437

death-rate. It is interesting to note that the cholera epidemicsof 1849,1856, and 1866 have each been followed in the suc-ceeding year by a slight rise in the mortality from calculus.The influence of rainfall upon the distribution of calculous

disease in England is very marked, and has been carefullyworked out. My friend, Mr. S. H. Miller, F.R. Met. Soc., hasbeen good enough to construct for the purpose of the presentinquiry a rainfall map of England, showing the mean annualrainfall in the separate registration counties for the ten

years 1872-81. Placing the map beside the calculus map,it is very remarkable to observe how the disease is confinedto those districts in which the rainfall is least. In no

English county having an annual rainfall above 35 in. doesthe disease attain a mortality of 1 per 100,000. Of thefifteen counties having a larger mortality than this, ten ofthem have a rainfall of less than 30 in. Just as we saw wasthe distribution of calculus, so we find the counties havingthe least rainfall all lie to the east of the second westernmeridian, and the majority of them between the 52nd and53rd degrees of north latitude. The same holds good withScotland. The bulk of the disease falls upon the eastern sideof tl!e country, where the rainfall is considerably less than onthe west. The annual rainfall of Aberdeen city (1872-81)was only 32 in., and of Caithness 37’9 in.; while thosecounties which we know, either from the hospital returns orfrom the direct testimony of the medical men themselves, tobe practically stone-free, have the following heavy rainfall :Inverness 52’0 in., Sutherland 43’9 in., Ross and Cromarty41’Oin., Argyle 58’4in., Perth 51’9 in., and Dumfries 53’5in.Ireland affords another instance of a heavy rainfall beingaccompanied bv a low death-rate from calculus. The reasonfor this is not far to seek. In the first place, a dry atmo-sphere means that more fluid is lost to the body by cutaneoustranspiration than is the case in a humid atmosphere: hencethe renal secretion is more concentrated in the former thanin the latter case. But this is not all. It has long beenshown that the immersion of the body in water of a lowertemperature than that of the body itself lessens the acidityof the urine. Consequently, the more frequently the inhabi-tants of any district are exposed to rain-baths, the less willbe their liability to the deposition of uric acid or calcicoxalate from their urine, neither of which substances aredeposited from other than acid urine. Mr. Cadge has pointedout the greater frequency of calculus amongst the childrenof the poor than amongst those of the wealthy. This cannotbe wondered at when we reflect upon the much greater fre-quency to which the children of the rich are subjected tothe process of bathing as compared with those of the poorerclasses.Season influences the admission of stone cases into the

Norfolk hospitals. From an analysis of 500 admissions tothe Norwich, Lynn, and Yarmouth hospitals, it appears thatfewest cases present themselves during the cold months-November to February. Their numbers increase duringMarch and April, and attain their maximum in May (withus the month in which the atmosphere contains leastmoisture). Next to May most cases were treated in October.The consumption of cyder as a beverage is popularly

credited as being a powerful prophylactic against stone,probably because the cyder county of England, Hereford, isalso the most stone-free. liy friend, the late Dr. Bull, ofHereford, pointed out to me, just before his death, thatstone was rare, not only amongst the poor, but also amongstthe upper classes of Herefordshire, amongst whom the con-sumption of cyder is but small. There are, however, goodreasons for believing that cyder and perry are betterbeverages than malt liquors for calculous patients.The fact of a heavy rainfall, so to speak, washing out the

disease, is of importance from a practical point of view.Not only are the counties in which it occurs suitable for theresidence of those threatened with calculus, but we shouldalso bear in mind the value of bathing, especially of coldbathing, as a prophylactic measure.

It only remains for me to tender my thanks to the numerousgentlemen who have assisted me in the present inquiry,especially to Dr. Ogle and the Registrars-General of Irelandand of Scotland. Although for the present the cause of thefrequency of stone in Norfolk has not been solved, yet certainfacts have been collected bearing on this point, which mayprobably form the basis of a future communication. In themeantime, it is hoped that the facts given above as to theconnexion of other diseases with calculus, and the influenceof rainfall and of season, may not be without interest.King’s Lynn.

