judiciously administered in accordance with a certain law, are capable of relieving the suffering of our fellow men, can there be a calling in life possessed of such responsibilities, and so noble, if properly fulfilled, as that of the physician? Think of these things. Ponder them seriously in your minds, and with all your energy and health and youth you will endeavor to attain those qualifications which will render you competent to successfully combat disease. It is my desire to place the importance of your calling in the most vivid manner before you; it is to endeavor to make you feel and love your profession with that firmness of purpose that will enable you to overcome the many serious obstacles which are ever npraised to impede your career; and if there be one among you, who has not now firmly resolved to further earnestly and diligently pursue his studies; if there be one who, having gone thus far, feels a distaste for the profession of medicine, let him here and now withdraw himself from the further prosecution of a pursuit which will become more and more repugnant as the shadows of life gather round him, and which will finally, from the neglect that will be almost a necessary consequence of such a condition of mind, desert him when it is too late to retrace his footsteps. There is no discouragement intended to be conveyed in these words, but I believe from my heart they are true, and I speak them conscientiously. Let us, then, in order to better appreciate the offices of the Doctor of Medicine, institute a brief comparison between the labors of the physician and those of other avocations in life. The merchant, for instance, toils for reputation and wealth, and rises to distinction among his fellows by his talents for business, and the promptitude with which his engagements are fulfilled. He attains, if successful, a high position, and is respected by the community in which he lives. The soldier, through the carnage of battle, amid slaughter and lamentation, by military prowess and foresight, rears a monument to his ambition and decorates his brow with the blood-stained laurels he has won. The statesman, by his "wit and words and worth, Action and utterance, and the power of speech by his perceptions and knowledge of political economy, gains for himself an enduring name, and lives forever in the hearts of his countrymen. The poet and the painter touch the imagination and the sensibilities, and incorporate themselves, by their works, with the age in which they live, and the nation to which they belong; but, gentlemen, whether it be the monarch upon the throne, who wields the sceptre of millions of subjects, whose word is the law and to whom thousands do homage; whether it be the soldier who has advanced to his coveted preferment; whether it be the merchant to whom wealth has extended the ease and luxury of civilized and refined life; whether it be the orator whose inspiring words have roused a sleeping nation from its lethargy of danger; or whether it be the poor in the hovel of wretchedness, or amid debauchery and degradation of both body and mind-all shrink in alarm from disease with its skeleton form, and sad images of suffering and death, and turn to the physician and surgeon for their aid, for the business of their lives is to cope with the king of terrors. After to-morrow night your battle with this adversary begins. Let us now consider what are the necessary wants of a young physician after the reception of his diploma. Practically speaking, his first want is money. He wants money, and as this world goes, he must have money, or he cannot eat, drink, shelter or clothe himself. I think I may safely say that the majority of young physicians are not possessed of an overwhelming amount of filthy lucre. If one in a class of this size has abundance, it is the exception which proves the rule. It is a most blessedly fortunate fact that the generality of physicians and surgeons are not in the beginning of their professional career overstocked with filthy lucre, an abundance of which I have known to spoil not only the best student I ever knew, but one of the best surgeons. Money, then, is as necessary to you as to all others, and you must have it; you want it. But there is a wide, wide distinction between working for the money with which to live, and toiling out your life-long existence for the love of it. The one is necessary to your life and position, the other is the root of all evil. Especially is this true in professional life. I venture the assertion that the doctor who practices his profession entirely for the love of the money he gets out of it, will do more dirty, contemptible tricks, both to his patients and his professional brothers, than any of you can conceive. It will make him pay three visits a day when one only is nec essary. It will make him call at lunch time, to prevent paying for his dinner. It will make him buy underproof alcohol to make his dilutions. It will make him use stale medicines, wear a seedy coat, use a rusty lancet and a dirty bandage. It will prevent his buying