In working life befallen me that after the mature acquaintance of fifteen years you have requested me to take so high a position, this henceforward will be my first and chiefest care. conclusion, I am sure that our heartiest and kindest feelings will follow Dr. Paget-I will not say into his retirement, but into the high and important duties he has to discharge in one of our national universities. We shall follow him with feelings of interest and kindly affection which none of us are likely to diminish. (Cheers.) The Council, after transacting the usual formal business, concluded its sittings. By an error of our reporter last week, Mr. Quain was made to read a wrong passage from the Report on Examinations at the General Medical Council. The first few words of both passages are the same, hence the error. The passage which Mr. Quain read was as follows: "In reviewing this examination, your visitors cannot avoid expressing their opinion that there is room for considerable improvement in the mode in which the proficiency of the candidates is tested in the important subjects of anatomy and physiology. It appears to your visitors that the principal reason for dividing the professional examination into two parts -one including the subjects of anatomy, physiology, and chemistry, the other embracing medicine, surgery, materia medica, midwifery, and medical jurisprudence-is to enable a high standard of knowledge to be insisted on by the examiners, since the student is able to give his undivided attention to each class of subjects long enough to acquire a thorough practical knowledge of them.' Instead of the above, the following passage was erroneously inserted : "In reviewing this examination, it appears to us that the examination in clinical medicine might be somewhat extended with advantage. A written report of two or more cases by the candidate would assist the examiner in forming his judgment, as it is difficult to avoid putting leading questions to the candidate when the examiner aids, as it were, in the examination of the patient. More specimens should be shown under the microscope, and pathological specimens might be exhibited. The examination on clinical surgery was more extended, but we noticed that no instruments were exhibited to the candidate, that there was no practical examination on bandaging, nor on the management of fractures and dislocations, no pathological specimens were shown, and still less was there any attempt made to test the candidate's knowledge of practical surgery by the performance of operations on the dead subject." OXIDE OF ZINC IN DIARRHOEA.-M. Revillout states that in the wards of M. Damaschino oxide of zinc is often prescribed with great success in all the forms of diarrhoea. The usual formula is three grammes and a half of the oxide, and half a gramme of bicarbonate of soda, divided into four portions, to be taken during the day. The soda is added to prevent the production of a soluble salt of zinc with the acids of the stomach. The measure is very efficacious in all forms of diarrhoea, even that met with in phthisis. M. Revillout has also seen many cases in which champagne, administered while effervescing, has proved an excellent remedy in vomiting and the hectic diarrhoea that often accompanies it in debilitated subjects. Young infants, too, suffering from constant vomiting of food, have been enabled to digest raw meat by employing champagne as a drink.--Gaz. des Hôp., July 18. INJECTION OF ERGOTINE IN FIBROID TUMOURS OF THE UTERUS.-In a communication to the American Journal of Obstetrics for May, Prof. Hildebrandt, of Königsberg, states that he continues to hold the high opinion of the subcutaneous injection of ergotine which he formerly did (Medical Times and Gazette, July 27, 1872, p. 101). In some patients it causes severe pain, compelling rest for an hour or two, but in many cases after he has performed the injection the women are able to walk home on foot. He has himself never met with abscesses, and he attributes their occasional occurrence in the practice of others to the too superficial introduction of the canula. He takes up a firm fold of skin and inserts the canula, not obliquely, but perpendicularly, into the crest of the fold to the depth of one-half the length of the canula, so that the fluid may always enter the thick adipose subcutaneous cellular tissue. As a rule, only the first three or five injections are painful, the others being more or less easily borne. ORIGINAL LECTURES. LECTURES ON CERTAIN CLINICAL VARIETIES OF CONSUMPTION. DELIVERED AT THE HOSPITAL FOR CONSUMPTION AND DISEASES By JAMES E. POLLOCK, M.D., F.R.C.P., (Continued from page 667, vol. i. 1874). AGE is an important modifying agent in every case of phthisis; 2. Strumous phthisis. 3. The ordinary continuous form of the disease (in greatest numbers). 4. The class in which cavity is rapidly formed. 5. The large class arising out of acute disease. 