252 DR. SAINSBURY: CHEMICAL CONSTITUTION AND THERAPEUTIC ACTION. was instituted ; and it is to be particularly noted that of SummingS up the evidence, so far as it is possible to sum up the total 17 cases 13 occurred in the period ending 1876. oon a subject as to which so much is still to be learned, we In the various streets within a quarter-mile radius of the seems to reach the general conclusion that, as a result of the hospital the percentage of the population attacked in the simultaneouss action of causes favourable to the spread of ten,years 1871-80 ranged from 4 per cent. to 25 per cent., infection,ii the contagion of small-pox may sometimes be con- the average being 9 per cent.2 In the workhouse, on the veyedv atmospherically to a distance much greater than had other hand, only some 3 per cent. were attacked. The tbeen usually admitted-a distance measurable by quarters of difference is certainly considerable; but the fact that the miles.r In endeavouring to summarise the agencies which cases in the workhouse practically stopped after 1876, 1:have to do with this result it is necessary to bear in mind when revaccination became part of the administrative thatt other unknown agencies may also be involved, and that system, goes far to account for the low attack-rate calcu- sometimess the joint action of all the known agencies may not lated over the whole eleven years. Whether, in addition, bet necessary, special activity of some, perhaps, atoning for anything (is to be attributed to the age-distribution of relativer deficiency or absence, and vice versâ, of others the workhouse inmates or to previous small-pox or to Keeping1 this in view, the factors whose coincident operation the well - regulated conditions as to ventilation, clean- (can produce the result in question may be subdivided as liness, &c. under which they were compelled to live, are having1 to do with (1) the contagium, (2) the atmosphere, questions as to which I have no information ; but, onandt (3) the population. 1. There must apparently be the hypothesis of atmospheric diffusion, it seems likely intensityi of virus depending on (a) the period of the that people who are mainly kept within doors will be less epidemic,( a rising epidemic being important, (b) concentra- exposed to infection than persons who walk abroad in the tiont of acute cases as centres of infection, and (e) possible special area without restriction of any kind. In regard,minori waves of epidemicity referring to particular days or however, to the whole comparison, it is to be borne in mindweeks,1 these waves constituting flood-tides of infectivity. that the theory of aerial convection does not exclude that2. (a) A foggy condition of atmosphere or light winds appear of personal communication, and in addition to the influence1to be of consequence, as observed both by Dr. Waterhouse of revaccination some part of the difference above indicated and: Mr. Power; and (b) possibly only the atmosphere of may well be due to excess of personal communication outside towns1 or cities may possess the necessary carrying power. the institutions as compared with the amount inside ; No good evidence has yet been adduced of such occurrences indeed, it is interesting to notice how this very theory comes in connexion with hospitals situated in rural districts ; but, in with regard to these workhouse cases. The general thesis no doubt, the failure here may be as much owing to want of was that the absence of small-pox was due to the absence population as to atmospheric condition. 3. Bearing in mind of personal communication, and that in particular this the conclusions arrived at by Dr. Whitelegge in his Milroy absence of personal communication was characteristic Lectures, it may well be the case that part of the influence of workhouses rather than Poor-law hospitals ; but when of a rising epidemic is due to the existence in any special attention was fastened on the fact that not 1, but 12 or area of a greater or less number of persons specially suscep- 15 cases had occurred within the workhouse, then at tible to small-pox and easily infected by its first active onset. once it was adduced in explanation that "the visiting The supply of such persons would be rapidly diminished or had only been stopped at one place one time, and that exhausted, and would not be renewed in the course of any for a very short time ; visitors came once a month." single epidemic. In Hackney Workhouse and Infirmary, which was about a quarter of a mile from the hospital and had in the eleven years 1870-81 an average of 643 inmates, the total number ON THE CONNEXION BETWEEN of small-pox cases originating within it amounted to about 20, again about 3 per cent. It was the custom here to CHEMICAL CONSTITUTION AND vaccinate very early all children born in the institution and THERAPEUTIC ACTION. to offer revaccination to all the inmates, but a good many BY HARRINGTON SAINSBURY, M.D., F R.C.P. LOND., refused it. The facts, therefore, are not unlike those relating to the of London Workhouse. As to the other institu- PHYSICIAN TO THE CITY OF LONDON HOSPITAL FOR DISEASES OF THE City CHEST AND TO THE ROYAL FREE HOSPITAL. tions mentioned, their officials were not called on for evidence, so that detailed examination of the cannot be made. figures IT has been of late the of medical if not In going over this part of the evidence in the Royal Com- years hope men, mission’s Report I made a note to this effect : Were their assurance, that chemical knowledge-the acquaintance there no other equal populations, not institutional (and, there- with the atomic structure of molecules-will lead them to a fore, with no check on personal communication), within more accurate understanding of the working of such molecules the area which 7 Near the end special equally escaped ? upon living organisms. Certain it is that, more recently, of my reading I found attention called to the fact that and on chemical lines, within a quarter of a mile of Fulham Hospital, within the pharmacology therapy, investigating numerous whose north-west segment of the circle, there were 121 houses have possessed themselves of compounds, which had entirely escaped from May 25th to the middle action they in a manner foresaw, and indeed sought of malice of September, though 153 admissions into the hospital had prepense. In proof of this statement, one need only point to taken place during that time. Here, then, was a place the long list of antipyretics and antiseptics on the one hand, which, as regards administrative effort within it to prevent and of anaesthetics and soporifics on the other, which have personal communication, was at the opposite pole from the been obtained from the aromatic and fatty series respec- workhouses, but which yet had not had a single case of small- tively. These for the most part are modern acquisitions ; but pox during these months. The evidence, however, was if they are hopeful signs-and they would be even more so if adduced, not to throw doubt on the power of personal com- the soil out of which these bodies sprang was not so alam- munication, but on that of the rival theory of aerial convec- ingly prolific-there yet remain for chemistry and pharmaco- tion ; but surely the facts are as applicable to the one theory logy to solve riddles so puzzling that one is compelled to as to the other. On the whole, I do not think that this reconsider the grounds on which belief in a definite relation evidence regarding these institutions can be looked upon as between chemical constitution and therapeutic action is at all sufficient to counterbalance the evidence on the other based. It is proposed to deal with this subject as follows: side. (1) to state the problem as it stands practically ; (2) to con- The practical conclusion of the whole question may be sider its chemical aspects ; and (3) to discuss its therapeutic said to have already been arrived at. Small-pox hospitals or pharmacological aspects. are not now erected in the midst of towns, and those already The problem of the relation between chemical constitution’‘ in existence are being more and more sparingly used; indeed, and therapeutic action requires proving-(a) by demonstrat- is seems where the power of aerial convection still doubted it ing that, in a series of compounds containing as a constant to be assumed that the prevention of personal communication one element or group functioning as an element, there is is impracticable and that accidents incidental to the system of traceable a corresponding constancy of effect ; and (b) by hospital treatment of small-pox within populous districts demonstrating that in a series of compounds built up must be accepted as inevitable, so that the only remedy under the one theory, as under the other, is the removal 1 Perhaps one ought to differentiate between composition and con- of such institutions to a distance from populous stitution, reserving the former term to describe differences in the num- places. ber and nature of the elements present in compounds, and the latter to describe the arrangement or grouping of the elements—i.e., structure 2 See Table, p. 48, Report of the Royal Commission. proper,—but to avoid complication I shall make no such distinction. I DR. SAINSBURY: CHEMICAL CONSTITUTION AND THERAPEUTIC ACTION. I 253 on the same type there is traceable a constancy o bination.