books, subscribing to periodicals, or purchasing instruments. He will be a great borrower. It will make him lie to his patient to prevent an honest physician being called in consultation, for fear of losing the patient and the family. It will make him boil his corks, and, for aught I know, count his globules, so many to the pound, so many to the dose. Get money for what it is worth, but not for the love of it, to keep and to hoard. How, then, are you to enable yourselves to live? First, then, by a stout heart, and by self-reliance; these two requisites you must have; and I do assure you when we contemplate the position of science of to-day, there is something that tends at least to astonish us. The thoughtful student must stand bewildered at the boundless realms before him; realms of so noble a character that they give tone and magnificence to the age to which they belong; an age that, when compared with those that have passed away, rises so superior, so wonderfully prominent, that the institution of a comparison can only be accomplished after considerable research and mature thought; and what is still more surprising is the fact, that each degree upward in the scale of scientific research is marked with increasing rapidity, that an estimate of averages will give to this present, over every former condition of mankind, an immense preponderance, and if there be offered no sudden impediment to this onward march, we may reasonably suppose that how far soever the scientific physician of to-day is above his brother of the olden time, just so much greater may be the position of the coming doctor over us. But with a stout heart and a determination to succeed, obstacles will gradually but steadily be overcome. Success in the treatment of one case leads to a reputation, and when you have a fair reputation, honestly acquired, then you will have no difficulty in finding the wherewithal to live. There was no more celebrated surgeon than Sir Astley Cooper; let me mark for you in dollars and cents his progress. In his first year he netted about $25; the second, $130; the third, $320; the fourth, $480; the fifth, $500; the sixth, $1,200; the seventh, $2,800; the eighth, $3,660; the ninth, $5,555; and the tenth, $10,500; after this his income amounted to over one hundred thousand dollars per annum. That man worked for the love of his profession, and the lucre came as a secondary consideration, which it is, and ever must be Having then looked out in a measure for your bodily wants, what is it you should desire next? A reputation. To acquire a reputation, a laudable ambition is necessary; not an overweening desire for ascendency, cially in those points wherein the rougher nature is not that ambition which "Let it once But play the monarch, and its haughty brow but a tempered aspiration for elevation in a profession To acquire reputation you must have "honesty of purpose.' What do I mean by honesty and morality of purpose? This-that you will attend your patient for the sake of curing him. At once you say, why this is the object of all physicians! I say to you that this is not so in many cases, in very many cases. Many a doctor feels a very great interest in a patient, because he has an interesting case, and because he desires to witness the effect of medicine administered according to the law Similia Similibus Curantur. Yes, this is the true spirit of action. Be cause the patient lives in a brown stone mansion in Fifth Avenue. Shall I say yes? Because he desires to keep an influential family. Shall I say yes or no? Because he expects a large fee. Yes? Because Mrs. Smith, living in another brown stone house across the way, may send for him professionally. Shall I say yes or no? Put these thins all together, and in six years from this date you will see what I mean by honesty of purpose. The physician with honesty of purpose, while he certainly desires what is termed an influential and a well-paying family, will not neglect a poorer patient in a forlorn street. He will even slight the fashionable hysterical female with globus hysterices, lying on a rosewood bedstead, and gyrating her nervous extremities under a silken coverlet, for a hospital patient that lies at the point of death or in a critical condition, He will spend an hour or half a day, without pay, working for the good of his brothers, his science and his school, and give a hurried call to the wealthier patient with a headache from last night's champagne. And, gentlemen, put this down as a rule, and remember it too: in the majority of cases greater reputation has come from the care and attention bestowed upon the poor, than has resulted from the obsequious attention to the rich. Ask any professional celebrity in this country how he attained his reputation, and you will find that it was poor Mrs. A. who had a singular tumor which he removed in a peculiar manner, after days and nights of thought, and weeks and months of attention; or it was the constant attendance for years upon the poor at a hospital; or it was the restoration to health of a pauper afflicted with an