2 Medical Times and Gazette.

suddenly. Another disorder, not very rare, I shall mention, for it is a very perfect illustration of this polarity: the disorder known as hour-glass contraction. This is a case in which you have action of the cervix or lower part of the uterus, while you have inhibition of the upper part; and if you could reverse the conditions the case would be cured. Such a case is generally called hour-glass contraction, but that is only one-half of the disease; it is quite as truly hourglass expansion, for the contracted part is not the only diseased part: the inactive part above the contraction is quite as much in a morbid condition of inhibition as the contracted part is in a morbid condition of action.

I shall now read you the notes of the case.

M. C., aged forty; married thirteen years; has had six children, the last being born three years ago; had a miscarriage a fortnight before her admission to "Martha." Catamenia began when she was twenty years of age, and have been regular, lasting seven days. Was in good health till the miscarriage, which she thinks was caused by fright, and occurred in the fourteenth week of pregnancy. She was told by her medical attendant that everything had come away. From the miscarriage, for ten days, she had had great pain in the hypogastrium, and continuously lost blood, which was sometimes discharged in clots. Then for two days she lost no blood, but had a profuse watery discharge. After this the loss of blood recommenced. On admission the cervix is open so as to be just permeable by the finger, which discovers nothing near the internal os. The uterus is bulky, the probe entering easily four inches; it is retroverted and retroflected, but easily replaced. Half-drachm doses of the liquid extract of ergot to be given thrice daily. She is extremely anæmic. Pulse 130; temperature 98°. At the visit two days after admission the bleeding and discharge of clots was still great. The cervix uteri is now widely open, so that two fingers may pass easily. Nothing is found in or near the cervix. The uterus is less bulky, and can be felt to contract during examination. As high as the finger can be pushed a fleshy substance can be felt. It is found to be an indurated placental mass, firmly adherent to the uterus, and is removed piecemeal by forceps. An hour afterwards she had a sever rigor with temperature 104.2°; but this passed off, and now for several days she is very well, the bleeding being arrested.

Note the conditions here. At first the cervix was permeable only by one finger, and nothing could be felt as high as it could reach in the cavity of the body of the uterus. Ergot was now given; it brought on active contractions, which could be felt when the woman was examined. This action of the uterus drove nothing into the cervix to dilate it; but it dilated spontaneously, so that after two days of ergot two fingers could be easily passed up into the uterus to remove a firmly adherent placental fragment, the extraction of which by forceps led to the hæmostasis and progressive recovery of the patient.

A disease closely connected with such cases as I have just mentioned is fibrinous polypus. This is a retention of blood, of a clot of blood which becomes indurated and externally decolorised, which retains connexion with adherent shreds of placenta, which has all the symptoms of a polypus, and which lies with its stalk in the body of the uterus, and the body of the polypus generally in the cervix. This mass of retained and adherent blood-clot becomes more and more decolorised externally so as to have a tough fibrinous exterior, and hence its name. It is treated as a polypus is treated.

The best example of retention in connexion with pregnancy is seen in the most characteristic cases of secondary hæmorrhage. To illustrate this I shall mention a case which occurred not many years ago in my own practice. A woman was delivered in natural labour at the full term. Her uterus was found to involve itself naturally until nine days after labour. Then she had sudden copious hæmorrhage. This was secondary hæmorrhage, not from a retained bit of placenta nor of membranes. The copious flooding was only partially external, for the uterus became rapidly dilated to be at least the size of a four-months pregnancy, and was filled with soft clot. The woman was in danger from the hæmorrhage, though there was not much externally, for it was mainly retained. The case was treated just as hæmorrhage would be after delivery: the womb was made to contract, and to maintain the contraction. When emptied of clot it was of the size of a healthy uterus about nine days after delivery in the healthy puerperal state.

I now come to consider cases of retention of blood in the virgin uterus, or in the uterus uninfluenced by recent. pregnancy.

Some women have slight discharge of menses, and only pass the blood when they are standing. The flow stops when they lie down. This is explained or explicable in two ways the blood-pressure, increased by standing, may cause the flow only when the woman is out of bed; but in many women there can be no doubt that the blood does flow in small quantity, and is retained in the womb, and passes out of it on standing.

It is a common thing for women and practitioners to be deluded into supposing that a woman has prolonged menstruation by the circumstance that many women, after menstruating, retain a little blood in the womb, which comes away brownish for days after real menstruation has finished. These days of brownish discharge are not days of menstrual flow, but days of the flow of dissolving, retained, and altered blood. There is the closest analogy between this and bloodtinting of the lochia after delivery by the dissolution of the clots retained in the mouths of the uterine sinuses.