6. Marked hereditary predisposition exhibits its influence at this period. In advanced life the disease is slower. Insurance offices act on the supposition that after forty-five the danger from phthisis ceases; but very many die of it after this age. Brinton considered that after forty half the danger was over. I have notes of 174 cases over forty-five years of age. Of these thirty-three were in the first stage, seventy-one in the second, and forty-two in the third. Two thirds were males. The phthisis of early life is characterised by destruction of pulmonary tissue without limit, by inflammatory actions almost continuous; while concentration of the disease in one part of the lung, moderated and remittent inflammatory attacks, and excessive tendency to degeneration mark the phthisis of age. Chronic deposits in the lung, which have been tolerated for years, often break up in old age, and this is called senile phthisis. This form is often fatal without any tubercle. Chronic indurations, fibrous over-growths, which degenerate and soften, break down into cavities of a dark sloughy appearance without membranous lining. Profuse hæmoptysis is rare. Out of 351 cases in my own practice, only forty occurred after forty years of age. Pain, fever of a high character, and gastric disorder are rare. I do not propose to describe the symptoms of senile phthisis, but to call your attention to the fact that age modifies the disease both in its symptoms and progress, and especially to notice the more than doubtful character of cases which often pass for bronchitis in the aged, but which are in reality ulcerative diseases of the lung, in which old deposits resulting from attacks in early life often break up and assume finally the true characters of phthisis. Hæmoptysis is a symptom of so much importance, both to the patient and his friends, that I must detain you for a few minutes while we consider its meaning and bearing on the progress of our cases. For practical purposes we may say that there are two varieties-the congestive and the mechanical. The first is common to all stages of phthisis, and is, in fact, a congestion of the lung, the hæmoptysis being only the symptom. The latter is almost confined to the stage of cavity, and is nearly always due to the rupture of an aneurismal dilatation of a branch of the pulmonary artery passing through a cavity, the walls of the vessel having shared in the ulcerative destruction of all the lung tissues. You will remember how blood vessels resist ulceration, as is so often seen in surgical cases; and it is truly wonderful to reflect on the rarity of fatal pulmonary hæmorrhage when we see daily in our dissections such entire destruction of so vascular an organ as the lung. It seems necessary to the production of the fatal accident that the coats of the vessel should have become diseased and undergone dilatation, for in all our cases a patient dissection will not fail to discover this lesion. This form of hæmorrhage is perhaps always fatal, although not always at the first attack. If nature, however, gives us time and makes a clot, we may assist by using those remedies which promote coagulability of blood and influence the contractility of the vessels through their nerve-supply. To this class of remedy belong ergot, turpentine, alum, and gallic acid, also acetate of lead, which sometimes acts like a specific. Some late experiments of Dr. Blake in the Journal of Anatomy and Physiology, show that the injection of acetate of lead into the vessels causes contraction of the arterioles of both the pulmonary and the systemic circulation. Cases of very profuse hæmoptysis are much more common in the male than in the female. In 351 of my own cases, 267 were men. The age most attacked was between twenty and thirty; the youngest was a girl of eleven. Children, as a rule, are free from this accident. It is not to be asserted that all these cases had pulmonary aneurism, but all those who actually die of hæmorrhage may be presumed to suffer from this lesion. The congestive form of hæmoptysis is more common, and considering its results, is perhaps the more serious affection of the two. It is common at the outset of continuous progressive phthisis; but acute tuberculosis has no hæmoptysis. It is very important that you should regard this disorder as an attack rather of congestion of the lung than as a hæmorrhage. It is astonishing how we are all led away by names; and if called suddenly to such a case the practitioner will naturally think of the best styptic remedy, and hasten to save the patient from perishing by loss of blood. These cases do not die of hæmorrhage, and, indeed, are all the better for the depletion. But how are you to distinguish the two cases-the mechanical loss of blood to which you must fly with all your remedies, from the congestive, where you may let the blood flow with advantage to your patient? In mechanical hemorrhage your patient has but one symptom-loss of blood. He is pale, weak, haggard, with a cool hand and failing pulse; he gasps, for his heart is weakened by the loss, and should he become more anæmic he will die. And this will have come upon him all at once, perhaps while he was stooping or coughing violently, or while he was eating. In congestive haemorrhage your patient has been forewarned. He has felt his breath tight and short, perhaps has had pain through the chest to the shoulder. He is hot and flushed, and his pulse is tense or bounding. His temperature invariably rises, and in a sharp attack will touch 103 or 104°. Repeated florid haemorrhages occur, a cupful at a time, yet your patient is not readily exhausted by such losses. Indeed, he feels relieved in breath and cough, and excepting that he is alarmed by the sight of so much blood, does not feel very ill. If