anomalous ffction. deficient. Not of the same organization, but endowed with different sensibilities, a different nature, a different taste, and subject to different bodily affections. The woman is as necessary to the man as the man to the woman; the one to the other as the sun to the soil, the rain to the parching earth, the light to the organ of vision. And yet with all this the effort is being made to disturb this wonderful harmony of the species. Woman must be a money getter and a money maker in the same spheres as man. She must be educated as a man, taught with men in the same schools. Those delicate sensibilities which place her so far above the man must be torn away; those powers which God Almighty gave her as a help-meet must be altered and hardened. Don't talk to me of the weakness of the sex, or prate of the inferiority of woman. If you desire to know the power and force of character of a good and true woman, marry one; care for her, tend her, love her; then when you are worn down with work, she will help you; when you are discouraged, she will cheer you; when you are despairing, she will support you; when you are attacked, she will defend you; when you are deserted by all your men friends, close at your side will you ever find her; when you are unfortunate, she will cleave closer to you; when you are in difficulty, she will be certain to find a way for your release; and neither time, nor change, nor aspersion, nay, even crime itself, will separate her from you. "Oh! woman mother, woman wife, The sweetest name that language knows, Before temptation's lightest breeze, To her who on her bended knees Not many friends my life has made, Few have I loved, and few are they Such are the words of one of our best poets. Especially is this true in surgery. The reputations of the greatest surgeons have been made by attendance upon the poor. The operation for anchylosis of the knee, Mott's ligation of the innominata; the introduc tion of silver sutures, and many others, were per- to its close. Therefore, my friends, must I say goodformed upon those who did not belong to the wealthier classes of society. The next great want of a physician is a wife. A wife, a help-meet. Don't marry for money alone; take it if it comes with the wife, as you receive it when it belongs to a reputation. Don't marry for position in society; your diploma given to you at the end of the term opens the door to the best social circles; nay, to the bedchambers of royalty itself. Don't marry because the old ladies say you ought to be married. This is the flimsiest reason of all. Marry for love, clear affection, whole-souled devotion to a noble wonian. It appears to me that the great tendency of this age is to depreciate woman. Recollect God created man and gave woman to be a help-meet for him. Not of an inferior body, but more beautiful in shape, proportion, and comliness; not of an inferior intellect, but in many ways superior, espe by. THE TREATMENT OF TAPE-WORM.-Its chief characteristic is the injection of large quantities of warm water into the colon, after the administration of the anthelmintic. The diet is first regulated, food being given which is supposed to be distasteful to the tapeworm-bilberry tea, sour cucumber, salted meats. The intestine having been, as far as possible, emptied by laxatives, a dose of the extract of pomegranate bark (prepared from the fresh bark) is administered, and then a large quantity of warm water is injected into the rectum. The theory is that the worm, previously brought down into the colon, is prevented by the water from attaching itself to the wall, and is brought away by the liquid in its escape. It is asserted that in every case in which this treatment was adopted the head of the worm was removed.-London Lancet. THE SECONDARY OR IMMEDIATE CAUSES BY WALTER Y. COWL, M.D., NEW YORK CITY. A consideration of this important subject appears desirable at the present time in view of the following facts: First, There is a broad distinction between the primary and the secondary causes of death. Second, It is the duty of the physician to know as far as possible what is the immediate cause of death in his patient. Third, There is an increasing demand among medical men for exact registration of the causes of death, both primary and secondary, by Governmental author ity. Fourth, There is a general lack of exact knowledge regarding the different immediate causes of death, and the fundamental distinction between them and the primary causes. Fifth, But few of our text books upon the science or principles of medicine, or general pathology, speak of the various modes of dying, and those few but briefly. That there is a broad distinction between the pii mary and secondary causes of death is readily perceived upon reviewing the clinical history of any disease that may end fatally--as pneumonia, for example, in the course of which there may suddenly appear a severe dyspnoea with universal subcrepitant rales, showing the presence of pulmonary edema; this, by preventing the air-cells from receiving sufficient