Women in healthy, although not in ordinary menstruation,. sometimes pass clots, and the slight pain with which they pass them, and other evidence, prove that these clots had been retained in the uterus and discharged by uterine contraction and opening of the cervix. Such clots are generally small.

But there is a rare condition of the discharge of menstrual clots which is important to know, because you may be misled as to the virtue of a female if you do not know what I am to tell you. This is best told and illustrated by a case which occurred in my own practice very long ago, and in which, being ignorant of the occasional retention of menstrual clots till they are partially decolorised, I had great difficulty in believing that the woman was a virgin, as she asserted. She was a virgin, and there could be no doubt that the clot which she discharged was menstrual. It was of the shape and size of the uterine cavity, and was decolorised upon the surface just as a fibrinous polypus is, but not so thoroughly or deeply. The size of these clots is very small, the cavity of the unimpregnated uterus being in cubic capacity about, or rather under, half an inch. The clot contained in the uterus, as in this case, may expand the uterus without dilating its walls, for you must remember that there is a great difference between the capacity of an ordinary empty uterus (the cavity being then mainly a potential one) and the capacity of a uterus which is expanded -all the difference between a collapsed empty bladder and the same when full. You must not judge, then, from the condition of a healthy unimpregnated uterus, how big a clot it may contain when expanded. An empty bladder contains nothing; but the same expanded, without any alteration except in position of its walls, may hold a pint. So with the virgin uterus.

Whether the uterine cavity expands and dilates in the unimpregnated state so as to contain and retain a large clot, I cannot say. I know of no case of the virgin uterus expanding so as to contain and retain a large clot, say as big as a hen's egg. I do know of cases in which it has expanded so as to contain a large soft clot, but in these cases the cervix was expanded as well, and the clots were not retained for any length of time, were not hard nor decolorised. The women were flooding.

Retention of clots is a common thing in cases of cancer of the body of the uterus or of fibroids; and the blood is expelled in the form of clots, or comes away dissolved as brownish discharge.

I have said that the unimpregnated healthy uterus is not known to expand so as to contain and retain a large clot; and the last thing that I have to say, in regard to these various conditions, is that the diseased uterus not only has its cavity expanded in cases of cancer and of large fibroids, but it is almost certain that it may be expanded when a little polypus is growing upon its internal surface, so as to have a large cavity sufficient in capacity to contain many polypi as big as that one which leads to the dilatation of its cavity. Of this we had a good example in "Martha" a few weeks ago, in a woman whose case presented dangerous conditions, whose pathology was inexplicable, and who died apparently of disease of the stomach. She had a constant brownish discharge from her uterus. On dissecting this woman, there was found adherent, near the fundus, a small

mucous polypus about the size of a hazel-nut. This woman had had a large family, but had not been recently pregnant. Her uterus had a large cavity, and measured four inches and a half from the external os to the end of the fundus. Here there was a distended or dilated cavity filled with blood, which came away in clots, as pure blood, and as brownish discharge, there being always a large quantity retained in the dilated unimpregnated uterus, such dilatation being probably caused by the growth of a small polypus near its fundus.

All these cases are treated on the same principles. You have in ergot of rye a powerful agent, not for inducing pains, but for inducing continuous, or tonic, or permanent contractions-in other words, retraction of the uterus. Ergot of rye, then, in all these cases is an invaluable remedy, from this power which it has over unstriped muscular fibre.

To produce temporary contractions you may resort with advantage, in various circumstances, to the use of cold, suddenly applied, and for a short time. You may also use heat, for heat has very much the same power of stimulating uterine contractions as cold has; indeed, sometimes heat applied externally or applied in the form of a hot vaginal lotion seems to be more powerful than cold similarly applied. In these cases of retention this is all the treatment-at least, it is the chief part of it. But you have often not only to produce evacuation of morbidly retained blood, but to stop hæmorrhage. Now, in order to stop hæmorrhage, you have, in addition to ergot and heat and cold, two great remedies, the rules for the application of which I have no time to discuss to-day, but which I shall mention only. One is the powerful mechanical remedy of a plug, restrainng the flow of blood by counter-pressure, the plug being placed in the vagina or cervix uteri.