CASES OF POISONING BY SQUILLS.BY E. BECKIT TRUMAN, M.D., F.C.S..

PUBLIC ANALYST FOR THE BOROUGH OF NOTTINGHAM.

(Concluded from p. 392.)

Chemical tests.-On the hypothesis that in the originalmixture tincture of digitalis might have been substitutedfor ipecacuanha wine, or that in the case of both mixtures ofA.’s dispensing tincture of digitalis might have got into theipecacuanha wine bottle, and hence been dispensed in bothcases, 1 took 10 grains of tincture of digitalis, and also106 grains of A.’s second edition of the mixture (therebeing prescribed 90 minims of ipecacuanha wine in960 minims of the mixture). These two quantities I

separately extracted in the way described above. Theextract from the mixture was of a light straw colour, thatfrom the tincture of digitalis was of a light brown-showing that this substitution could not have taken placc.The reaction known as Grandeau’s test for digitalinewas also tried, but the results need not be given. So dis-

tinguished a toxicologist as Dr. Stevenson1 says, "I havefound this reaction to succeed tolerably well with the Frenchand German varieties, but I am doubtful whether it ischaracteristic of digitaline." And in a note to me, dated 9thof March, 1886, he says : "I have no faith in the chemicaltests for digitaline. Squills in its action is like digitalis, Iknow, and others say its chemical reactions are similar."These chemical reactions are therefore to be taken for whatthey are worth, and as, at present at any rate, inconclusive.

Cardiac tonics, or cardiac OMOMs.— " With a larger dose,the stage of stimulation is followed by one of peristalticaction, and final arrest in systole."2 These poisons includethe following: 3 Corroval, which arrests the heart’s action inthe frog in live and a half minutes; Antiaria toxicaria (upas treeof Java), in from five to ten minutes; Veratrum viride, sevento eleven minutes; Tanghinia venenifera (Madagascar ordealpoison), five to fifteen minutes; Manganja (the Strophanushispidus), eight to fifteen minutes; Digitalis purpurea. tento twenty minutes; Urginea scilla, or scilla maritima, four-teen to twenty minutes; (corresponding to Experiments 4and 8 in my list); Dajaksh, thirteen to twenty minutes;

I Vao, fifteen to twenty minutes; ]1jrythrophlaeum gmneense’

(a large African tree), Nerium oleander (the South Sea rose),Thevetia nereifolia, Convallaria majalis,4 Apocynum canna-

, binum (Canadian hemp), and Adonis vernaliseThe special poison in the present cases.-So far as my

reading goes, with the single exception of veratrum viride,there is at present no means of distinguishing between themembers of this group of cardiac poisons, either by chemicalor physiological tests. We require to have the activeprinciples of these drugs separated, and to have them care-fully examined by chemical and physiological methods, witha view to finding out reactions that are characteristic, beforewe shall be able to affirm with certainty the presence orabsence of any one member of this group in a solution, or inthe dead body (as we do not know that the action of veratrumviride is peculiar to it alone). If, however, the series ofphenomena above described as occurring in the frog’s heart,after hypodermic injection, be observed, we may certainlysay that one of the drugs mentioned has been taken. Of thefifteen drugs mentioned, we may, in considering the causeof death in the present cases, exclude eleven as being mostunlikely to be found in a chemist’s shop, and by this meanswe may narrow the inquiry to the four remaining-viz.,veratrum viride, digitalis purpurea, urginea scilla, and con-vallaria majalis. Veratrum is excluded at once, as it causescessation of respiration before it arrests the heart’s action.Digitalis may be excluded for the following reasons. Thetwo officinal preparations are the infusion and the tincture;the’experiment described first under the heading chemicalTests" shows that the residue from 10 minims of tincture of

1 Guy’s Hospital Reports, 1866, Fagge and Stevenson on PhysiologicalTests for certain Organic Poisons, and especially Digitaline, p. 44.

2 Brunton: Pharmacology, Therapeutics, and Materia Medica, 1885,p.276.

3 Fagge and Stevenson, op. cit. Brunton, op. cit. Blyth, "Poisons,"1884.4 Dr. Sansom, THE LANCET, April 3rd, 1886, says that convallaria

lowered the pulse from 112 to 80, 76, and 72.5 British Medical Journal, April 10th, 1886, p. 709.