air, frequently causes death in a few hours. Thus, we have the primary cause-the patient's disease, pneumonia-and the secondary or immediate cause--the mode of dying, by apnœa. Again, in death from phthisis as a primary cause, we almost always have as the secondary a gradually increasing exhaustion or asthenia, which, like all the secondary causes of death, is a result of the primary cause. These morbid results of disease or injury which are liable to cause death it is the duty of the physician or surgeon to study and understand, so that as soon as they appear: he will recognize them, if such is possible. This early recognition is important, for two reasons: First, It may so affect the treatment, hygienic and medicinal, that the fatal termination is prevented or postponed. Second, It generally changes the prognosis for the worse, and thus is oftentimes extremely valuable to the patient's family. The secondary cause of death, however, is sometimes very obscure, as well as the primary cause; for we must all admit, with Wagner,* that "In individual cases, even where a well-conducted autopsy is made, it is often difficult to determine the exact way in which death has been brought about. Even where we have the most striking anatomical changes, it is not always easy to specify the immediate cause of death." This shows the necessity of watching the dying patient in order to discover at that time, if possible, the immediate cause of death, and not to leave its determination to the autopsy alone. After the death, it is now required in this and some other large cities, by special law, that the doctor shall render a return of the causes of death, primary and secondary, and, in regard to certain diseases and accidents, with great exactitude. This great exactness required will, no doubt, in time, be extended to other important diseases, in order that the statistics collected, from being exact, will be of greater value to medical science. Thus does it behoove a physician, first making carefully his diagnosis, to attentively observe the signs and symptoms of his patient, particularly at the end, to discover with certainty, if possible, the immediate cause of death, in order to both render a correct certificate and obtain precise and positive knowledge of the different modes of dying. Too many physicians leave their patients, when death seems imminent, simply to the care of their friends, and we may ascribe to this, in part, that prevalent lack of exact knowledge in regard to the different immediate causes of death and the fundament 1 distinction between them and the primary causes, which is so very apparent upon consulting the files of death-certificates at our Bureau of Vital Statistics. But perhaps the general practitioner is not so very much to be blamed, for there is little said, in our present text-books, on the different ways in which people die, and still less given in our college courses. But few works speak collectively of the immediate causes of death, although they are so small in number, and what has been written, moreover, is almost entirely the work of a quarter of a century ago. In reality, it appears to be a field of medicine which has been greatly neglected for the past score of years; perhaps because its study does not tend to modify treatment so much as that of other subjects. Its full theoretical consideration would require a previous course of extended experimentation, observation, and experience; therefore, this paper, which has a more practical than strictly scientific intent, can give but the results of some study and research on the subject, and the observation of a series of sixty cases of death and subsequent autopsy, occurring in hospital practice. * Bichat has said that death begins either at the head, the heart, or the lungs. Dr. Watson, however, considers this division insufficient and unsatisfactory, as it does not include anemia (as in profuse hæmorrhages), nor that from starvation (or asthenia, as in phthisis, dysentery, etc.), yet he does not make a classification himself. Considering the facts-that life directly depends upon the supply of normal blood, which is furnished by the ingestion and digestion of a proper amount of food, and persistently furnished only during the absence of wasting or blood disease, and that exhaustion is due to starvation, indigestion, waste, or blood change-we must conclude that death from asthenia is directly due to a chronic progressive anemia, to a failure of the blood. We are now prepared to make a classification of the secondary causes of death, as due to Failure of the blood, FAILURE OF THE BLOOD is due to acute anemia, asthenia, or toxæmia. Acute anemia is the result of profuse hæmorrhage. lar, or absent pulse; paleness of the entire surface, cold Its prominent symptoms are a feeble, slow, and irregusweat, dilated pupils, dim vision, vertigo, and speedy loss of consciousness. The heart, veins, and arteries are found empty after death; all the organs are pale and shrunken. the result of any disease, but more especially of starAsthenia, exhaustion, or