- Email: [email protected]
CATGUT LIGATURE IN THE TREATMENT OF ANEURISM.
519 and did accumulate without such admission, and I havenanner. This probably had some influence on the result, Ias the double hitch is clumsy, and difficult to draw tight as verified pathologically that this is decidedly correct.
well as to maintain at the required tension while the second flitch is being tied ; consequently the inner coats were completely cut through in Mr. Treves’s case, but only very in4 completely so in the other two. This seems to me to be Does he forget how Dr. W. Roberts, in his celebrated experi-clearly shown by the description, the inner coat in those two ments, found that by injecting five drops of hypodermiccases being uninterruptedly continuous from the proximal solution of morphia into one of his flasks of steralised beef- to the distal part of the vessel. This incomplete division tea he could produce full putrefaction in forty-eight hours ?of the inner coats was probably the cause of the entire But Mr. Moxhay even asserts that water at 100° to 103° Fahr.absence of coagulum, which is such an important factor in may havedestroyed, or rendered harmless, these micro- the process of repair. My own experience of the catgut ligature has been uniorganisms. This, however, is a principii petitio. I would refer him to the literature of the subject, and he shall find formly satisfactory. I have used it on the femoral artery that, although they are neither Zulus nor Boers, yet they are nine times, on the external iliac twice, on the carotid artery unwilling to die without a struggle. The above temperature three times, on the common femoral once, and on the would rather favour their development. Dallinger and Drysdale brachial, radial, and ulnar each once. In none has there bave shown that while 104° Fahr. suffice to kill adult septic been secondary haemorrhage, failure to obliterate the vessel, monads, their spores are capable of germinating after sub- or other mishap. Some of the wounds have suppurated jection to a heat of 300° Fahr. for ten minutes (W. Roberts). freely ; latterly they have all healed by first intention under Now, although no harm resulted through injecting water in antiseptic treatment. I look upon this result as dependent upon the special care Mr. Moxhay’s case, it does not follow that his proceeding is I have always taken to thoroughly divide the inner which if this were then the on so, universally applicable; principle which Listerism is founded would be made assailable. coats, and to observe that the first hitch does not slip while I never objected to a free opening-quite the contrary. the second is being drawn tight, and I always add a third It is to the proceedings with which " free opening" is asso- for additional security. It is the more necessary to attend to these points in using catgut in consequence of its stiffness ciated that I object. Mr. Moxhay will please observe that °° empyema proper" and slipperiness as compared with silk, if it is not suffiand " circumscribed empyemic abscess" are surgically ciently softened in carbolic solution just before being used. similar and proper. We have now more definite information If the inner coats are cut through, and the ligature tightly about the case though. There were clearly two collections tied, I believe that complete obliteration will be brought of pus encapsuled by false membranes, and this fact of itself about in almost every case, and even in spite of suppuration goes to teach us how we should explore the pleural sac in occurring. It was because this was not effectually done that such cases, and break up, as far as possible, all intersections these two failures took place, and they do not afford a particle of reliable evidence that suppuration is an end to be I am, Sir, your obedient servant, early. either aimed at or desired. On every principle of surgery JOHN LOWE. Mchfield, March 14th, 1881. there must surely be additional safety in securing immediate union by the plastic operations of nature, uninterfered with CATGUT LIGATURE IN THE TREATMENT by the degenerative inflammatory action which suppuration implies. Catgut, if of proper quality, and properly applied, OF ANEURISM. is, in my opinion, by far the best material yet known for To the Editor of THE LANCET. ligature of arteries, whether in their continuity or otherSIR,—Having had some experience in the ligature of wise ; but if the well-established rule in surgery, that the arteries with catgut, may I ask for space in your columns inner coats must be divided by the ligature, be not carefully and if, as there seems to be some prospect, are. to add my mite to the discussion which is now going on observed, turn should be made to the long-abandoned practice of using l’i propos of the paper recently communicated by Messrs. broad