the resolution, the speakers were

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