438

digitalis was of a bright and decided brown, whilst thatfrom 106 grains of Mr. A.’s mixture was only of a light strawcolour; and Exps. 4, 8, and 17 in the table of physiologicaltests show that whilst a nearly equivalent quantity, or 110gfains, produced cessation in systole in twenty and seven-teen minutes, 10 minims of tincture of digitalis in the sametime only slowed the heart’s action from 39 to 18-i.e., the 110grains of mixture were more powerful than 10 minims oftincture of digitalis, and yet that they did not contain 10minims is shown by this colour test. The infusion may beexcluded also, for a quantity equal in potency to 10 minimsof tincture of digitalis, and therefore not so potent as the 110grains of the mixture, would amount to at least twodrachms-that is, the mixture would consist entirely ofinfusion of digitalis; and this is shown by the specific gravityof 1209, and also by the separation from it by chemical meansof fixed oil and cane sugar, not to have been the case. Thefourth drug mentioned, convallaria, is not officinal, and isnot much used; still, it is possible, as suggested in an articleon these cases in the British Medical Journal of March 27th,1886, that "some of the bulbs of the lily of the valley mighthave become accidentally mixed with the bulbs of the squill,from which the vinegar had been prepared. The differencein size between the bulbs of convallaria and of squill is verygreat, but after they were sliced and dried, it is just possiblethat they might be confounded." Considering, however,that cases of poisoning by squills, although rare, are recorded,we may, I think, conclude that in these instances the syrupof squills was the toxic agent; being of exceptional strength,due to the variation in strength of the bulb, to which I shallrefer shortly. It was thought that possibly the stock fromwhich this exceptionally potent syrup of squills was obtainedmight be existing in the manufacturer’s store. Dr. Goldie,the medical officer of health for Leeds, was written to, and

Irequested to institute inquiries of the wholesale dealer whosupplied Mr. A. He, however, found no evidence of want of icare in preparing the syrup or vinegar; and we have notbeen able to ascertain the facts relative to the gathering ofthe samples of squills, either as to date or place of collection ;nor to procure a sample from the stock supplied to Mr. A.Remarks.-The symptoms of poisoning by digitalis, which

were not present in the cases which are the subject of thispaper, are insensibility and dilatation of the pupils. Therecorded cases of death from squill poisoning are so few thatbefore we can give a comprehensive and accurate list of thesymptoms we must have a much extended list of cases. Ican only find records of two fatal cases in man, and in oneof them neither the symptoms nor the post-mortem appear-anegs are given. In the other case, which Christison quotesfrom Lange, the stomach was found to be " everywhereinflamed." This is somewhat different from the post-mortemappearances in the case of the girl Ethel, where a fewinflammatory patches were found; and very different fromthe appearances in Orfila’s two dogs, if we admit them incomparison, where the digestive canal was "normal." Thedifference may have been due to a possibly fresher conditionof the squill bulb that was the cause of death in Lange’scase. By drying, the acridity is got rid of (Pereira). Hagarmentions a volatile oil which would be dissipated in drying,and Landerer found in the fresh bulb a bitter extractive,which he did not find in the dried one. The heart, in the ’Icase of the dog recorded by Fagge and Stevenson, was foundfull of blood; the heart had stopped in diastole. Concerningthis I would quote Brunton, who says, in reference to thewhole group of cardiac poisons, "This stoppage of theheart in systole occurs in frogs, but in higher animals theheart may stop in diastole." Hager mentions four active Iprinciples as present in the squill; of these, two arrest theheart’s action in systole, and one in diastole. It may be that ’,the two former are more readily absorbed by the frog’s tissuesthan the third, and that the contrary is the case with thedog. The experiments which I have made and recordedhere simply show (and are not intended to show more)that with the chemical extracts made from the mixturedelivered to me I obtained the same results with the frog’sheart as with a known poison belonging to the digitalisgroup, and pharmacologists and toxicologists agree in sayingthat the members of this group all produce the same effecton the frog’s heart. Death of the heart ensued in Experi-ments 4 and 8 in seventeen and twenty minutes; whilst thetime recorded by Fagge and Stevenson in poisoning bysquills is fourteen to twenty minutes. That the symptomsin thee children and the post-mortem appearances in thecase o the one that died are consonant with what little we

