Some Landmarks in the History of Lead Poisoning

SOME LANDMARKS IN THE HISTORY OF LEAD POISONING

By RALPH R. MAJOR

KANSAS CITY, KANSAS

REPRINTED FROM NEW SERIES, VOL. 3, NO. 2, PAGES 218-227 ANNALS OF MEDICAL HISTORY PUBLISHED BY PAUL B. HOEBER, INC., NEW YORK

PAUL B. HOEBER, INC., 76 FIFTH AVENUE, NEW YORK

SOME LANDMARKS IN THE HISTORY OF LEAD POISONING^ RALPH H. MAJOR

KANSAS CITY, KANSAS

of Aegina is frequently sensation unimpaired, at other times held up by the medical his- with involvement of both motion and torian as an example of the sensation. So, whatever Paul’s short- PAULlow state into which the prac- comings, he has left us the first titioner of medicine in the seventh account of epidemic lead poisoning century had fallen, because he fre- that we possess today. This, to be quently apologetically disclaimed any sure, may be only a description of originality and because he constantly what the Ancients also saw but their emphasized that the ancients knew accounts have either not been pre- all of medicine that was worth know- served or are not as yet unearthed. ing and that he was merely their Avicenna, the “Prince of Phy- humble scribe. However, Paul has sicians” some three hundred years, his good points. Few physicians, an- centuries later observed the same cient or modern, have been so modest species of epidemic colic and wrote as to write seven books of medicine that “the paralysis is the crisis of the without claiming any originality, and colic; and to many the sensation Paul, despite his self-effacing attitude, remains, and those who recover, re- did make some solid contributions cover by paralysis, for nature expels to medical science. In his Third this material and brings it to the Book of “De re medica,” he writes exterior.” in a very interesting fashion about an Neither of these writers, however, epidemic of colic which prevailed in expresses the belief that the disease his time. they described was the result of lead. Yet many before Paul I consider moreover a colicky affection, physicians which still becomes violent from a kind were familiar with the effects of lead. of collection of humors, which took its Indeed Nikander, who wrote his “ origin from regions in Italy, moreover Alexipharmaca” in the 2nd century in many other places in Roman territory b.c. describes both colic and paralysis whence it spread like the contagion of a as the result of the ingestion of lead. pestilential plague. Wherefore in many Nikander’s verses on cerussa as trans- cases it passed into epilepsy, to some lated by Euricius Cordus close with: there came loss of motion with sensation unhurt, to many both, and of those who Interdum obrepens oritur cum frigore somnus, Torpet Ianguentia fell victims to the epilepsy, very many iners motus, membra fathiscunt. died. Of those indeed who were paralysed, not a few recovered, for the cause which Sometimes a stealthy stupor comes with a attacked them ended by crisis. chill is The feeble limbs droop, motion becomes slow, This description generally ac- then still. cepted as the first description of lead colic, since our author describes at- Nikander’s verses on litharge were tacks of colic followed by paralysis translated by Jacques Grevin de Cler- of the extremities, sometimes with mont into quaint sixteenth century 219 Some Landmarks in the History of Lead Poisoning French, in the following spirited considered the father of materia, passage: medica, wrote that cerussa “causes hiccough, cough and dryness of the N’ignores ie te pri’, la Litharge mortelle Dont la charge se sied dans Ie ventre, & cruelle Fait autour du nombril enfler & tournoyer Un grand vent tout bruyant, tel que peut essayer & Un homme tourmente par la douleur cachee P A V L I* Que Iui est apportant I’incurable trenchee: j$GI>NETA OP VS DE RE ME* elect niweprimtm mte^rm, Latinita* This verse is too to picturesque te donatum per IO A N N E M a be marred by translation. Sir C V I N T E RI V M Harrington dot John could probably have Andernaem, turned it into equally quaint Eliza- ftorem me bethan English. But the reader with diem* only a passing knowledge of French ADTECTIS IN EVNDEM DO sees here a striking picture of the {{ijjitnis & utilijjimis anno* poor man who has taken litharge only rationibuf ab eodem Ander* net* atis to be tormented by an intense inward elncu.br f pain and the stirring up of a mass of C'VM INDICE COPIOSISSIMO gas which blows out his navel and causes an incurable colic. These passages leave no doubt in our minds that Nikander who has been described as the most ancient medical writer after Hippocrates, knew fijrud Andream Arriuabenum* that lead produced both colic and Venrt.f< D I I * paralysis. He also was familiar with the M X X X X disturbances of lead Fig. i. Title-page of Paul of Aeginas “de re ocular poisoning: Medica.” 1542. Falso modo ante oculos rerum simulachra videtur. tongue, the extremities become lan- False images ofthings only are seen before the guid, the mind gives way, the limbs eyes. arc paralysed,” and Galen very ex- Indeed Nikander might well be plicitly warned against drinking water called the poet laureate of lead colic. that ran through lead pipes, which But this term would fail to do justice caused those who drank it to be sub- to his pharmacological or poetic tal- ject to intestinal disorders. Vitruvius ents, for he wrote verses not only remarked that “water is much health- about lead but about many other ier from clay pipes than from lead poisons. Nikander was praised by pipes: since it seems to be poisoned Cicero, imitated by Ovid, but Plutarch by the lead, for white lead is formed was unkind enough to say that his from it: this moreover is said to be works had nothing poetical about harmful to the human body.” them except the meter and that his Paracelsus, in his works Das Neudte style was bombastic and obscure. Buck in der Artzney (“de Contrac- Many other authorities were also turis”),das istvon krummen und lahmen familiar with certain features of lead Gliedern (the ninth book of thera- poisoning. Dioseorides, who is usually peutics, “de Contracturis,” that is Annals of Medical History 220