Then you have another set of remedies called styptics, which really act also mechanically by clotting the blood or by corrugating and hardening the bleeding surface. These remedies-the plug and styptics-are not remedies for retention, but for bleeding, and I shall only say that our experience of the best styptic, the perchloride of iron, is sufficient to show that you must be very cautious in its use, and not only in the use of it, but of any other styptic, for experience has shown that even in the unimpregnated uterus the styptic may pass into the uterine veins in the broad ligament, and produce changes there-tanning the parts— which would be fatal if the woman survived. Tanning is therefore seen only in cases which have proved fatal from some other cause; and in one case which occurred in "Martha " lately, death was produced by embolism. The styptic had clotted the blood, and the clots had passed into the woman's lungs. You must be cautious, and at present I employ not an iron styptic, but tincture of iodine.

SUBSTITUTE FOR COD-LIVER OIL.-Dr. Emmet, in his recent work on Gynecology, recommends the fat of pork, properly prepared, as an excellent substitute for codliver oil. A portion of a rib, free from lean, is selected, and soaked in water for thirty-six hours to get rid of the salt, and then boiled slowly, the water being often changed, until the meat is thoroughly cooked. It is to be eaten cold, in the form of sandwiches cut very thin. Thus prepared, it forms, according to Dr. Emmet, a very nutritious and concentrated article of diet, and one which can be often retained by irritable stomachs.-New York Med. Jour., December.

CHOLERA IN JAPAN.-According to dispatches from Mr. Bingham, Minister of the United States to Japan, and communicated by the Secretary of State to the National Board of Health (Bulletin No. 23), official reports show that the total number of cases of cholera which have occurred in Japan from the commencement of the epidemic in April up to October 21 was 156,204, of which number 89,702 (57.43 per cent.) proved fatal. The epidemic is stated to have now virtually ceased throughout the empire. Mr. Bingham expresses the opinion that the number of deaths would have been much fewer if the Government of Japan had been aided instead of being resisted by certain foreign powers in its endeavours to prevent the spread of contagion by land and maritime regulations, and adds that it affords him gratification to know that the efforts of the Government of Japan to save the people of that empire from the pestilence were seconded by his Government.

ORIGINAL COMMUNICATIONS.

TRANSUDATIONS AND EXUDATIONS.

By ALEXANDER JAMES, M.D., F.R.C.P.E., Lecturer on Physiology, and Clinical Medicine Tutor, School of Medicine, Edinburgh.

In the following paper I propose to lay before you the results of some inquiries which I have made on the composition of various transudations and exudations. The transudations were the pleural, peritoneal, cutaneous, and cerebral; the exudations were the contents of abscesses, inflamed bursæ, and inflamed joints. In these inquiries my object has been to discover how much the composition of these fluids is influenced by simple physical processes, more especially by filtration. The action of this in the case of the transudations is obvious, they being simply filtrates. The exudations, on the other hand, have not such a simple explanation, but with them also I hope to demonstrate the importance of taking this process into consideration.

and makes the same observation as regard the proportion of salts. Similar investigations have been made by many others (d)-Heller, Scherer, Simon, etc.,-and their results, though not obtained from fluids effused under identical conditions, coincide in the main with those given above. I do not, however, give them, because the fluids which I wish here to consider are those which occur under conditions precisely identical, i.e., which are transuded in one individual, simultaneously, and due to a general cause.

On examining these results we find-first, that the amount of mineral matter remains nearly constant in all cases; secondly, that the amount of organic matter presents great variations in individual cases; thirdly, that in the different transudations a distinct relationship can be detected as regards the proportion of organic matter, the pleural being richest in it, the subcutaneous poorest, the peritoneal occupying an intermediate position. Further, from the observations of Schmidt, etc., we may conclude that the fluid of the cerebral ventricles has always a larger proportion of solid residue than the subcutaneous transudation. This relationship in the proportion of organic matter has been expressed by Schmidt in the following rule:-"The quantity of albumen (equal to total solids) contained in a transudation is dependent on the system of capillaries through which the transudation flows."(e) What I now propose to do is to show that, in order to find an explanation for this relationship, we will obtain considerable information by studying the physical conditions existing simultaneously in connexion with the various capillary systems. In the first place, then, if a portion of a fluid holding organic matter

(a) "Characteristik der Epidemischen Cholera," 1850. (b) Virchow's Archiv, vol. ix.

(c) "Physiological Chemistry" (Cavendish Society), vol. ii., page 316. (d) Becquerel and Rodier differ from others in stating that the peritoneal fluid contains the largest proportion of albumen (Speer's translation, page 479).