know of squill-poisoning 1 shall endeavour to show. Thesechildren had been taking half a teaspoonful of syrup of knownsquills twice a day for ten weeks. Squills is cumulative inits action; therefore small doses might occasion death aftersome weeks’ administration. But we cannot suppose thatthis cumulative effect should occur at so nearly the sametime in children of the age of three and a half and five, whenboth were taking the same dose. Add to this fact that a singledose of the mixture last made up caused intermission of thepulse in a child of eight (Lilian). Squill varies in strength;the outer scales are stronger than the inner (the outerscales contain more scillain); the fresh bulb is strongerthan the dried (volatile oil and Landerer’s extractive islost in drying); the bulb gathered in summer is strongerthan that gathered in autumn (in summer the squill containsless sugar, and the increase of sugar in the autumn is pro-bably due to the sugar which is one of the two bodies intowhich glucosides split up): the red variety is stronger thanthe white. That the squill varies in strength is shown byExperiments 13, 14 and 15, in which the same quantity ofsyrup of squills from three different sources produced thefollowing effects: In Experiment 13, in forty minutes itslowed the pulse from 38 to 36; in Experiment 14, inforty-seven minutes from 36 to 10; and in Experiment 15,in thirty-eight minutes from 36 to cessation. From somevariation in the strength of the squill used - probablyfrom imperfect drying - a syrup was presumably made,containing in poisonous proportion the active principleswhich are normally present, but in smaller quantities; andthis exceptionally strong syrup was used in dispensingthe last mixture which the children took. This view of thematter is confirmed by the fact that Mr. A.’s syrup, takenfrom the same bottle which he had used in making up thislast mixture, had an intense and persistent bitter taste, likethat mentioned as possessed by scillitoxin, the glucosidewhich arrests the heart’s action in systole.The following symptoms observed in these children are

mentioned by authorities quoted :-Paralysis of the legs-Orfila (dog), Pereira (rabbit), Fagge and Stevenson (dog).Nausea and vomiting-Orfila (dog), Christison (man), Pereira(man), Fagge and Stevenson (dog). Drowsiness-Orfila(dog), Christison (man). Sudden accession of death-Orfila(dog), Fagge and Stevenson (dog). Hurried respiration-Orfila (dog), Pereira (lower animals). Intermittent pulse-not mentioned.Post-mortem appearances.-Lungs normal-Orfila (dog).

Intestines normal-Orfila (dog). Fluid blood-Orfila givesone case as containing only fluid blood, another had bloodclots.

Conclusions.-1. That squill is not a safe drug to use forroutine, and especially popular or lay, practice. 2. Thatbeing so variable and, when strong, so potent a drug, itshould be looked upon by the profession as unsuitable foruse until a solution of standard strength can be produced.3. That in the meanwhile its use should be discontinued.Nottingham.

REMARKS ON THE GENERAL TREATMENTAND DRESSING OF WOUNDS.

BY JAMES WHITSON, M.D., F.F.P.S.G., F.R.M.S.,ASSISTANT-SURGEON TO THE GLASGOW ROYAL INFIRMARY.

DURING the last few years the treatment and dressing ofwounds have undergone a marked change for the better.The introduction of the antiseptic system has led to

improvements in both these ways which not long ago wereundreamt of. Prior to this great epoch in surgery, woundsof any magnitude were daily to be seen discharging largequantities of pus, and at brief intervals epidemics of pymmiadecimated the wards of hospitals in a manner truly alarming.Under an antiseptic régime, however, these complicationshave been banished as if by the enchanter’s wand, and atthe present time suppuration is a factor with which weseldom require to deal, while pyaemia and hospital gangreneare scourges almost unknown. To all who were familiar withthe difficulties surrounding the early elucidation of the

subject, it need scarcely be remarked that the realisation ofsuch a degree of excellence has not been achieved at a singlebound. On the contrary, the standpoint now held by anti-