concerning crooked and lame mem- remedies the people sometimes rose bers) speaks of Von Ursprung der up against him and made things so Contractur die auss der Colica ent- unpleasant that he was forced to seek another location. Another physician in those distant NICANDRI times who has left us a good account POET AE ET MEDICI AJU of a case of lead poisoning Jean Alcxiphdrmci was tiquifinti Thtridcd cr m Fernel of Amiens. We remember him uerfturedaftd,per EVfUClVM Cordum,Mcdicm* as a patriotic Frenchman who, smart- ing with resentment because syphilis IDEM IN EADEM. was so universally called the morbus Contrdquosqjfudsmorfus iftusqj mcdtUt gallicus or French disease, insisted Nic&ndriru, fdcro cArmine Mufrdocct, that it be called the Disease of Prtterqudmdir* liuentu uulncrdlingu*, Venus or the venereal disease, as lUudnullapotefimccrc curamlm- Jacques de Bethencourt had suggested. Erg) quis hdnc dubitctpciorcm dicercpcjlcm» In his treatise “de Iuis vcnereae” he um que totus cunfta Q hubet ucnouliber* records the following history: A painter of Anjou, thirty years of age, of a good and sound constitution, noticed for the first time in 1557, that his fingers were heavier than usual, that they were numb and difficult to move; after several days he felt them contract and move convulsively, finally the affection was progressively aggravated, until the fingers remained flexed and could not be fRAN C O F OR DIAE Apui Cbr& extended. Moreover, the affection fimm Egcnclphw* reached the hands and arms, and so by the chilling nerves Fig. 2. Title-page of Nikanders “Theriaca of the and tendons, & Alexipharmaca.” 1532. Translated by Euricius filled with a thick humor, they became Cordus. heavy, trembling and numb. Soon after he experienced the same trouble in his springt an Handen und Fiissen aus- feet, and walking became impossible. getheilt (concerning the contracture However, he had very little pain in his that comes from the colic distributed feet, nor in his arms and hands. The poor to the hands and feet). Paracelsus, who fellow, as if he had not had already as one of his critics remarks “in the enough ills, saw a symptom appear much midst of the most incomprehensible more serious and much more painful; for jargon, sometimes writes intelligibly” an acute and unbearable pain now evidently in the course of his wander- attacked his stomach and hypochondrium ings saw and studied lead colic. It and extended throughout his abdomen. did not let has also been pointed out that Para- This pain up during the day or night, it was attempted but in vain celsus who was very fond of prescribing to ease it with clysters, hot applications, lead as a remedy, may have himself baths and other remedies. caused many of the cases he saw. Indeed this may explain in part the Fernel attributed the attack to circumstance that when he located in cinnabar, a mercurial pigment which a town and began dispensing his the painter constantly wiped off his 221 Some Landmarks in the History of Lead Poisoning brushes with his fingers. Later authors, tered references by physicians to lead however, have seen in this account the colic, it was Francois Citois who first description of a typical case of paint- established its right, as it were, to be ers’ lead colic with paralysis and have Nicander. jt5. pointed out that salivation, which would have occurred had the intoxica- tion been due to mercury, was absent in Fernel’s case. So that it was more than probable that the painter from Anjou became ill because he had the failing of wiping off lead paint from his brushes with his fingers. It is also a matter of interest that by a curious coincidence, Fernel describes on the same page of his “de Iuis venereae” the case of a friend of his who took, on the advice of an Empiric, powdered lead for his gout. This friend, after a terrible dysentery, became constipated Quod genusinuitx mortis,lethalc vcncnum Contincant in febeftia, & hcrba.doces. and suffered from atrocious colics. Proptcrca VidorNicandri nomenadeptus Perpetuoextabit: virusat omne f'ugit. This case he cites as a warning against the internal use of lead. Fig. 3. Portrait of Nikandf.r. (Courtesy of Felix Platter, who published the Surgeon General’s Library.) first classification of diseases in 1602, describes colic with paralysis. In his considered a distinct disease, in his “Praxeos Medicae” he speaks of the diatriba de novo et populari apud colic with “atrocious pains & attacked Pictones dolore colico biliaco which by torments whence they call them appeared in 1617. In this work, dedi- Tormina, the Germans call them kri- cated to his patron, Cardinal Riche- men (gripes). lieu, Citois described an epidemic of spasmodic colic occurring in the prov- Noises in the belly & creases, now in one place now running about in several ince of Poitou in 1572, and following this publication, we see the disease places . . . Constipation attacks many & or . “colic of Poitou” colica pictonum . . Terrible convulsions weakness may moreover follow these pains now: described with increasing frequency which was unknown to most of the an- in the medical texts of the time. cients, but is frequent in our generation. Citois described in great detail the Now these complications may be general disease which he says appeared in the and affect the greater part of the body: province of Poitou in 1572 and grad- now circumscribed they damage only ually became milder. He notes also certain parts. Thus impairment of motion that it had been previously observed been has frequently described. in Paris and Picardy and moreover Platter’s description of lead colic is in Silesia, Moravia and throughout excellent but his explanation is less southern Germany. Citois begins his happy for he blamed it upon a reten- dissertation with the remark that his tion of bile. century had seen several other new While there are many other scat- diseases which were the instruments of Armais oj Medical History 222

