Joseph Coats

Preliminary Communication on the Pathology of Aneurysms, with Special Reference to Atheroma as a Cause: Read in the Section of Pathology at the Annual Meeting of the British Medical Association Held at Newcastle-on-Tyne, August, 1893

eruption may be said to flourish may be altered from the normal in many ways. Any portion of the multifarious tissues and structures which go to make it up may suffer perversion, and so weaken it as a whole. In course of its progressive development with the growth of its owner, it undergoes much alteration ere it attains its perfection, and again during the period of decline its essential features sustain important modifications. Occupation in its turn marks its imprint on it, the kind of clothing worn, the rank of life, the food partaken of, or the beverage indulged in, the place of residence (whether permanent or occasional) all influence it more or less perceptibly. Certain drugs taken too constantly or too long, or some only once or but for a brief period administered, have power to change for the time or even permanently its characteristics. Taking the diseases we are concerned with in order, we find that in chronic ringworm of the scalp the soil occupies an all-important place. The disease, as a rule, to which exceptions are few, is met with in children from shortly after infancy till puberty is reached, at which era or soon after it seems, in the immense majority of cases, even though untreated, spontaneously to get well. Now this is the period during which the sebaceous glands of the scalp, if not most active, are at least most liable to disturbance of function. During this time the hair there is becoming thicker and stronger; indeed, the hair-producing energy of the system is being expended almost solely in that area. While possibly it would be too much to say that seborrhlea of the scalp is then most frequent, it is certainly more readily set up than later on. Once the trichophyton has established itself, a condition indistinguishable from the drier form of seborrhcea, the pityriasis amiantacea of older writers, is set up, and this persists, unless kept in check by treatment, till, or in many cases even long after, the extinction of the parasite. So much is this the case that chronic ringworm in which the hair grow-s fairly well over the affected area is often mistaken for an ordinary example of dandruff. A form of seborrhmea is therefore closely connected with tinea tonsurans capitis, and this is also supported by a fact which has come under my observation in the few instances in which ringworm of the head in adults has come under my notice, that in them the scalp was particularly scaly. But this will not account for certain facts, such as the relative frequency of the disease in Great Britain, France, and in some parts of the United States, as contrasted with its rarity in Germany, Austria, and even in India, where ringworm of the body is of such daily occurrence. Whether race or climatic influences play a part in this is undecided, but the state of the soil is at least a factor which must in all successful modes of treatment be taken into consideration. It is just possible that in consequence of the growth of hair in other regions at and after puberty, an alteration unfavourable to the luxuriant fructification of the trichopyton occurs in the scalp Again, in psoriasis a seborrhoeic element must be recognised in a very considerable proportion of instances. Unfortunately, I have no statistics of my own which bear on the age at which psoriasis is most frequent, but Nielsen, of Copenhagen, states that in 548 examples it was reported to have begun in 241, or 44 per cent., before the age of 14, showing a peculiar susceptibility of the integument to this complaint antecedent to puberty. Again, alcoholism, which favours materially the development of a seborrhceic condition, not only aggravates psoriasis, but induces the development of a worse type of the disease. In many cases we can easily determine this seborrheeic element; and indeed it is difficult in a certain proportion to say whether they should be classed as seborrhoeic eczema or as psoriasis. This difficulty arises, perhaps, most often in connection with psoriasis of the scalp, but may also be encountered in cases where the complaint is principally or wholly confined to the trunk. Other examples, again, show little trace of this perversion of glandular activity. Dr. Byrom Bramwell showed to the June meeting of the Edinburgh Medico-Chirurgical Society an instance of psoriasis, which, when she showed herself at my out-patient clinique before her admission into his wards, presented a remarkable dryness of the skin, combined with a disposition to the production of, or transformation into, general exfoliative dennatitis. After treatment by thyroid feeding alone, and rest in bed, on which followed the separation of abundant flakes of dry cuticle, the skin eventually assumed a peculiar silky softness, accompanied by the total disappearance of the psoriasis. Here, so far as we can infer, the soil was directly influenced by the treatment, and to its modification weshould ascribe the departure of the disease. Lupus erythematosus is also associated with disordereI sebaceous function, and though it is now agreed that the special inflammatory rocess, in which in so far as objectivesymptoms have revealed the disease mainly consists, does. not necessarily start from the sebaceous glands or their investment of vessels; still, in many cases we can easily convince ourselves that the scaly or warty accretion which forms. is closely connected with the sebaceous gland system. The disorder may eventuate in destruction of these glands and of the hair follicles, leading to permanent alopecia and genera} aridity of the surface implicated. The resemblance, too, which some instances at least of lupus erythematosus exhibit to some of psoriasis must have struck many observers. Lastly, there is an item in common to all these ailments from the therapeutic side. There are at least three remedies. which act more or less beneficially on all alike. These are sulphur, chrysarobin, and pyrogallic acid. Sulphur in one form or another has been found to do good service in ringworm of the head and in lupus erythematosus, as well as iri the cases of psoriasis in which the seborrhenic element is. most prominent. Though my own experience has not beei great, authorities of note can be cited as to the alleged effil cacy of pyrogallic acid in all three. In psoriasis the value of chrysarobin is undoubted; in tinea tonsurans capitis we have, among others, Duhring and Hutchinson ascribing to it the foremost place in obstinate cases; and quite recently the latter author has recorded some most interesting examples of cure in lupus erythematosus from the prolonged use of weak ointments of the drug. Part, at least, of this beneficial action is certainly due to the influence these agents exert on the soil. We may not yet, it is true, have the power to affect the soil on which we labour in as powerful a manner as the agricultural farmer can his by means of slag-phosphate powder. This, according to Professor Robert Wallace, whent applied to the poorest description of exhausted pasture land, iS known to have a marvellous effect in softening and sweetening the herbage generally, but more especially in developing the growth of white clover-an essential preliminary to the production of a thoroughly good and dense cover of permanent grass. Our object is rather to restrain the fertility of the extensive flora dermatologica, which Dr. Unna has shown to be so plentiful on the skin. The care of the soil is a factor in this, attention to which, it is to be hoped, will not be wholly omitted in the discussions.