(e) Schmidt's "Epidem. Cholera," and Lehmann, page 315.

and salts in solution is made to filter through a membrane, what changes does it undergo ?

On this point Hermann says (f) :-"True solutions pass through the medium unchanged. Viscid fluids, such as solutions of albumen, starch, and gum, filter less perfectly, a portion only of their contained substances, in amount varying with the pressure, being able to percolate. If, indeed, the pressure is very slight, the whole is retained on the filter. Under slight pressure, therefore, the blood loses, by filtration, water, salts, sugar, etc., which form true solutions, while under a greater pressure it is deprived of more or less of its albumen, fibrinogen, etc."

Thus, then, we see that the amount of organic matter passing through varies directly as the pressure-i.e., that with a high pressure a large quantity of organic matter, and with a low pressure a small quantity, will filter through. These considerations, then, explain clearly why the proportion of salts remains constant; and from them also we might readily conclude that the difference in the proportions of solid constituents effused by the different capillary systems is due to the blood in these capillaries being subjected to different degrees of pressure.

That this occurs, and how this is effected, is what I have to demonstrate. Before doing so, however, let me mention a few other considerations.

We might suppose, for example, that one reason why the fluids transuded into the pleura, peritoneum, and cerebral ventricles were thicker (if I may use the term) than that effused into the subcutaneous tissue is, that in the case of the former the fluids are mixtures of transudation from the capillaries and secretion from the serous membrane, whereas in the latter it is a transudation alone. This, however, although it must be taken into consideration, will not explain why the peritoneal fluid is thicker than that of the cerebral ventricles, and the pleural thicker than either. Again, we might suppose that the blood varies in composition in the different capillary systems, more especially, for example, in the case of those of the abdominal cavity, where we should expect that the performance of the function of absorption is likely to bring this about. Or again, it may be that the pressure varies in the different capillaries, that the capillaries vary as regards the permeability of their walls, or that the absorbent vessels may be more numerous, and the absorbent function more active, in connexion with one of the systems than another. Further, we must remember the connexion of dropsies with nervous lesions.(g) All these are possible agents in producing the variations in the chemical composition of the fluids which we are discussing, and, as such, must be taken into consideration. I trust, however,

that I may succeed in demonstrating that in the physical conditions operating in the different cavities we have by far the most important factors.

Let us, therefore, neglecting the special secretory action of the serous membranes, suppose that we have the following alike conditions existing in the various capillary systemsviz., same composition of contained blood, equal permeability of capillary walls, equal activity of absorbents. Let us further suppose that the blood-pressure in the interior of the capillaries is the same, and allow that the fluid transuded into the subcutaneous tissues (which, as we have seen, contains the smallest proportion of solid residue) is the result of this pressure alone. Why is it that transudations into the pleura contain organic matter in so much greater abundance ? To understand this we must remember that the lung with its contained air-cells, blood-capillaries, etc., is an elastic structure, and that it is in the thorax always more or less. stretched. The amount of this stretching, or, in other words, the collapsing power of the lung, varies, of course, according to the amount of air contained in it. Hutchinson (h) estimates it in two cases as follows:I.-(a) Containing breathing volume of air. 8.2 in. water. vital capacity 17

:

20

(b) II.—(a) Containing breathing volume of air. 10 (b) vital capacity Donders' estimate is 75 mm. Hg (less than 4 in. water) at the end of expiration, and 9 mm. Hg (about 4 in. water) at the end of inspiration, and 30 to 50 mm. Hg (about 15 to 21 in. water) after a forced inspiration.

We must further remember the very great force which the inspiratory muscles are capable of exerting-the force varying, as Hutchinson has shown, from 1.7 to 7 in. Hg. Arguing theoretically, therefore, from the enormous aspiration which the thorax can produce, we might easily imagine that, in cases of increased pressure in the lung capillaries, or still more in cases of obstruction to the entrance of air into the lungs, we should have the transudation of fluid into the pleura correspondingly favoured. To ascertain this point clearly, however, I have tested it experimentally, and the following I give as one of my most successful results :(i)—

The lungs and trachea of a freshly killed cat were taken, washed, and emptied as much as possible of blood. To the pulmonary artery a tube was connected by a canula, this tube communicating with a reservoir of water. The pulmonary veins were ligatured, and it was so arranged that the lungs could be placed under the receiver of an air-pump, the trachea communicating with the outer air by a tube. Water with a head of 13 in. was then passed through in quantities of 100 cc. at the time, and the results noted.

transuded

through 50 cc.; the rest in the lungs. pleura,

Second Third Fourth

8 cc.;

50 18,, 15

39

(Artificial respiration by air-pump) Fifth, 100 cc. passed into lungs in 51 min. (Artificial respiration stopped.) Sixth, 100 cc. passed into lungs in 12 min. (Trachea tied; artificial resp. applied.) (k) Seventh, 100 cc. passed into lungs in 10 min.