God’s wrath upon a sinful and unre- Following the description of Citois pentant world, particularly lues vene- in 1617, the “colic of Poitou’’ or rea, sudor anglicus, plica polonica and “bilious colic,’’ as already noted, takes its place in medical literature as a definite syndrome. Sydenham in his “Processus Integri” has a brief chapter, “De coliea Pictonum’’ and writes, “This is a sort of colie, which is wont to degenerate into palsy, depriving the patient of the use both of his hands and feet [a fact noted by Riverius in his chapter on Palsy], and which is extremely common in the West Indies, where it destroys many persons.’’ Thomas Willis wrote of colics with atrocious paroxysms and griping in the belly which were often followed by weakness and paralysis. Sydenham did not speculate as to the causation of the colic. Willis is more bold and explains it with the aid of his favorite theory, a spiritum animal- ium dejectu. Daniel Sennert, who saw and described many things clearly, even though he believed in witchcraft and pacts with the Devil, wrote:

. . . many widely different places, such Fig. 4. Jean Fernel —Joannis Fernelius Ambiani as Moravia, Austria, Franconia & many a colic for where the scurvy. And now colica pictonum other places have strong, sulphuric & tartaric wines are in use it is was added to the list. common & frequently leads to paralysis, Citois describes the characteristi arthritis and epilepsy . . . Such a colic colic which seized the patients and indeed was widespread in Silesia and in gives a particularly graphic account the Duchy of Tuscany in the year 1621. of the palsies. In describing the Wepfer was very familiar with this patients he writes: colic which he ascribed to “wine either . . . they are seen moving about excessively sour or fumigated with through the hamlets like ghosts or sulphur and bismuth and mixed with statues, pale, filthy, thin, with their other ingredients and adulterants.” and hanging hands crooked down from Bernardino Ramazzini in his “De their own weight, they can be moved Morbis Artificium Diatriba,” the first only with great effort to the mouth or treatise on pub- upper parts of the body and not down to occupational diseases, the feet but only to the muscles of the lished in 1700, noted that potters who thighs. Their gait is ridiculous rather work with lead often show its noxious than provoking pity, the voice noisy effects. “For in them,” he says, “at and rattling. first tremors appear in the hands, soon 223 Some Landmarks in the History of Lead Poisoning