you examine his chest you will find dulness in a patch over a portion of the lung, and a more or less fine crepitus. You are, in fact, looking at a case of pneumonia, and you had better call it so, and treat it accordingly. Our ancestors would have bled such a case, and I am not sure that they would have been wrong. We give saline medicines and ice, slightly purge with salts, cup over the chest, and keep the patient quiet and his room cool; and we forbid the use of styptics. After a while there is relief, and the patient is better, his chest symptoms are less urgent for some time, and he regains flesh, but probably not up to the point which he had reached before the hæmorrhage. I believe it will be found that an increase in the extent of physical signs will have occurred after attacks of congestive hæmorrhage. In other words, the congested portion of lung never entirely clears up. You will notice subcrepitant sounds at the part which during the hæmorrhage presented dulness, bronchial breathing, etc. The prognosis in cases of hæmoptysis will therefore be derived from a careful consideration of the cause, and unless the patient be greatly exhausted by loss of blood, and especially if the digestive system be unimpaired, you may safely look for a tolerably long period of quiescence after the attack. I have often had occasion to observe that some of our most chronic cases have commenced by a smart hæmoptysis. As regards the continuance of the hæmorrhage during an attack, you can have no better guide than the pulse and the temperature. With a maintained temperature of 100° or 103°, and a rapid, full, and somewhat hard pulse, you may be sure that a patient when spitting blood will shortly have a recurrence of the attack. I know of no symptom by which we are enabled to prognosticate an attack of profuse mechanical hæmoptysis. The patient often dies as if shot, and in many instances before the resident medical officer can reach the ward, while dissection shows the whole of both lungs filled with blood. Chronic cases, which have been overdone with oil and iron, are very subject to sharp attacks of hæmoptysis. Temperature. The observations which I have to make on temperature partly confirm those of other observers. The clinical value of the thermometer is very great in phthisis, and is especially important as indicating congestion or inflammatory events. It is first necessary to establish what is the normal temperature of phthisis when in a quiescent state, no special congestions being present. Mr. Bartlett has kindly conducted observations for me through all the hours of the day and night, and we may conclude that in ordinary quiescent phthisis the minimum temperature, 98° or 97°, is in the early morning (about three to six or seven). The higher temperature, 99° to 100°, occurs about three to six or seven in the afternoon. Such cases are generally gaining, certainly not losing flesh; nutrition is good; chills and sweatings are absent; yet withal there may be a slight, steady, and progressive advance in the physical signs, and the crepitant sounds may be slowly on the increase. This is also true of weight. An increase of weight may take place while the physical signs are advancing. In hæmoptysis of the congestive kind, I have observed a pretty constant relation of high temperature, the thermometer registering up to 102° to 103° and 106°. The entire thermometrical range in phthisis is small, and may be stated as from a sub-temperature of 96° to 106°. It is very rarely above this. A pretty free hæmoptysis will cause a fall, and the lowered temperature may be maintained even in cases in which the hæmoptysis does not recur. In recurring hæmoptysis a high temperature is maintained, and is a most valuable guide both to prognosis and treatment. The mechanical hæmoptysis, due to ruptured aneurism of the pulmonary artery, is not accompanied by rise of temperature. Considerable congestion accompanies this condition. A sustained fall of temperature to 95°, or lower, after a high range, is not uncommonly the precursor of death. I am not prepared to state whether high temperature in phthisis is the result of the constitutional disorder or of the local irritation. The question is ably discussed by Dr. Ringer and others, but has not much practical value. These conditions are so united (constitutional disorder and local irritation) that to me they seem inseparable. In practice it may be accepted that while high temperature is not the measure of the extent or amount of local mischief, it is never present without inflammatory congestion. A small deposit in the lung, if undergoing inflammatory change, will run the temperature up to 103°, while a more diffused and extensive deposit in the lung may slowly soften with a thermometrical range of one or two degrees only, as is seen in chronic quiescent phthisis. The existence of gastric disorder is so grave a complication of phthisis, that it enters into all questions of prognosis, and is only second in importance to congestions of the lung. Disorder of the mucous gastro-intestinal membrane is recognised by the tongue, which presents several varieties of morbid conditions, and by nausea, or absolute intolerance of food, vomiting, and diarrhoea. Your patient is thus reduced by both insufficiency of food and by the waste of diarrhoea. The tongue is generally furred