From these experiments we obtain precise information on two very important points: first, that where no hindrance exists to the entrance of air into the air-cells of the lungs, the inspiratory act will favour the transudation of fluid from the lung capillaries into the pleural cavity; and secondly, that when the air-passages are obstructed, this same inspiratory force is for the most part at least expended in causing this fluid to transude into the air-cells. In this latter case there will, however, be transudation into the pleura from the capillaries of the costal parietes. Clinically, therefore, we should expect that, in cases of Bright's disease or of obstruction to the circulation alone, as in heart-affections, hydrothorax will result, whilst in cases where the entrance of air into the air-cells is impeded, as in bronchitis, pressure (f) Professor Gamgee's translation (second edition), page 122. Lehmann says, page 818, "that the transudation will be richer in albumen in proportion to the slowness with which the blood passes through the capillaries."

on trachea by tumours, croup, etc., ædema of the lungs is in addition most likely to occur.

But it is necessary to examine the mechanism by which, as we have seen, hydrothorax is produced, a little more minutely. Is the aspiration produced by the inspiratory act sufficiently powerful to cause the transudation into the pleura of a fluid much thicker than that transuded into the subcutaneous tissue by intracapillary pressure alone?

If the fluids which we have examined had been from cases with obstructed air-passages we might have had little doubt (h) "Cyclopædia of Anatomy and Physiology"-" Thorax."

Medical Times and Gazette.

as regards this, the inspiratory power amounting, as we have seen, to from 1.5 to 7 in. Hg. But the fluids which we are considering were taken from cases (Bright's disease, etc.) where we may assume that there existed no marked obstruction to the entrance of air into the lungs.

The aspiration power, therefore, by which transudation into the pleura is produced, will depend on the elasticity of the lungs alone; and the estimates of this, as we have seen, never exceed 20 in. water. Further, we must remember that as fluid collects in the pleura the lungs will correspondingly retract, and so this power will be gradually reduced in force. The results of Homolle(1) also show that this aspiration power is inconsiderable in amount. In his cases of pleuritic effusion the intrathoracic tension was tested by a manometer, and the greatest negative tension obtained was (Case IV.) 38 mm. Hg in inspiration, and 33 mm. Hg in expiration.(m) This is about 19 and 16 in. wateri.e., less than the collapsing force of the lungs as estimated at the end of the fullest possible inspiration. This aspiration power, therefore, is never very great; and it will be noted in the table that transudation took a long time to occur. On the other hand, we have to remember, however, that the intracapillary pressure must be very small; and it is with this that we must compare it when we wish to judge of its effects. What the intracapillary pressure is we have no precise means of discovering; but when we remember the smallness of the venous pressures, and that the sectional area of the systemic capillaries may be estimated as being 800 times that of the aorta, (n) we can, I think, admit that this aspiration, though equalling no more than 10 or 12 in. water, will have the effect of causing the transudation of a somewhat larger relative quantity of organic matter.

On this subject further experimentation seems desirable, as the results hitherto obtained have not, as far as I am aware, been very definite. Dybkowsky (o) endeavoured to cause an increase in the pleural fluid by ligaturing the aorta below the diaphragm, and by causing paralysis of the thoracic vaso-motor nerves. On killing the animal after a time no fluid was found in the pleura.

He found, however, that fluid introduced into the intercostal tissue always made its way into the pleural cavity.(p) Apart from this, however, there is another reason why pleural fluid should be thicker than that found in the subcutaneous tissue. Hoppe-Seyler has shown that, in cases of ascites due to cirrhotic liver, the more the fluid increases in amount, the more concentrated does it become.

The explanation of this is, that by the lymphatics and peripheral branches of the systemic veins absorption is constantly going on, and as the water is the constituent of the transudation which is absorbed in most abundance, it (the transudation) is consequently constantly becoming more concentrated. Thus, then, concentration will vary directly with the rapidity of absorption, and as in the chest the negative pressure of inspiration is immediately followed by the less negative or slightly positive (in forced expiration) pressure of expiration, we can easily understand how this process will be favoured.