chronic anemia, may be vation, old age, chronic hæmorrhage, or exhausting diseases such as phthisis, dysentery, typhoid fever, *Recherches sur la Vie et la Mort." "Lectures on the Science and Practice of Medicine." London, 1848. P. 64. cancer, continued suppuration, etc., etc. Probably The blood in the pulmonary capillaries is not oxymore than one-half of all deaths are due to asthenia. genated, consequently the vaso-motor nerves of the Its symptoms are a feeble frequent pulse, much smallest arteries, which govern the rate of supply to accelerated on slight exertion, feeble or imperceptible the capillaries according to the rapidity of oxygena heart impulse, cold extremities, paleness, emaciation, tion, cause these arteries to contract, and allow but a general weakness, flabbiness of the muscles, wrinkled small part of the blood to flow on; that part goes inelastic skin, vertigo, frequent syncope, and a slow through the left heart and is found as venous blood death. in the pulmonary veins and systemic arteries after After death the adipose tissue is found in most cases death; by far the greater portion, however, is kept much diminished, the muscles are atrophied, and all back by the spasmodic contraction of the termini of the organs, perhaps excepting the diseased one, are the pulmonary arteries. The right heart is powerfound below the normal size and usually pale and less from distention and the great resistance to the flabby. onflow of the blood, and after death is found filled, as are the larger systemic veins also, with fluid blood, more especially if the death has been sudden, while the left heart and pulmonary veins are nearly empty. Embolism of the pulmonary artery is the result of thrombosis of some large systemic vein from phlebitis, pyæmia-puerperal (fever) and surgical-phlegmasia dolens, from ligation or section, and from admitted air. The symptoms, in the main, are those of apnoea; there is an intense want of air, yet the inspiration is free and often deep, and pallor is frequent, although livor is more common. The pulse is small and irregu lar, or absent; the second sound of the heart and the cardiac impulse are increased; there is tetanic extension and coldness of the limbs, and involuntary evacuations. Death is sudden. The pulmonary veins and left cavities of the heart are found empty, the right cavities and systemic veins greatly distended. From apnoea it is differentiated by the absence of all causes of the former, by the suddenness of the attack, ability of free inspiration, absence of rales, and presence of the respiratory murmur. Toxemia or blood-p isoning is the result of infection with the virus of a rapidly fatal blood disease,* or with certain animal or other poisons, as that of the rattlesnake, prussic acid, etc These viruses or poisons act upon the blood-cells, and thus render the blood incapable of nourishing the tissues to a rapidly increasing extent, until the patient dies of an asthenia, but one which, different from that of other exhaustive diseases, develops with extreme rapidity, and produces death after but a short period of fever or the other symptoms of the disease. Without doubt, in many cases where the nervous system is constitutionally weakest it is the first to fail, and death occurs in coma or convulsions. Toxæmia could be here assigned as an intermediate cause of death. On the other hand, in uræmia, cholæmia, simple narcotic, and some other forms of intoxication, the poison seems to have an intrinsically greater effect upon the brain than the other parts of the system, and hence toxæmia (rather as an inte mediate than an immediate cause) produces death by coma or convulsions. Blood poisoning should only be considered the immediate cause of death when the patient dies before general as henia from fever, exhaustive drains or lack of food, cardiac asthenia from fever, or any complications-as pneumonia or pulmonary cedema-have had time to develop themselves The patients are those who are said to die of the intensity of the disease itself who are" death struck" from the beginning. The symptoms of fatal blood-poisoning are the symptoms of asthenia combined with those of the particular blood disease present. The blood after death is dark, lacking in fibrin, and thinner than nor mal, except sometimes in cholera. FAILURE OF THE LUNGS is due to apnoea or embolism, or thrombosis of the pulmonary artery. Apnoea (signifying lack of air), or, as it is more often called, asphyxia, is due either to obstruction of the air passages, as in croup, pneumonia, capillary bronchitis, oedema pulmonum, undue anesthesia," etc., etc.; to an inability on the part of the lungs to respire sufficient air from compression, as in pleurisy, pneumothorax, ascites, burial alive, etc.; to muscular spasm, as in tetanus and strychnia poisoning, or to paralysis of the muscles of respiration. Its symptoms are a sense of want of air, strong contractions of all the muscles of respiration, both ordinary and extraordinary, with absence or faintness of respiratory murmur, gasping and lividity, and finally