at the back and red in front, or it may have a red central stripe and red edges and top, or it may be simply red all over, presenting a stripped smooth appearance. This last is the worst variety of tongue seen in phthisis, especially when it is accompanied by aphtha. A curious fact about this red tongue is that it may exist for a long time without either diarrhoea or vomiting, but it is most commonly associated with the former, and the intestine is found ulcerated. I have, however, seen extensive ulceration of the ileum after death where there had been no diarrhoea during life. To give tonics and cod-liver oil in such a state of the digestive system seems a great mistake. Support your patient well with milk, egg, broth, jelly, and bread-and-milk, and give very little drugs of any kind. Perhaps bismuth and opium will relieve more than anything else, and the tongue often cleans or loses the scarlet redness under its use. The occurrence of aphthæ in advanced phthisis is always a serious warning symptom. The nurses will tell you it means death, and so it does sometimes; but aphthæ often clear up and disappear, and it is not till after the patient has had two or three attacks that the grave disorganisation of the mucous membrane occurs which immediately precedes the fatal issue. You will probably expect that I should detain you for a few moments by a consideration of the proper treatment of phthisis, and especially by a statement of what is done for that disease in this hospital. Let me begin by stating results. The vast majority of our patients-perhaps 90 per cent.-are much benefited by their residence here. They gain in weight, improve in general health, and are stronger in digestion. In a large number the expectoration lessens in quantity and becomes easier. The patient's nights are therefore more tranquil, for cough is relieved and fever is moderated: and cough and fever are the two enemies of sleep which we have to combat. How do we set about to put our patient into these more favourable conditions? First of all, we give him rest; and in these days you are familiar with the physiological influence of rest in treating all diseases. When a patient is admitted here he leaves behind him generally a poor and crowded house, and the misery of witnessing often the daily struggle for subsistence in the very chamber where he sits or lies-an unwilling witness of the toil which he cannot share and in which he was perhaps once the foremost bread-winner. Here he can lie down by day or night without the distraction, it may be of restless children, or the surroundings possibly of some trade. For the time he is fully cared for and has all his wants supplied. Dull enough work, you will say, waiting in even the best of hospitals for two or three months with nothing but the routine of mealtimes and the physician's and chaplain's visits to enliven the long hours! Well, so it is. But here we do not exactly leave our case to such stagnation. We have books and papers, and some games, and kind visitors, who are content to talk and read; and it is surprising what a light a well-dressed cheerful lady visitor will bring with her into our wards. Then, as you know, we have evening amusements in winter-music, often of a high class; light dramatic entertainments; readings, grave and gay, but generally the latter. Having been one of the originators of these evenings, I have watched them with much care, and I may say that I have never known any mischief to arise from them. Let me say also to my younger hearers that in visiting a ward filled with cases of chronic disease the physician should be rather cheerful than sombre-with a grave feeling, it may be, in his heart, but a ready encouragement on his tongue and in his manner. He should see the bright side as well as the dark, and ever bear in mind the many cases of phthisis which have outlived unfavourable predictions. There was a time when all cases of cavity in the lung were condemned to speedy death. Let us remember the plump figures and rosy cheeks which we occasionally see even in the third stage of phthisis! About temperature and ventilation I must say that, perhaps, we have too much of the first and too little of the latter in the hospital. Our winter temperature is about 64° day and night, and I think 60° would be better. Again, we are too much crowded here, and we greatly want a country house in a dry, rather elevated locality, to which we could send a certain class of our patients. I am not in favour of grouping consumptive people together, yet it is a necessity of our position that we should do as much good as we can with the means at our disposal. We have neither the means nor appliances for treating phthisical patients in separate sleeping-rooms, but I wish we had. I do not think that their aggregation in day-rooms, of course within certain limits, does any harm. It can do no good to anyone suffering from a like complaint himself to witness the deaths of others, and these cases ought to be in separate chambers. Some of these drawbacks, you will observe, are inseparable from all hospitals. I do not believe that a high temperature in or out of doors is good for all, or even for most cases of phthisis. In highly heated rooms, as was the old practice, many a patient has been done to death. The cases of phthisis which, after an experience of thirty