This hypothesis is directly corroborated by Dybkowsky in the article before mentioned. He found that with solutions of Berlin blue, etc., if these were injected into the pleural cavity of a living dog, absorption rapidly took place; but that this did not occur if the animal were killed immediately after

(1) Revue Mensuelle de Médecine et de Chirurgie, February, 1879: "De la Tension Intrathoracique dans les Épanchements Pleuraux.

(m) The greatest positive pressure which Homolle obtained was (Case II.) 15 mm. Hg at the end of expiration. From these data we can readily understand how, unless in cases of paralysis of the intercostal muscles, as in empyema, "bulging of the intercostal spaces " is so rarely seen. (n) Of course, I do not propose this as an estimate of the capillary pressure. Küss estimates the systemic capillary pressure as of the atmosphere, about 36 or 48 in. water. The pulmonary capillary pressure would be considerably less." Manual of Physiology" (Dr. Amory's translation), page 105. By experiment (N.v. Kriess) it has been estimated in the capillaries of the hand at 38 mm. Hg.-Landois' "Physiologie," page 173.

(0) Ludwig's Arbeiten, 1866: "Ueber Aufsaugung und Absonderung der Pleurawand."

(p) I am indebted to my friend Dr. Graham Brown for affording me an opportunity of the perusal of Runeberg's paper, "Ueber die Filtration von Eiweislösungen durch thierische Membranen." Runeberg's results are contrary to those indicated by Hermann, etc., as he found that with increased pressure the amount of albumen which filtered through was not materially increased. How the respiratory movements will favour the transudation of albumen, however, may be imagined from his Conclusion No. 8-“ Der albumingehalt des Filtrats ist bei demselben Druckgrad beträchtlich grösser, wenn die Membran einige zeit vorher vom Druck befreit war, als wenn sie unter Einwirkung des Drucks gestanden hat."

the injection. He also found that the rapidity of absorption increased with the activity of the respiratory movements. The transudation into the pleura, therefore, has a larger proportionate amount of solid residue than that of the subcutaneous tissue as the result of the respiratory acts. (To be concluded.)

OBSERVATIONS

ON YAWS.

(A REPLY TO DR. GAVIN MILROY.)

By H. A. ALFORD NICHOLLS, M.D., C.M. Aber., M.R.C.S., Medical Superintendent of the Dominica Yaws Hospitals, Surgeon to the Roseau Infirmary.

BEFORE the emancipation of the slaves in the West Indies, the disease Framboesia, better known by its African name of Yaws, excited a great deal of attention not only amongst the many able medical men who then practised in these colonies, but also amongst many of the authorities in Europe. In nearly all the works on medicine published in those days were to be found long articles on this disease, and most of these writings might be studied with advantage at the present time. Since the day of emancipation, however, as the West Indies declined in prosperity, and as other and larger possessions were added to England's colonial empire, this curious disease, which for the most part attacked the negroes, has been all but forgotten. Articles on Yaws are no longer written for the periodicals, the disease has ceased to find a prominent place in works on medicine, and but for the researches of two men-Imray of Dominica, and Bowerbank of Jamaica-a blank of nearly forty years would separate the Yaws records of the past from the writings of the present day.

For many reasons, which are too lengthy to enter into here, the subject of Yaws has become one of considerable interest to most of the medical men in the West Indies, as well as to many of the members of the profession in other parts of the world. This interest is just now centred in Dominica, for in this island the disease has of late years made rapid strides, and the Government of the Leeward Islands have undertaken a task-so far as I am aware, never before attempted-namely, that of ridding the country of the disease by the forcible segregation in hospitals of those affected with the malady. Passing by altogether the question of Yaws, the experiment is one which should engage the special attention of those interested in public health, for in Dominica is now being done,'as regards Yaws, what has been recommended by some of our ablest and most far-seeing hygienists to be carried out in the eradication of other contagious diseases.