insensibility, convulsions, and coma; the attack accompanied often by vertigo, tremor, and paralysis. Its pathology as at present determined, may be briefly expressed: FAILURE OF THE HEART is due to cardiac asthenia, thrombosis of the cavities, or embolism of the coronary arteries. Cardiac asthenia is the result of fatty degeneration, muscular strain, pericarditis with effusion, myocarditis, pneumonia, phthisis, valvular disease, angina pectoris, leucemia, and certain zymotic or infectious diseases, especially those with fever. It is fatal from intrinsic inability to overcome resistance to the flow of blood in fatty degeneration and myocarditis. In pericarditis, with effusion, primarily from intrinsic weakness due to maceration of the cardiac muscle in the effusion, and secondarily from exhaustion developed by the heart's continuous beating through a compressing fluid in a tightly stretched sac. In valvular disease, phthisis, and pneumonia, the development of the asthenia results from the heart's having a more and more difficult labor to perform; the same is also true of leucemia and the essential fevers in which there is an obstruction to the blood current (stasis) in the capillaries from their dilation and the greatly increased numbers of adherent white blood-cells; to this is added diminished nutrition of the cardiac muscle from vitiation of the blood (in infectious disease by fever or the poison of the disease or both). In death from muscular strain, as where an oarsman dies in his race, the heart undoubtedly fails from lack of power to meet the excessive resistance offered by the almost continuous contraction of the muscles, and the greatly increased call for blood, due to the rapid metamorphosis necessary to such tremen dous exertions. The distinctive symptom of cardiac asthenia is a pulse which is more feeble and more accelerated than the general (as indicated, for instance, by the muscu *Such fatal infections or zymotic ciseases are yellow, cerebro-lar strength) would produce, a pulse which, upon exspinal, typhus, typhoid, and pernicious malarial fevers, variola, scarlatina, measles, cholera, di htheria, septicemia, and erysip This term is inc rrect, as it signifies a state of pulselessness rather than a lack of air, and hence apnoea is the more proper elas. term. ertion, becomes very rapid, and quite irregular both in force and rhythm, and at last stops during some general muscular effort. The diagnosis is also made by exclusion of the other secondary causes of death, by its suddenness, and by the presence of a primary cause of cardiac asthenia. The cardiac cavities are found distended with blood, and the walls often softened. Cardiac thrombosis as a cause of death is the result, in rare instances, of pneumonia and of acute endocarditis with rheumatism or other disease; in the former, from the slowing of the current in the right heart, and the increased coagulability of the blood; in the latter, from increased coagulability of blood, and inflam mation, and roughening of the endocardium, upon which fibrin is more easily deposited. It also occurs in post-partum anemia, due to hæmorrhage or other cause, because of the increased coagulability of the blood and the diminished velocity of the current. The symptoms of cardiac thrombosis are severe dyspnoea, cyanosis; a feeble, small, irregular pulse, which may be either slow or frequent; cold extremities, delirium, convulsions, coma, and more or less sudden death. The diagnosis, which is mainly by exclusion, is often difficult, except upon post-mortem examination, when the beart-clot must be found to largely fill the cardiac cavity. Embolism of either coronary artery presents the same symptoms as thrombosis of the cardiac cavities; it is the result of thrombi from the left hear, as in valvular disease. Its occurrence is rare and the diagnosis is extremely difficult without autopsy. FAILURE OF THE NERVOUS SYSTEM is due to shock, coma, convulsions, or cerebral anemia. Shock is a paralysis of the nervous system in whole or in part, at times complete, again incomplete, and is either the result of a sudden injury to the nervous mass, as in wounds, contusions (fatal concussion), and extensive compression of the brain or cord, or the result of an intense impression upon the nervous system, as in death from lightning, capital operations, or operations with much hemorrhage or prolonged and deep anesthesia, burns, opening and exposure of the abdominal cavity, rupture of the heart, or other severe injury (not centric). Shock is more often fatal than statistics indicate, especially after operations, which it may follow with death as late as the third or fourth day. There is a considerable probability that in many, if not all cases, shock acts principally through the sympathetic, and thus upon the heart, producing death by a true cardiac paralysis; but as of this we are not certain, the term shock is best retained until time shall establish the facts. Again, there are instances in which an anemia of the brain is evident; among such cases of shock are undoubtedly