years, I have seen last longest, have been those which were most freely exposed to fresh air-travellers in this or other countries. Abundance of pure air is surely the first desideratum for the treatment of this and of all chronic diseases involving respiration. Not cold air, of course; and in acute bronchial or congestive attacks there is a necessity for a raised temperature. But the ordinary phthisical patient will tell you that he does not cough much or most in the open air at any season of the year. Of course, I might diverge here into the question of climate, but this demands more time than we have now at disposal. I would just say that I have seen many patients who have benefited most by climates where the air is dry, clear, and what is called "bracing," and many more who did not do well in the hot, relaxing, and sheltered spots which have obtained so much repute in consumption. Study such cases as you go along in practice, and do not be too much carried away by names or great authorities on climate. But we have as yet only got our patient into the ward, and described the preparations which await his arrival there. We must now feed him before we physic him. The diet here is good, simple, abundant, and nutritious. A great deal of good milk is consumed, and the sick man may here have as much of everything as he likes. We used to weigh out the meat, giving about eight ounces to each, but we have long since given up that plan; and while everyone has enough, we consume less on the whole than on the old plan. My own practice is to give a moderate allowance of whatever stimulant the patient has been accustomed to, and which he can digest, be it beer, wine, or even spirits, in small quantities; and if he be a smoker, I let him smoke in moderation. And now what drugs shall we give him? I ask at once, why give him any? And unless the latter question be answered satisfactorily he should have none. Never prescribe without a reason and a motive which will bear your own careful examination. First, then, we have no specific for consumption. When you bear in mind what a multiform disease it is, you will not wonder at this. For many coexistent morbid conditions, affecting a great number of structures of differing anatomical arrangement and varying function, how could we have a single remedy or one specific which should reach the morbid cause? What, then, are the indications for the rational treatment of this disease? There are several, and they ought to be drawn from a study of the disease and its dangers. What is the greatest danger to which a consumptive person is liable in the progress of his case? Excluding copious hæmoptysis and pneumothorax, which are accidents, I would answer-undoubtedly inflammatory congestions of the lung tissue. First, we meet all lung congestions with active treatment. When you notice raised temperature and pulse with more or less of dyspnoea, you will generally find a patch of dulness in some part of the lung, with possibly crepitation or tubular breath-sounds. A hæmoptysis may accompany this, and, if so, you must not set to work with styptics to stop the hæmoptysis, but treat the lung congestion and let the hæmoptysis alone. Medicines of the nutritive and tonic class are much employed here. Chief among the first, of course, is cod-liver oil, and I have nothing to add to its praise or to detract from its merits. When it agrees it certainly rapidly increases weight, both by improving the digestive process and by adding a pabulum to the blood. It certainly increases fat, and this is probably due in part to its furnishing elementary fat globules. The form in which fat is deposited is supplied. From whatever cause, it undoubtedly promotes favourable changes in the lung. It is very observable that the cases in which the moist sounds are becoming dry, and the side undergoing slight retraction, are generally those with which a full dose of oil agrees. But pray observe about cod oil fattening that your patient may be improving in weight, while all the time the physical signs of disease in the lungs are extending. Overdoses of oil are to be avoided, as they only embarrass the digestion. Half an ounce twice a day seems to me the maximum. Some years ago I induced an amateur farming friend of mine to use cod oil in feeding bullocks, pigs, and sheep, and we carried out our experiments in separate stalls with every precaution as to other food. The result was that we readily fattened all the animals (and even cheaply at the then price of oil), but we found that an overdose frustrated all the good. A butcher, to whom we sold some pigs so fattened, and who was entirely ignorant of our experiments, as he lived a long way from the farm in a distant town, remarked that the fat of the pork was yellow and "fishy" in smell and taste, and it was this lot to which we had given excessive quantities of oil. We found half an ounce a full dose for an ox, and less than that for a pig. Neither treacle nor oilcake fattened these animals as readily as oil. In using tonics I believe it will not answer to prescribe indifferently quinine or iron or bitters of varied names. As appetising tonics strychnia and gentian, or quinine and cascarilla or cusparia, are good when the tongue is clean and pale. But many nervous, pale people who are sensitive to drugs cannot take quinine. In such cases a bitter