ligatures, and attempting merely to approximate the Trevesand Macartby to the Medical and Chirurgical Society ? sides of the vessel, I venture to predict that it will not be Mr. Treves’s case was one in which the carotid and sub- long before more failures will be heard of. I have had four opportunities of observing in post-mortems clavian arteries were both tied in the same patient for innominate aneurism, the carotid first by Mr. Adams, the the changes effected by the catgut ligature. I will not go into the details of the cases, as it is unnecessary for my subclavian, three weeks later, by Mr. Treves. Mr. immediate purpose. Briefly, the following were the conMacarthy’s was one in which the subclavian was tied for ditions met with :1. Ligature of external iliac for haemorrhage ; death after axillary aneurism, and amputation at the shoulder-joint became necessary from bursting of the tumour two months sixty hours. Ligature firmly in position, and but slightly afterwards. Both patients died ; the first one hundred and changed ; internal coats divided ; firm conical coagulum above and below, adherent their bases to the seat of eight daysafter the ligature of the carotid, the second sixty- ligature, and also to the sidesby of the vessel. four daysafter ligature of the subclavian. Of the three 2. Ligature of common femoral ; death in eleven days; arteries tied only one was permanently obliterated, the wound healed by first intention; ligature completely abother two became pervious after a time, although with con- sorbed ; vessel firmly closed; divided edges of inner coats siderable narrowing of the channel. Antiseptic treatment visible, and turned inwards; firm conical coagulum above was adopted in all three, and answered perfectly in twoand below, adherent as in the first case. viz., Mr. Adams’s carotid case and Mr. Macarthy’s sub3. Ligature of superficial femoral; death after twenty-eight clavian case, both wounds uniting rapidly by first intention. days ; wound suppurated freely, but suppuration did not It failed in Mr. Treves’s case, in which the wound opened reach down to the vessel ; artery firmly closed, and conand suppurated freely; and this was the only one of the stricted at seat of ligature, which had disappeared ; firm three in which the artery was permanently obliterated. conical coagulum adherent, as in the other two cases, but The inference sought to be drawn from these cases is that fainter in colour. rupid and immediate union may be injurious by not exciting 4. Ligature of external iliac for haemorrhage; death in sufficient inflammation and effusion around the vessel-the thirty days ; sloughing of wound extending towards artery, repair being, in fact, too perfect; whereas when there is but not reaching it or affecting peritoneum ; artery firmly suppuration greater thickening and solidification will be closed and constricted at seat of ligature, which had disensured. It is against this doctrine, which I consider to be appeared ; firm, pale coagulum for some distance above and illogical and misleading, that I write to protest. It seems below, and apparently undergoing absorption. clear to me, from the account given, that the two failures The deaths in these cases were from causes quite indearose from theligature not being effectually applied; and pendent of the ligature. The uniformity of the result as the one success was obtained, notwithstanding the dis- regards coagulation and closure is remarkable, and goes advantage of the suppuration, because the vessel was far to show the desirability of thoroughly dividing the inner throughly secured. Mr. Barwell pointed out in THE coats. The use of a substance which will be removed by LANCET for March 5th that Mr. Adams and Mr. Macarthy vital absorption, the enils of which riity, therefore, be used a double and then a single hitch in tying their knot, cut short, is a great advantage, as it appears from the last ’.’.’Li’eMr. Treves used a single hitch, repeated in the usual two cases mentioned that plastic effusion may take place
Moxhay says he may have introduced germs through injecting water ; now this is what I object to. Would Lister do this? and, if not, why does Mr. Moxhay persist in murdering the expression, "perfect Listerian precautions"? Mr.
’’
520
ligature and vessel, so as to shut them off from sale than practice, by which innocent men-as pointed out processes which may be going on in the super- by your correspondent, L.R.C.P. Edin. (THE LANCET, Feb. ficial parts of the wound. 5th)—are lured into very delusive purchases. I hope you I am, Sir, your obedient servant, will keep your vigilant eye on this undignified style of work, JAMES R. LANE. I am, Sir, your obedient servant, Norfolk-square, March 14th, 1S81.
around the
unhealthy
L. S. C,
March, 1881.
THE CHLOROTIC MURMUR.
MANCHESTER.