they are paralyzed” and he adds of Wiirtemberg in 1696 was so im- “that rarely anybody sees a potter, pressed with these facts that he issued in whom the countenance is not a decree making it a capital crime to cadaverous and leaden.” Sydenham’s remark that this colic “is extremely common in the West Indies” shows how widespread the malady was. William Hillary, who went to Barbadoes in 1752 and re- turned to London in 1758, described the disease in that very interesting book, “Observations on the Changes of the Air and the Concomitant Epidemical Diseases in the Island of Barbadoes,” which first appeared in 1759. “This Colic,” Hillary observes, “is most commonly called the Dry- gripes, and dry Belly-ache, and is a most painful Disease.” He noted that those who “are immoderate Drinkers of spirituous Liquors, especially such as are fiery and new . . . are the most subject to this cruel Disease.” He described the “griping Pains to the Bowels, which are soon after zf- much distended with Wind” and the Fig. 5. Portrait of Sir George Baker. (Courtesy of Surgeon Generals Library.) “Faeces, when they are discharged afterwards, are in little hard dry add litharge to wine. However, these Lumps like Bullets.” He mentions scattered facts about the colic of also the “unusual Sensation and Ting- Poitiers were either unheeded warnings ling along the spinal Marrow; which or lacking conviction. The mystery soon after extends itself from thence was finally cleared up by the well- to the Nerves of the Arms and Legs, known investigations of Baker on and they become weak, and that Devonshire colic. Weakness increases till those extreme Devonshire colic had probably been Parts become paralytic, with a total endemic for centuries. William Mus- Loss of Motion, though a benumbed grave in 1703 wrote: Sensation often remains.” The dry belly-ache, Hillary saw . . . indeed there is another colic, in occasionally while practicing in Bath Devonshire, caused by the excessive use of cider crude and acid; it indeed comes but neither he nor his colleagues had from this, it infests only those, who are clear idea of its cause. For any in the habit of drinking it, and moreover centuries it had tormented its victims. for this reason are affected: since during Sennert came very close to discovering those seasons when the cider is abundant the cause and Vicarius described colic it spreads among the people; on the and paralysis following the addition contrary when the apples are not abun- of litharge to wine. Indeed the Duke dant it is rarely seen. [He mentions a Annals of Medical History 224 gentleman who had what they call the He was nine times president of the colica pictonum ending in paralysis] the College of Physicians. On June 29, joints then were weak, thin, without 1767, he read his famous paper, “An motion. Inquiry concerning the cause of the Dr. Huxham who is perhaps best Endemial Colic of Devonshire,’’ before known for his “Essay on Fevers” the College of Physicians. gave a very accurate account of the Baker is mentioned in “The Gold- Devonshire colic as he saw it. Headed Cane” as a friend of its fourth illiam Pitcairn, and In the beginning of the autumn 1724, owner, V a season particularly remarkable for an described as “that profound and abundance of apples, it spread itself all elegant scholar.” over the county of Devon, among the To him the whole medical world looked populace especially, and those who were up with respect, and in the treatment of not very elegant and careful in their any disease in the least degree unusual, if diet; and that, though it may not rage it was desired to know all that had ever with the same degree of violence, and been said or written on the subject, may affect a vastly less number of people, from the most remote antiquity, down yet it infests that county more or less to the case in question, a consultation every autumn. was proposed with Sir George Baker. Huxham describes the colicky pains From his erudition everything was expected. and paralysis in a vivid way. He also notes that apples were so abundant Baker’s erudition and his familiarity they were thrown to the hogs. “But with the medical literature of the the swine-hogs, as well as the swinc- past, probably suggested to him the gluttonous similarity men, suffered from the between colica Pictonum , abuse of the apples; and all of them Devonshire colic and Nikander’s de- wasted greatly in their flesh, and scription of the effects of lead. many died.” Huxham expressed his Baker was doubtless more or less conviction that the Devonshire colic familiar from his childhood with was due to the tartar, extracted from Devonshire colic. Although only two the apples in the process of making years old at the time of the great cider. epidemic which Huxham described, Huxham’s explanation however yet he doubtless saw succeeding epi- failed to satisfy one doctor at least demics, and in later life, after becom- and a little over twenty-five years ing a physician, he developed an later Baker began his remarkable especial interest in this disease. Baker’s studies. George Baker was the son keen mind saw an anology between of the Vicar of Modbury, Devon, lead colic and Devonshire colic and where he was born in 1722. He was he studied Huxham’s account closely. educated at Eton and Kings College, “For although” he said “I always Cambridge, taking his m.d. degree in pay that deference, which is due, to 1756. He first began practice at Stam- the authority of this celebrated phy- ford