with an acid, as nitric acid and calumba, agree best. You will find our physicians divided between the combination of an acid or an alhali with a bitter; and, as many hogsheads of gentian and soda are consumed here in the year by both inand out-patients, you may fairly ask to what class of cases they are most applicable? I believe it will be found that a form of irritable dyspepsia is most benefited by it; our formula contains also hydrocyanic acid, and it is very popular here. You will select your tonic, then, to suit your case. In the ་ gastric irritation so common in phthisis, where the tongue is red and the papillæ prominent, with nausea and a tendency to diarrhoea, I have used bismuth with the greatest advantage. It seems to allay the irritation of the mucous membrane, which is so formidable a complication of chronic phthisis, and one of the greatest miseries of the patient. When combined with opium in diarrhoea cases it is almost specific, and you will find it more useful than chalk and catechu. Quinine is highly valuable in phthisis. It supports strength and promotes appetite, and the larger number of cases improve under its use. I have not found it check the hectic of phthisis. In very large doses-ten to twenty grains-it will reduce the temperature, but the pyrexial condition returns when it is discontinued, and I do not think the patient has gained much by the experiment; neither has the daily shiver been checked by quinine. For this symptom I have prescribed arsenic with great advantage, and in a large number of cases it stopped the febrile access where quinine had failed. Arsenic appears rather to influence the morning access of fever, which occurs about 11 a.m., and it acts by cutting short the cold stage of the remittent attack. I have not found it so useful in arresting the afternoon access. The sweatings of phthisis do not appear to be under the influence of either arsenic or quinine, but they are generally checked by gallic acid or oxide of zinc, and the first is the best remedy. It will often fail unless given in twenty grain doses. Iron is eminently useful in treating chronic phthisis. It undoubtedly corrects the anæmia, and improves the quality of the blood, giving the patient more colour and vigour, and it often improves the appetite. It is inapplicable in all feverish conditions, probably helping to more free oxidation and waste of tissues, and tending to keep up the pulse and temperature. I never prescribe iron while the patient has hectic. selecting a preparation of iron, if you try many experiments, as I have done, you will probably find the tincture of perchloride the best form. It would appear to enter the system more readily than any of the other preparations. Its solubility and bland effects on the mucous surfaces commend it to our use. In Iron does not appear to be useful in proportion to the quantity of the base contained in the solution; and, just as we observe that chalybeate waters, which contain only infinitesimal quantities of iron, often act most favourably on the blood, so of this preparation. The citrate seems comparatively inert, but the sulphate is highly useful in certain cases. I cannot conclude this notice of drugs without speaking of opium. Who could treat phthisis without opium? By it and by morphia we allay cough and diarrhoea, and soothe the irritable mucous membrane of the bowels. It is best not to check or overpower the secretion-cough of phthisis. The patient must expectorate, and you will add to his distress by checking this necessary act. But there is an irritable frequent cough, occurring not so much in the morning as throughout the day, and often at mealtimes, causing retching, which ought to be and is effectually relieved by small doses of morphia. A combination of morphia and hydrocyanic acid is very popular here, given simply with mucilage and syrup. It seems a mistake to combine expectorants with opium, and cough mixtures often contain most opposite ingredients. Here, as in all prescribing, great simplicity and some single aim in view should be your rule. Has your patient a difficulty in expectorating, raising an adhesive frothy sputum, with long fits of coughing? Here alkalies and expectorants will help him; but avoid much opium in such cases. Morphia in combination with chlorate of potash is most useful in the exhausting cough of laryngeal ulceration. Here, also, small blisters to the larynx are the best cough medicine. I must also call your attention to the use of opium in a solid form in the last stages of many miserable forms of phthisis, as pneumothorax, where the result is not immediate. Half-grain doses of opium, with camphor, given every three or four hours, will commonly relieve the malaise of the patient, and support his nerve-power without disturbing either his digestion or his sensorium. And now, gentlemen, when I ask myself and you to what purpose is this minute discussion of the clinical phenomena in a chronic affection, I am not without hope that you will share my feeling when I reply that, not only is all true knowledge a gain, but that by our careful study, and that of many other observers in this and foreign countries, we have attained a degree of precision in diagnosis and in prognosis which is a very precious addition to the humane belongings of our art. There was a time when all cases of phthisis were