To the Editor of THE LANCET. (From our own Correspondent.) SIR,—Dr. Balfour entirely ignores my explanation as to how I came to mistake his views. He surely must admit 1BIONSALL FEVER HOSPITAL, it appears, is larger than is that it is possible to miss a paper even in THE LANCET. for infirmary patients, and for those for whom pro required Having missed his paper, I maintain, firstly, that I was vision is reserved on behalf of the city of Manchester, and entitled to consider the views expressed in his work on the that it has been the custom to admit patients from the sub. heart as representative of his opinions ; and, secondly, that urban townships, as well as pauper patients, on certain the conclusion at which I arrived after studying his sixth terms. The annual loss to the infirmary in keeping up an chapter-viz., that "he denies that the so-called basic mur- establishment so much in excess of its requirements is, in murs of anaemia are ever arterial " was a logical conclusion, and round £1500 the Board of numbers, annum, per justified by his argument as a whole, and by the passages Infirmary have come to the conclusion that the present the ar. which I quoted in my last letter in particular. the and with authorities must rangements sanitary poor-law I have already expressed regret that I should have coupled so revised as to prevent any further encroachment upon Naunyn’s name with the chlorotic murmur. As an ex- be their funds. An adjourned conference on the subject was I I in tenuating circumstance, was, think, justified stating that such trustworthy authorities as Dr. Bristowe and Dr. held on the 17th inst., the Infirmary Board beicg met by of the health department and most of the Fothergill had come to the same conclusion on this point as representatives local of the boards outlying districts. Considerable discusmyself, and I am glad to know that neither Dr. Bristowe sion took place as to the best and most equitable mode of nor Dr. Fothergill takes exception to my having done so. The explanation which Dr. Balfour gives of the redupli- distributing the excessive expenditure, the following resocated second sound in mitral stenosis is not mentioned, much lution being ultimately adopted :-" That an arrangement less accepted, by any writer to whom I have been able to be made that will distribute the ascertained annual loss of refer. (Since this paragraph was originally written I have £1500 on the Monsall Fever Hospital, in fair proportions, learned from Dr. Balfour that the explanation is his own.) amongst the several sanitary authorities of Manchester and The same argument which Hayden brings against the the district, and that the said arrangement be calculated upon the mean percentage of the population and rateable theory that the reduplication is due to asynchronism in value of property, and, further, that a charge of 3s. per head the closure of the segments of either sigmoid valve seems to be made for each patient sent ; this arrangement to per day with force here. apply equal in for three years." This scheme bids fair to be force Hayden says: "I have repeatedly made the following make good the deficiency upon an equitable basis, and reobservation, which seems conclusive as against the unival- lieve the infirmary funds of an expenditure which presses vular origin of double second sound. Whilst a double second sound was equally audible at the orifice of the aorta hardly upon them, and ought to be accepted by the authorities, and pulmonary artery, but most distinctly so at a point in- as the infirmary, a public chaiity, should not be a loser in a termediate to, and equidistant from both, a single second matter which so deeply concerns the health of the city and sound only existed at the distance of an inch or so district. Last week Mr. Cornelius Neale Dalton, the inspector of external to either orifice in the horizontal line. Manifestly if derangement of synchronism in the closure of the segments the Local Government Board, held an inquiry at the Manof either set of valves had been the cause of reduplication, chester Town Hall in reference to an application which has the latter would have been audible to an equal distance been made by the corporation for a provisional order to from the orifice in the directions inwards and outwards, and enable them to acquire inter alicc certain powers of raising it would have been most distinct at the orifice itself, and money, and providing privies and ash pits in buildings where not midway between the two orifices."-(Diseases of the manufactures were being carried on; with these by-laws I do not propose to deal, but the 5th section greatly affects Heart, p. 127). medical profession of this city, in so far as the corporaBut, further, is it a fact that the systolic closure of the the tion asks power to require a notice of cases of infectious which Ceradini is sound attended valves, by any describes, at all ? I understand that the distinguished Professor of diseases to be given to the medical officer of health by the of premises when such cases occur, and also by the Physiology in the University here is in the habit of teaching occupiers in attendance on such case, and to provide for man medical that the second sound is not due to the closure but to the his remuneration for each case reported. It was stated as a which follows the closure. Dr. writes stretching Fothergill plea for the necessity of compelling householders and the me that in his opinion the systolic closure of the valves, in medical attendant to inform the sanitary authority of the a fluid in equilibrium, could not cause an audible snap. existence of infectious diseases that last year the number of I am, Sir, your obedient servant, deaths in the city