th se resulting from intense emotion which are thus strictly analogous to simple fainting, although so much more severe in de- ! gree; this cerebral anemia, however, we believe depends upon a paralyzed sympathetic and consequent paralysis and distension of the large veins, more es pecially those of the portal system (afferent), which alone are able to contain the great mass of the blood. Whether cerebral anemia is present in all cases of shock, we are at present unable to say. * Its symptoms are a feeble, generally slow and intermittent or irregular pulse, slow sighing respiration, pale face, cold sweat, vertigo, involuntary evacuations, cold extremities, nausea and vomiting, and more or less sudden death. The diagnosis is also made by the suddenness of the attack, the presence of a primary cause of shock, and a fall of temperature † more than 3° F. (in fatal cases). H. Fischer. "Ueber den Shock: Sammlung Klinischer Vorträge. Herausgegeben von R. Volkman." Quoted by Nothnagel on Cerebral Anemia," Ziemssen's Cyclopedia of Practical Medicine." Wm. Wood & Co., New York, 1876. +In all cases, perhaps excepting urethral fever. Wagstaffe: "St. Thos. Hosp. Reports." We cannot as yet determine from post-mortem examination what essential change (if any) has been effected in the nervous mass, nor where, if at any particular place, such change may lie; we cannot place it at the medulla or par vagum alone, as inclination might lead us to do when considering the sudden death from perforating the floor of the fourth ventricle, for life and the heart's action do not absolutely depend upon the brain or spinal cord-living anencephalous foetuses have been born and continued existence for a greater or lesser length of time; in animals the heart's action has kept up after both brain and cord have been removed, while artificial respiration was performed; thus it has been established that the contractions of the heart depend upon the ganglionic nerves lodged in the muscle itself. Again, sometimes in death by shock the heart is found contracted, while generally it is distended, so that we cannot say that it is always due to an irritation of the par vagum. Clinically, we have at present no division of shock, except as due to the various diseases and accidents which cause it. Coma is the result of a lack of the proper supply of normal arterial blood to the brain; as in cerebral congestion, cerebral compression or cedema, uremia, cholemia, narcotic poisoning or cerebral anemia, or from embolism, etc. Its distinctive group of symptoms are those of general anesthesia and paralysis, more or less complete. Death follows the paralysis of the respiratory centres of the pons and medulla, sometimes with apnoea from obstruction of the bronchi by mucus. The gross changes found post-mortem vary with the primary cause of death. Of what minute changes take place in the nervous mass we are as yet to a great extent ignorant, and can only infer clinically that they are general throughout the brain, differing probably in that respect from simple shock, which most often does not affect the entire brain or at least not equally throughout, as evidenced by the retention of the pow ers of thought, speech, the special senses, and muscular action to some degree, which are totally abolished in well marked coma. Coma seems to affect chiefly the cerebro-spinal system; shock chiefly the sympathetic. The difference in the force of the pulse appears to bear this out.. Convulsions as an immediate cause of death are, like coma, the result of a disturbed intra cranial circulalation: as in cerebral congestion, from insolation, alcoholism, etc.; cerebral compression, from hydrocephalus, apoplexy, depressed bone, and tumors; acute inflammation of the brain or its membranes, as in cerebro-spinal fever and encephalitis, cerebral œdema, cerebral anemia, epilepsy, uremia, eclampsia of parturition and the puerperium, and peripheral irritation as in dentition The distinctive symptoms are sudden, more or less general, contractions of the muscles, with suspended respiration, lasting but a short period of time and recurring with increased frequency until death. To what intrinsic process or change of condition in the nervous mass they are due, as well as the principal seat of the change, we cannot as yet positively say, although probably within a short time Nothnagel's theory of "irritation of a convulsion-centre" in the pons will be settled. Fatal cerebral anemia without shock, convulsions, or coma, is the result of the sudden removal of blood (virtually) from the brain to the portal system, as in entirely unloading a long-distended bladder, withdrawing ascitic fluid improperly, certain cases of rapid parturition, of removal of large abdominal tumors, and sudden muscular exertion calling the available blood elsewhere in aortic obstruction. The symptoms vary somewhat according to the primary cause of death, but are mainly those of simple syncope prolonged. The diagnosis, however, which is mainly by confining the primary cause to one of those mentioned, is often difficult |