regarded as uniformly fatal; whereas we now know that this is not true in every instance; and we are enabled to point out with much certainty the cases of the disease where more favourable results may be expected. It is much to know that some cases of inflammatory origin may be rapid in their early stage, and almost exhaust vital powers, yet after a time may yield to nutritive changes of the system, and the patient be restored. It is also valuable to have separated off the acute tuberculosis and acute phthisis from forms of ulcerative lung disease, which tend by the development of the fibrous element at least to great chronicity, if not to a cessation of all morbid action. Our researches also have established for phthisis as a whole a much longer term than the pathologist of fifty years ago dared to assign it. Between the nine months of Louis and the nine years of Williams, what a vast difference! Is it merely that we have discovered a greater longevity for phthisis than had been suspected? or have we indeed contributed by our modern treatment to a happier result? I believe we may consider that modern science has conduced to prolongation of life in consumption, and that by the double method of interfering with old and hurtful treatment-such as depletion and removal to hot, low, and damp climates,-and by directing our efforts to improve the nutrition of the body, to fortify the blood by cod oil and iron, and by selecting the bracing air of elevated localities for such of our patients as can obtain removal. I am proud to think, also, that this hospital has indeed contributed much to the knowledge which we possess of phthisis. By its two valuable reports, by the works of Cotton, Walshe, Williams, Thompson, Edward Smith, and Powell, we have helped largely to forward the science of medicine as applied to this class of affection. We have certainly proved ourselves to be more than mere specialists, and, by the very variety of our published views, have offered to criticism the assurance that we are fettered by no blind adhesion to the limited views of any school of pathology. THE MEDICAL PROFESSION AT LYONS.-According to the enumeration just made by the Préfet du Rhône, there are in Lyons 163 doctors of medicine, 17 officiers de santé, 127 pharmaciens, 79 herboristes, and 89 sages-femmes. IN further examining the condition of our patient, we first feel both radial pulses simultaneously, noting whether the arteries are firmer or more tortuous than usual (atheroma). If there be a marked difference between the two radial arteries, we feel both brachials simultaneously; if these be equal, the difference between the two radials is due to irregular distribution. If the brachials differ, in all probability there is some abnormal physical cause to account for it-possibly an aneurism, the mode of detecting which we shall afterwards describe. Should the radial pulses be equal and regular, but small and feeble, we elevate the wrist to a level with the head, if the patient be standing or sitting; if lying, we elevate the arm to its full length perpendicularly to the body. Should the pulse then become extinguished, or nearly so, the patient is anæmic, and possibly anæmia is his sole disease; but we must never, under any circumstances, rely upon one symptom, however apparently trustworthy, but merely note it as an aid and a guide in our further investigation. Should the pulse, after elevation of the arm, remain still small and feeble, but distinct, the cardiac disease, if present, is mitral. Irregularity of the pulse confirms this suspicion; extreme irregularity points to the probability of the affection of the mitral valve being constriction rather than dilatation. Should the small, feeble, and possibly irregular pulse remain not only distinct after the elevation of the arm, but become more so, the systolic impulse being followed by such a sudden and complete collapse as to render the impulse apparently more marked, then we have to do with a double lesion, a mitral and also an aortic regurgitation. This form of pulse is, however, not always well marked, in many cases is not easy of detection, and is therefore not to be relied upon unless the collapse is distinct. In simple aortic regurgitation, however, the peculiar sensation conveyed to the finger, and well known by the terms hammer or Corrigan's pulse, is usually well marked, and frequently so greatly increased by elevation of the arm as to become almost painful, and wholly unmistakable.-"On the Diagnosis of Disease of the Heart," by George W. Balfour, M.D., F.R.C.P.E. (Edinbur is Medical Journal, June, 1874). GENERAL MEDICAL COUNCIL. We had neither time nor space last week for more than a very short comment on the debate on the Reports of the Visitations of the Medical Examinations in the Queen's University in Ireland, but our readers will have read the rather full report we gave of the debate itself, and we think they will have sympathised with Sir Dominic Corrigan in his gallant, though rather warm defence of the body he represents; and we confess he would have our sympathy very fully but for his attack on Dr. Parkes. We gave so full a report of the debate because the members of Council who moved the resolution pointing to the defects in the examinations, naturally limited their observations almost entirely to those defects; and as the