Presidential Address on the Spontaneous Healing of Tuberculosis: Its Frequency and the Mode of its Occurrence

The number of deaths assigned to tuberculosis in tile Registrar-Generals Reports does not represent the real prevalence of the disease. Of the whole deaths in Scotland, about 15 per cent. are assigned to tuberculosis. I believe this percentage to be considerably too low, at least in the case of children. If we accept the figures as approximately giving the proportion of deaths from tuberculosis in adults, we have still to make

An Address Delivered at the Opening of the Section of Pathology and Physiology.

jun., read his paper on this subject in the Surgical Section at the Dublin Meeting, that hospital surgeons in general have taken up the question in earnest, and have put to the test the advantages claimed for this over the usual operation. I have not myself yet performed the inguinal operation in any case of cancer: but there are doubtless many gentlemen present who will give us their exk)eriences, and so will enable us to form a judgment upon its merits. I am bound to confess tlhat, having opened the descending colon in the left loin 103 times, I find it in some respects an unsatisfactory operation. Now and again it is not unattended with difficulties; but I have never found these insurmountable. In stout persons it will sometimes be found that the bowel is in front of the anatomical line; in the thin and wasted, the enpty gut may have dropped down, as it were, so as to form an attenuated cord by the side of the spine. In these cases the peritoneum may require to be opened; and in others an opening may be unintentionally made. With cleanliness and care in avoiding the introduction of putrescible material, there need be no fear of inserting the finger freely within the cavity of the abdomen in search of the truant bowel, and the accidental wound need not so much as interrupt the even tenour of the operation. It has happened to me more than once to have opened a tightly distended colon and the peritoneal cavity by the same incision, and to have become suddenly conscious of the accident only during a copious flow of liquid freces over the entire wound; and yet I am not aware that any disastrous effects have ensued. The tightly distended bowels secure an accurate closure of the wound, and I have always taken c1re to second this by seizing the cut edge of the colon with forceps and dragging it to the surface. It is not on account of the difficulties we sometimes encounter, or of the accidents which cannot always be avoided, that I am dissatisfied with this long established operation; neither is it because of the high mortality which undoubtedly attends it when undertaken for relief of complete obstruction, a mortality which I am prepared to show arises more from the circumstances preceding the operation than from the operation itself; but rather because of its lailure in a number of instances to secure that complete diversion of the fTeces which it is intended to bring about, and because of a tendency to a gradual stenosis and even closure of the opening, on the one hand, or of unmanageable prolapse of the bowel on the other, which in a not inconsiderable number of cases detracts materially from the comfort to be derived from a perfect operation. It is claimed for inguinal colotomy that, when rightly performed, there is no possibility of fccces finding their way beyond the opening in the aroin, that the removal of a portion of the free border and the kinking of the bowel secure a continued patency of the artificial anus, and that prolapse may be effectually prevented by the use of a properly constructed truss. If these claims should prove to be well founded-and the examples I have seen in London, in Leeds, and in Newcastle would seem to support them-the chief drawbacks of colotomy will have been removed. The lumbar opening will continue to be preferred when the disease is so high up as to render it uncertain if an inguinal opening will enable the bowel to be reached, and probably also in cases of great distension where an immediate opening for relief of obstruction is imperative. Not long ago a man, whose coloin I had some months previously opened, returned in a condition but little, if at all, improved by the operation, which had wholly failed to prevent the dribbling of feeces through the rectum, although the artificial opening had remained patent as at first. To his complete relief I performed the operation of colectomy. The colon, having been cleared from its attachment to the lumbar opening, was dragged outside and completely divided. Having then temporarily secured the upper end with an encircling ligatnre of silk, so as to prevent the escape of f;eces, and given it in charge of an assistant, I first dealt with the lower portion, and finding it empty, I was able at once securely to close it by stitching with fine silk its invaginated wall in such manner as to oppose two serous surfaces throughout the entire circumfererce. lThus safeguarded agairst any back flow of its contents, the distal end of the bowel was dropped into the abdcminal cavity. The upper open end was thEn stitched all round to the edges of the lumbar wound, and in this way the whole of the contents of the bowel were perforce dischlarged tbrough the lumbar opening. [low far this operation may be safely undertaken as a primary proceeding we have not sufflicient evidence to show. Should it prove on trial to be not more fatal than the ordinary method, it is clear that by its means we shall more completely accomplislh the chief end we seek to attain-niamely, the diversion of the intestinal contents through the loin, and the detaching of the diseased rectum from the alimentary canal. It has been proposed, indeed, and even, I believe, essayed to accomplish, the removal of the cancerous bowel through the lumbar or inguinal opening, and( that such a procedure may, in exceptional instances, be warranted, I can well conceive; but for the present our choice of operation in cancer of the rectum would seem to lie between proctectomy as performed from the anal extremity on the one hand, and some form of artificial anus on the other.