in Lincolnshire but removed sician, I have for some time conceived to London in 1761. He rapidly ac- doubts concerning the solidity of his quired a large practice, became phy- doctrine” (that Devonshire colic was sician to Her Majesty’s household, due to the tartar of cider). and was created a baronet in 1776. Baker first assembled some inter- 225 Some Landmarks in the History of Lead Poisoning esting data. He found that in the many years sold sugar of lead to the county of Kent a certain gentleman farmers for the purpose of correcting who thought his cider was too sour sour cider.” And Baker closes by say- boiled it with honey in a brewing- ing that it seems most probable that vessel, capped with lead. All who lead is the cause of the disease. “In drank of it were seized with Devon- this opinion, however, I may have shire colic. He also learned that in erred; but I shall be happy even in the parish of Bury Pomeroy the cider my error, if it shall excite some more as soon as made was stored in a successful inquirer to investigate, and large leaden cistern. Those “who to discover a truth of so much real drank the eider, thus prepared, were importance to human society.” most cruelly tormented by the Devon- But the proof was complete. Lead shire colic: and that many died.” was removed from the cider presses in He was also much impressed by the Devon and Devonshire colic became fact that while the cider of Devon- a matter of history. Confirmations of shire produced colic, the cider of Baker’s views came from various parts Herefordshire produced no such of the world. It was found that in the effects. West Indies, rum was distilled through Baker finally proved his thesis con- pewter worms and the pewter con- clusively by demonstrating that the tained a considerable quantity of lead. cider of Devonshire contained lead So the dry belly-ache that Hillary while that of Herefordshire did not. saw was caused by lead in the rum. He showed further that in Devonshire Two other very important obser- it was a common practice to line the vations in lead poisoning were made cider-presses wflth lead. later. In 1834 Henry Burton examin- Baker’s investigations created a ing patients in St. Thomas Hospital, great storm. He was denounced as a London, noted an important diag- “faithless son of Devon”; the lead he nostic sign of lead poisoning. found in his experiments, came, it was asserted, from some shot which were In a total number of fifty patients, [he used to cleanse the bottles and which wrote], who were examined whilst under had accidentally been left in them. the influence of lead, a peculiar discolora- The colic, it was loudly proclaimed by tion was observed on their gums, which not discern the of his opponents, was due to the humors I could on gums several hundred patients, who were not under of the body. This second objection he the influence of lead . . . The edges of did not deem worthy of an answer, the gums attached to the necks of two one but the first he demolished by or more teeth of either Jaw, were dis- pouring the cider through a cloth that tinctly bordered by a narrow leaden-blue would not allow shot to pass through line, about one twentieth of an inch in and then demonstrating lead in the width, whilst the substance of the gum cider. apparently retained its ordinary colour Still the storm raged. To one of his and condition. opponents, he wrote, “I here appeal to the conscience of one person, in Nothing further of importance was particular, whose zeal has induced added to existing knowledge of lead him to oppose my opinion in print, poisoning for over sixty years. Then whether it be not true, that he has for in 1900, Hamel, working in Grawitz’ Annals of Medical History 226 clinic, studied 25 cases of lead poison- cal classic, a model of clear accurate ing and found in all but 2, basophilic thinking, careful experimentation and granules in the red blood cells, the lucid presentation. same granules that Grawitz had de- Sporadic cases of lead poisoning scribed the previous year, in severe still occur, but they are usually recog- anemias. This observation was soon nized easily by the demonstration of a confirmed by numerous investigators lead line on the gums and of baso- and its great importance in the diag- philic granulations in the red blood nosis of lead poisoning established. cells. Indeed, the presence of a lead line Epidemics of lead colic, once so and basophilic granulations have saved frequent, are now practically un- many a patient with the tentative known. Their disappearance has been diagnosis of intestinal obstruction due to Baker’s demonstration that from an unnecessary surgical opera- “Devonshire colic” and colica picto- tion. The observations of Burton and num were nothing other than lead of Hamel were thus also of tremendous poisoning. The world has long since importance and they may be rightly forgotten that Baker was physician considered as ranking with the other to Queen Charlotte or nine times landmarks in the history of lead president of the College of Physicians. poisoning. His elegant and on learned writings The words written in italics: i.e. colica epidemic catarrh and epidemic dysen- pictonum, appear in the original in italics; tery are known only to the medical words written with small capitals below: antiquarian but his “Inquiry con- as, krimen and das neudte buch in der cerning the cause of the Endemial artzney, are written in the original in Colic of Devonshire” remains a medi- Gothic type.