from infectious diseases was 423, and BYROM BRAMWELL. Edinburgh, March 18th, 1881. assuming that for every death eight cases recovered, the large number of 3884 cases would be reached, and yet only 85 cases were removed to Monsall Fever Hospital, and 94 to PRIVATE DISPENSARIES. the Children’s Hospital daring that period. The corporation To the Editor of THE LANCET. were further of opinion that it is only by systematic inforSIR,—I have noticed various allusions of late in your mation given by medical men who are brought into contact valuable journal to what you call "private"dispensaries, with such cases that infectious diseases can be adequately dealt with. and generally of an unfavourable character. The profession A deputation of the Parliamentary Committee of the generally will sustain this representation. I was waited Medico-Ethical Association, consisting of its President, on a few weeks ago by the unqualified assistant of a well Dr. Lloyd Roberts, and its Secretary, Dr. Pierce, together known proprietor of these cheap dispensaries. His object with the President of the Society, Dr. John Roberts, Dr. was to beg a few shillinga under the following circumstances : Peatson, and the Honorary Secretaries, waited upon the He and his other unqualified colleagues had all at one fell inspector with a view of giving support to the general After swoop been discharged by his master, and, as his wages were principle contained in the by-law quoted above. only 25s. a week when in work, he was impecunious. He considerable discussion the inspector decided to recommend told me that he saw most of the patients and attended a the responsibility of reporting the cases to be laid, as the good deal of the midwifery. Such a system as you point corporation desired, on both the householder and the out in last week’s LANCET is deluding to the working classes medical attendant, but fixed the fee to the latter at the rate and discreditable to the men who carry it on. I have noticed, of two-and-sixpence per case. The forms of infections too, a tendency to make dispensaries rather with a view to disease scheduled were typhus, typhoid, variola, rubeola,
well as to maintain at the required tension while the second flitch is being tied ; consequently the inner coats were completely cut through in Mr. Treves’s case, but only very in4 completely so in the other two. This seems to me to be Does he forget how Dr. W. Roberts, in his celebrated experi-clearly shown by the description, the inner coat in those two ments, found that by injecting five drops of hypodermiccases being uninterruptedly continuous from the proximal solution of morphia into one of his flasks of steralised beef- to the distal part of the vessel. This incomplete division tea he could produce full putrefaction in forty-eight hours ?of the inner coats was probably the cause of the entire But Mr. Moxhay even asserts that water at 100° to 103° Fahr.absence of coagulum, which is such an important factor in may havedestroyed, or rendered harmless, these micro- the process of repair. My own experience of the catgut ligature has been uniorganisms. This, however, is a principii petitio. I would refer him to the literature of the subject, and he shall find formly satisfactory. I have used it on the femoral artery that, although they are neither Zulus nor Boers, yet they are nine times, on the external iliac twice, on the carotid artery unwilling to die without a struggle. The above temperature three times, on the common femoral once, and on the would rather favour their development. Dallinger and Drysdale brachial, radial, and ulnar each once. In none has there bave shown that while 104° Fahr. suffice to kill adult septic been secondary haemorrhage, failure to obliterate the vessel, monads, their spores are capable of germinating after sub- or other mishap. Some of the wounds have suppurated jection to a heat of 300° Fahr. for ten minutes (W. Roberts). freely ; latterly they have all healed by first intention under Now, although no harm resulted through injecting water in antiseptic treatment. I look upon this result as dependent upon the special care Mr. Moxhay’s case, it does not follow that his proceeding is I have always taken to thoroughly divide the inner which if this were then the on so, universally applicable; principle which Listerism is founded would be made assailable. coats, and to observe that the first hitch does not slip while I never objected to a free opening-quite the contrary. the second is being drawn tight, and I always add a third It is to the proceedings with which " free opening" is asso- for additional security. It is the more necessary to attend to these points in using catgut in consequence of its stiffness ciated that I object. Mr. Moxhay will please observe that °° empyema proper" and slipperiness as compared with silk, if it is not suffiand " circumscribed empyemic abscess" are surgically ciently softened in carbolic solution just before being used. similar and proper. We have now more definite information If the inner coats are cut through, and the ligature tightly about the case though. There were clearly two collections tied, I believe that complete obliteration will be brought of pus encapsuled by false membranes, and this fact of itself about in almost every case, and even in spite of suppuration goes to teach us how we should explore the pleural sac in occurring. It was because this was not effectually done that such cases, and break up, as far as possible, all intersections these two failures took place, and they do not afford a particle of reliable evidence that suppuration is an end to be I am, Sir, your obedient servant, early. either aimed at or desired. On every principle of