Upon several occasions the opinion of Dr. Gavin Milroy has been sought by the Colonial Office on certain of the measures adopted, or proposed to be adopted, by the Government in their efforts to rid Dominica of Yaws, and Dr. Milroy's Reports have been invariably sent out for the information of those officers concerned. Last July Dr. Milroy was furnished with certain documents, amongst which was my last Report, and he was invited by the authorities at the Colonial Office to make any observations the perusal of the papers might suggest to him. Accordingly, on August 13, he wrote a letter to the Colonial Office, and his article in the Medical Times and Gazette of October 11, headed "Observations on Yaws," is this letter with the opening paragraph left out. In due course I received a copy of Dr. Milroy's letter, and, to my surprise, I found it full of what I believe to be unsound reasoning and conclusions hastily arrived at. In reply I wrote a despatch, in which I drew attention to particular passages in the letter, and entered somewhat fully into certain questions on which Dr. Milroy and myself would seem to hold different views. Dr. Milroy has published his official letter without any reference to my rejoinder. I now publish the substance of my reply, suppressing, of course, certain suggestions and remarks which were intended alone for the information of the Government.

The first subject to be considered is the one of diet. There can be no question as to the advisability of giving an ample supply of good nourishing food to all classes and all conditions of men; and if Dr. Milroy had contented himself with recommending an improvement in the dietary of the Central Yaws Hospital, he would merely have been doing what I did before him, and nothing could have been said against this

portion of his letter. The funds at the disposal of the Government for the Yaws Administration are, comparatively speaking, very small; and, in referring to the subject in my last Report, I say, on page 5, "the necessity of economy in the expenditure will not, however, permit of a more costly diet."

The nutrient value of the present dietary seems, however, to be altogether misunderstood by Dr. Milroy, who, in his letter, makes the following remarks (paragraph 7):—"No medical man in this country will be surprised that, with such a dietary in the treatment of a cachectic impetiginous disease, the results have not been so successful as could be desired, whatever may have been the medicinal remedies that are used." I would here remark that the first proposition in this paragraph is an erroneous one, for Yaws is not a cachectic impetiginous disease, as I shall presently show; and I would express my surprise that, after the perusal of my last Report, which proves beyond question that the results last year of the treatment of the patients in the Central Yaws Hospital have been most successful, Dr. Milroy should have unhesitatingly expressed a different view. On page 14 of my Report I say "The account already given of the fifteen months' work of this Hospital is most reassuring, and it will doubtless be received by the people with feelings of satisfaction "; and I may now add, that this view of the successful working of the Hospital is shared by the Board of Yaws Commissioners and by the Government.

During the time that the Yaws Hospitals have been in operation no less than 1212 patients have been admitted. Of this number 975 have been discharged cured, and only fifty-four have died. These figures are important, for not only do they prove incontestably the success, so far, of the Yaws Administration, but they show the extent to which the disease has prevailed in the island.

As regards the diet, Dr. Milroy goes on to say (paragraph 8): -"Independently of the extreme difficulty of combating a disease like Yaws, under such adverse circumstances as the daily use of so much innutritious and unwholesome food," etc. And again (paragraph 9), in speaking of the vegetables, he says "Only one sort is mentioned in the dietary as given on Sundays and Thursdays alone." If all this were true of the dietary of the Yaws Hospital, then Dr. Milroy's remarks would be perfectly just, and it would be impossible to say too much against a system which permits of "innutritious and unwholesome food" being given to patients detained nolens volens in the Hospitals until they are pronounced by the medical officers to be free from Yaws.

On page 5 of my Report the following occurs:-" In cases of children, and those who are in a debilitated condition [i.e., the subjects of cachexia], a special dietary is allowed, from which salt food is excluded. Two extra meals are given in these cases-one at 7 a.m., consisting of arrowroot and milk, or eggs and milk; and another at noon, which consists of soup made from fresh meat, and to which is added rice or vermicelli." On reference to the dietary, on page 15 of the Report, it will be seen that vegetable soup is supplied on three days of the week. This soup is made from yams, eddoes, peas, beans, ochroes, sweet-potatoes, and many other vegetables when they are in season. On Sundays and Thursdays four plantains, weighing over a pound (or an equivalent in weight of bananas), are given. Thus the patients receive vegetable food on five days of the week, and not on two days, as stated by Dr. Milroy; and instead of the vegetables being confined to one kind, as Dr. Milroy says, nearly every kind of vegetable grown in the country forms part of the food given to the patients. Then, again, it will be seen that the following note occurs at the bottom of the dietary "Fresh fish is substituted for salt when it can be obtained." On an average fresh fish is supplied once a week, but it sometimes happens that it is substituted for salt fish on the three days on which the latter is set down.

As regards Dr. Milroy's statement that the food is innutritious and unwholesome, on carefully examining the dietary, I can come to no other conclusion than that he refers to the salt fish, the farine, and the plantains.