References

1. Pauli Aeginetae. Opus de Re Medica phrasti Bombast von Hohenheim Para- nunc primum intergrum Fatinitate celsi genannt. Erster Theil. Franckfort donatum per Ioannem Guinterium. am Meyn. Joh. Wechels Erben, Anno Venetijs apud Andream Arrivaneum, MDCIII. MDXXXXII. 8. Ioann is Fernelii Ambiani. Therapeu- 2. Avicenna. Quoted by Baker. tices Universalis. Francfurti Apud 3. Nicandri. Poetae et Medici antiquissimi: Andream Wechelum, mdlxxxi. Theriaca & Alexipharmaca in Fatinos 9. Felicis Plateri, quondam Archiatri et versus redacta, per Euricium Cordum, Profess. Basil. Ord: Praxeos Medicae. Medicum. Francofordiae Apud Chris- Basilae, Impensis Emanuelis Konig, tianum Egenolphum, Anno mdxxxii. MDCLVI. 4. Fes oeuvres de Nicandre traduictes en 10. Citois. Quoted by Baker. vers francais par Jacques Grevin de 11. Thomae Sydenham, Medic doct. Opera Clermont en Beauvaisis. Anvers. C. Omnia Medica. Patavii, Typis Semi- Plantin, 1567. narii, mdccxxv. 5. Nicander. Alexipharmaca. Jo. Gorreaeo. 12. Thomae Willis. Opera Omnia Caloniae interprete. Parisiis apud Vascosanum, mdcxciv. De Anima Brutorum Patho- l 549- Iogici, Caput XV, DePassione Colica. 6. Dioscoridis. Fibri Octo graece et Fatine. 13. Danielis Sennerti, Vratislaviensis, D. Parisii Apud Petrum Haultinum 1549. & Medicinae in Acadamia. Witte- 7. Der Buecher und Schrifften des Edlen bergensi Profess. P. Medicinae Prac- Hochgelehrten und Bewehrten Philo- ticae. P. 594. Venetiis mdcl. Apud sophi unnd Medici Philippi Theo- Iuntas & Hertz. 227 Some Landmarks in the History of Lead Poisoning

14. Wepfer, Joh. Jacobi. Historiae apoplec- Cause of the Endemial Colic of ticorum. Amstelaedami apud Jans- Devonshire. Med. Trans. London, i: sonio-Waebergias, mdccxxiv. 175, 1772. 15. Ramazzini, Bernardini. Opera Omnia. 20. Burton, H. On a remarkable effect Genevae, Cramer & Perachon, 1716. upon the human gums produced by 16. Hillary, W. Observations on the the absorption of lead. Med. Chir. Changes of the Air and the Concomi- Trans., London, 23: 63, 1840. tant Epidemical Diseases in the Island 21. Hamel. Ueber die Beziehungen der of Barbadoes. London, 1766. kornigen Degenerationen der rothen 17. Musgrave, G. De arthritide symptomica. Blutkorperchen zu den sonstigen mor- Oxoniae, 1703. phologischen Veranderungen des Blutes 18. Huxham. J. Opusculum de Morbo Colico mit besonderer Beriicksichtigung der Damnoniensi. Londini, J. Hinton, 1752. Bleiintoxication. Deutscb. Arch. J. klin. 19. Baker, G. An inquiry concerning the Med., 67: 357, 1900.

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