surgery JOHN LOWE. Mchfield, March 14th, 1881. there must surely be additional safety in securing immediate union by the plastic operations of nature, uninterfered with CATGUT LIGATURE IN THE TREATMENT by the degenerative inflammatory action which suppuration implies. Catgut, if of proper quality, and properly applied, OF ANEURISM. is, in my opinion, by far the best material yet known for To the Editor of THE LANCET. ligature of arteries, whether in their continuity or otherSIR,—Having had some experience in the ligature of wise ; but if the well-established rule in surgery, that the arteries with catgut, may I ask for space in your columns inner coats must be divided by the ligature, be not carefully and if, as there seems to be some prospect, are. to add my mite to the discussion which is now going on observed, turn should be made to the long-abandoned practice of using l’i propos of the paper recently communicated by Messrs. broad ligatures, and attempting merely to approximate the Trevesand Macartby to the Medical and Chirurgical Society ? sides of the vessel, I venture to predict that it will not be Mr. Treves’s case was one in which the carotid and sub- long before more failures will be heard of. I have had four opportunities of observing in post-mortems clavian arteries were both tied in the same patient for innominate aneurism, the carotid first by Mr. Adams, the the changes effected by the catgut ligature. I will not go into the details of the cases, as it is unnecessary for my subclavian, three weeks later, by Mr. Treves. Mr. immediate purpose. Briefly, the following were the conMacarthy’s was one in which the subclavian was tied for ditions met with :1. Ligature of external iliac for haemorrhage ; death after axillary aneurism, and amputation at the shoulder-joint became necessary from bursting of the tumour two months sixty hours. Ligature firmly in position, and but slightly afterwards. Both patients died ; the first one hundred and changed ; internal coats divided ; firm conical coagulum above and below, adherent their bases to the seat of eight daysafter the ligature of the carotid, the second sixty- ligature, and also to the sidesby of the vessel. four daysafter ligature of the subclavian. Of the three 2. Ligature of common femoral ; death in eleven days; arteries tied only one was permanently obliterated, the wound healed by first intention; ligature completely abother two became pervious after a time, although with con- sorbed ; vessel firmly closed; divided edges of inner coats siderable narrowing of the channel. Antiseptic treatment visible, and turned inwards; firm conical coagulum above was adopted in all three, and answered perfectly in twoand below, adherent as in the first case. viz., Mr. Adams’s carotid case and Mr. Macarthy’s sub3. Ligature of superficial femoral; death after twenty-eight clavian case, both wounds uniting rapidly by first intention. days ; wound suppurated freely, but suppuration did not It failed in Mr. Treves’s case, in which the wound opened reach down to the vessel ; artery firmly closed, and conand suppurated freely; and this was the only one of the stricted at seat of ligature, which had disappeared ; firm three in which the artery was permanently obliterated. conical coagulum adherent, as in the other two cases, but The inference sought to be drawn from these cases is that fainter in colour. rupid and immediate union may be injurious by not exciting 4. Ligature of external iliac for haemorrhage; death in sufficient inflammation and effusion around the vessel-the thirty days ; sloughing of wound extending towards artery, repair being, in fact, too perfect; whereas when there is but not reaching it or affecting peritoneum ; artery firmly suppuration greater thickening and solidification will be closed and constricted at seat of ligature, which had disensured. It is against this doctrine, which I consider to be appeared ; firm, pale coagulum for some distance above and illogical and misleading, that I write to protest. It seems below, and apparently undergoing absorption. clear to me, from the account given, that the two failures The deaths in these cases were from causes quite indearose from theligature not being effectually applied; and pendent of the ligature. The uniformity of the result as the one success was obtained, notwithstanding the dis- regards coagulation and closure is remarkable, and goes advantage of the suppuration, because the vessel was far to show the desirability of thoroughly dividing the inner throughly secured. Mr. Barwell pointed out in THE coats. The use of a substance which will be removed by LANCET for March 5th that Mr. Adams and Mr. Macarthy vital absorption, the enils of which riity, therefore, be used a double and then a single hitch in tying their knot, cut short, is a great advantage, as it appears from the last ’.’.’Li’eMr. Treves used a single hitch, repeated in the usual two cases mentioned that plastic effusion may take place
Moxhay says he may have introduced germs through injecting water ; now this is what I object to. Would Lister do this? and, if not, why does Mr. Moxhay persist in murdering the expression, "perfect Listerian precautions"? Mr.
’’
520
ligature and vessel, so as to shut them off from sale than practice, by which innocent men-as pointed out processes which may be going on in the super- by your correspondent, L.R.C.P. Edin. (THE LANCET, Feb. ficial parts of the wound. 5th)—are lured into very delusive purchases. I hope you I am, Sir, your obedient servant, will keep your vigilant eye on this undignified style of work, JAMES R. LANE. I am, Sir, your obedient servant, Norfolk-square, March 14th, 1S81.
around the
unhealthy
L. S. C,
March, 1881.