Salt fish is the local name given to dried cod-fish, which contains a certain portion of salt added as an antiseptic preservative. Before cooking nearly all the salt is removed, and the fibres rendered soft by soaking in water, and the fish then, although not so nutritious as when fresh, contains a considerable amount of nutriment, and it is by no means unwholesome.

The farine, by which is meant cassava meal, is one of the staple foods of the people of the West Indies and South America. The starch obtained from this meal is known in England as tapioca. Dr. Pavy, in speaking of cassava meal,. and the bread made from it, says, "Both these products form important and valuable articles of food to the inhabitants of tropical America. They contain starch, vegetable fibre, and nitrogenous matter." (a) And in the article by Mr. A. Smith in Lindley and Moore's "Treasury of Botany,' on Manihot (the plant from which cassava is obtained) it is stated that the plants "yield an abundance of wholesome. and nutritious food."

Authorities speak even higher of the nutritious qualities of the plantain and banana. Pavy says, "Plantains and bananas furnish important and valuable articles of food to the inhabitants of many tropical regions. They even afford in some localities the chief alimentary support of the people."(b) In the article on Musa, in the " Treasury of Botany," Dr. Masters says-"Plantain-meal is obtained by powdering the dry fruit; it is very nutritious, and it contains not only starch, but protein or flesh-forming material. The natives of many parts of India live almost entirely on plantains." Lindley remarks-"They are most valuable plants (the Musacea) for the abundance of nutritive food afforded by their fruit, called in the tropics plantains and bananas."(c) Many other authorities might be quoted to the same effect, but it is unnecessary. It thus appears from the incontrovertible evidence of the highest authorities that the food which Dr. Milroy calls "unwholesome and innutritious" is, in reality, very wholesome and very nutritious. And when it is remembered that this diet is only given to those who are strong and vigorous-as the majority of the Yaws patients are-and that they thrive on it, and that they could get nothing so good in their own homes, Dr. Milroy's remarks on the subject call for considerable modification.

It is seen on perusal of Dr. Milroy's letter that he lays great stress on the opinion that the disease is a "cachectic impetiginous" one, and that all his arguments and opinions are based on this belief. He says (paragraph 1)-" In Cullen's Nosology,' Yaws is included in the class 'Cachexia," and order Impetigines' of diseases." "It is thus clearly seen what was the view which Cullen held as to the nature or physiology of the disease of Yaws." Cullen wrote about the middle of last century, and it is certainly strange that Dr. Milroy should go so far back to search for a definition of Yaws; the strangest part of it too is the fact that Cullen acknowledges that he never saw the disease. In my copy of Cullen's "Nosology," published in Edinburgh in 1810, I find on page 151 the following footnote:-"With: regard to Elephantiasis, Lepra, Framboesia (Yaws), and Trichoma, as I have not seen these diseases I dare not be more particular." I fail to find, also, any notice of Yaws in Cullen's work on the "Practice of Physic," published in Edinburgh in 1802. These facts alone would point to the injudiciousness of taking Cullen as an authority on Yaws; but when we find, a few years after Cullen wrote, eminent West Indian practitioners, who had large experience of the disease, recording in their works that Cullen was wrong in placing Yaws with the cachectic maladies, it is certainly difficult to understand why Dr. Milroy should have quoteď Cullen as an authority in this matter.

Dr.

In 1802, Dr. William Wright, in editing Dr. Grainger's essays on West India Diseases, says-" Dr. Cullen and other nosologists have classed the Yaws amongst the cachexiæ, whereas it ought to be amongst the exanthemata." David Craigie remarks-" The true nosological nature of the disease was, however, imperfectly understood by European physicians; for Sagar placed it amongst the Tubera or cachectic diseases with external swellings, and Cullen followed the example set by Sauvages in placing it among the cachectic maladies with syphilis, scurvy, elephantiasis, and leprosy." . "Dr. William Wright .. had themerit of first rectifying the erroneous notions to which the arrangement of the disease by Sauvages and Cullen had given birth." (d) This is very interesting, for it shows that not only was Cullen wrong, but that the arrangement was not his own, he having borrowed it from a French physician -Sauvages. In connexion with this subject it may be mentioned that Tilbury Fox, whose name stands amongst the:

(a) "A Treatise on Food and Dietetics." London, 1875.
le) "The Vegetable Kingdom," third edition. London, 1953.
(d) "Elements of the Practice of Physic." Edinburgh, 1896.

(b) Ibid.