Visitors' Reports were "taken as read," and it was impossible, on account of their length, for us to give even an abstract of them, it was only fair to give, as fully as we could, the great deal there was to be said in praise of the examinations. The debate was a very warm one, but both Dr. Bennett and Dr. Humphry, two of the visitors, spoke very strongly in praise of the general excellence of the examinations, and the latter said that his impression was that they were among the very best in the United Kingdom. To make anything like an attack on them in Sir Dominic Corrigan's presence was then indeed to beard the lion in his den, the Douglas in his halls"; and it is not to be wondered at if the lion lashed his tail somewhat. We are not prepared to think-as most probably Sir Dominic Corrigan thinks-that the Examinations in the Queen's University in Ireland are the best of all possible examinations in the best of all possible universities; but we certainly agree with the vote of the very large majority of the Council, which was to the effect that they" do not deserve anything approaching to a vote of censure." We mentioned last week that the consideration of the Reports of the Visitors of Examinations in Committee of the whole Council had been brought to a conclusion, and that the Council had entered on the discussion of several very important resolutions, founded on recommendations contained in those reports, or having reference to imperfections noticed in one or more of the examinations visited. The first of these resolutions was a "recommendation" of Council that each of the certificates, presented before admission to the examinations of the licensing bodies, "should include a statement from the teacher, or teachers, that the candidate had satisfactorily attended examinations, from time to time, held on the subject of study to which the certificate relates." This was agreed to, and we may venture to express a hope that the authorities of the several schools of medicine will be able to find some method of carrying the recommendation into practice; we feel sure that they will willingly do so if they can, for the deplorable state of unpreparedness in which some candidates present themselves for examination is anything but creditable to the schools from which they come. In the "notice of motion" on this subject, given by Dr. Humphry, the words used were " had shown a fair amount of knowledge at examinations," instead of "had satisfactorily attended examinations," and we must confess that the original phrase seems to us more satisfactory than that in the resolution finally carried. The discussion on the subject is a very instructive one, and we commend it to the perusal of our readers. The second resolution, which also was carried, was to the effect that "it is desirable" that in the examinations on some of the subjects of the curriculum-" such, for example, as botany, zoology, chemistry, and materia medica— the area of examination should be limited and defined." This arose out of the feeling, shown during the consideration of the visitors' reports, that not seldom the questions on these subjects were vague, or too large, or "over the heads of the candidates." Dr. Acland, in supporting the motion, observed that "what the Council had to secure was that men were well qualified for their ordinary professional duties," and that if the range of subjects was not, to some extent, defined so that an examiner might know what a student had been taught, "there was a very great chance that the student would be unfairly and unjustly examined." And Dr. Parkes remarked that "if the London University was obliged to limit the subjects of examination, even for the highest honours, it was much more necessary when they were dealing with the ordinary medical student. For example, a young man could not do more than learn the mere rudiments of chemistry in nine or ten months; yet in some of the examinations only two or three questions of the highest order were put." Sir William Gull was rather unnecessarily grand and denunciatory, seeing that the motion was for the limitation and definition of the area of examination. "If they were going to limit the area of knowledge," he exclaimed, "he hoped an earthquake would come and swallow up the Council. The great light of the profession (Hunter) did all he could to enlarge the area of study. If they were going to level the Council down to the stupid men, a parcel of twentyfour old women could do the work as well. The object of Dr. Wood's motion was to give common sense to the examiners and teachers; but it could not be done." Dr. Humphry replied that "the real point of teaching was to instruct a man well in the area in which he was taught, and it was impossible to instruct well over a very wide It was of no use saying that the thing was impossible, because it was actually done at Cambridge among other places. They were obliged to have the area defined in order that the teaching and the learning might be good." And the President "entirely disagreed from Sir William Gull. The subject connected with the study of medicine involved such an enormous number of facts, and imposed so severe a tax upon the memory, that he had long since come to the conclusion that if a diligent student were to make himself master of them, he would be a worse instead of a better man for the area. |