THE CHLOROTIC MURMUR.
MANCHESTER.
To the Editor of THE LANCET. (From our own Correspondent.) SIR,—Dr. Balfour entirely ignores my explanation as to how I came to mistake his views. He surely must admit 1BIONSALL FEVER HOSPITAL, it appears, is larger than is that it is possible to miss a paper even in THE LANCET. for infirmary patients, and for those for whom pro required Having missed his paper, I maintain, firstly, that I was vision is reserved on behalf of the city of Manchester, and entitled to consider the views expressed in his work on the that it has been the custom to admit patients from the sub. heart as representative of his opinions ; and, secondly, that urban townships, as well as pauper patients, on certain the conclusion at which I arrived after studying his sixth terms. The annual loss to the infirmary in keeping up an chapter-viz., that "he denies that the so-called basic mur- establishment so much in excess of its requirements is, in murs of anaemia are ever arterial " was a logical conclusion, and round £1500 the Board of numbers, annum, per justified by his argument as a whole, and by the passages Infirmary have come to the conclusion that the present the ar. which I quoted in my last letter in particular. the and with authorities must rangements sanitary poor-law I have already expressed regret that I should have coupled so revised as to prevent any further encroachment upon Naunyn’s name with the chlorotic murmur. As an ex- be their funds. An adjourned conference on the subject was I I in tenuating circumstance, was, think, justified stating that such trustworthy authorities as Dr. Bristowe and Dr. held on the 17th inst., the Infirmary Board beicg met by of the health department and most of the Fothergill had come to the same conclusion on this point as representatives local of the boards outlying districts. Considerable discusmyself, and I am glad to know that neither Dr. Bristowe sion took place as to the best and most equitable mode of nor Dr. Fothergill takes exception to my having done so. The explanation which Dr. Balfour gives of the redupli- distributing the excessive expenditure, the following resocated second sound in mitral stenosis is not mentioned, much lution being ultimately adopted :-" That an arrangement less accepted, by any writer to whom I have been able to be made that will distribute the ascertained annual loss of refer. (Since this paragraph was originally written I have £1500 on the Monsall Fever Hospital, in fair proportions, learned from Dr. Balfour that the explanation is his own.) amongst the several sanitary authorities of Manchester and The same argument which Hayden brings against the the district, and that the said arrangement be calculated upon the mean percentage of the population and rateable theory that the reduplication is due to asynchronism in value of property, and, further, that a charge of 3s. per head the closure of the segments of either sigmoid valve seems to be made for each patient sent ; this arrangement to per day with force here. apply equal in for three years." This scheme bids fair to be force Hayden says: "I have repeatedly made the following make good the deficiency upon an equitable basis, and reobservation, which seems conclusive as against the unival- lieve the infirmary funds of an expenditure which presses vular origin of double second sound. Whilst a double second sound was equally audible at the orifice of the aorta hardly upon them, and ought to be accepted by the authorities, and pulmonary artery, but most distinctly so at a point in- as the infirmary, a public chaiity, should not be a loser in a termediate to, and equidistant from both, a single second matter which so deeply concerns the health of the city and sound only existed at the distance of an inch or so district. Last week Mr. Cornelius Neale Dalton, the inspector of external to either orifice in the horizontal line. Manifestly if derangement of synchronism in the closure of the segments the Local Government Board, held an inquiry at the Manof either set of valves had been the cause of reduplication, chester Town Hall in reference to an application which has the latter would have been audible to an equal distance been made by the corporation for a provisional order to from the orifice in the directions inwards and outwards, and enable them to acquire inter alicc certain powers of raising it would have been most distinct at the orifice itself, and money, and providing privies and ash pits in buildings where not midway between the two orifices."-(Diseases of the manufactures were being carried on; with these by-laws I do not propose to deal, but the 5th section greatly affects Heart, p. 127). medical profession of this city, in so far as the corporaBut, further, is it a fact that the systolic closure of the the tion asks power to require a notice of cases of infectious which Ceradini is sound attended valves, by any describes, at all ? I understand that the distinguished Professor of diseases to be given to the medical officer of health by the of premises when such cases occur, and also by the Physiology in the University here is in the habit of teaching occupiers in attendance on such case, and to provide for man medical that the second sound is not due to the closure but to the his remuneration for each case reported. It was stated as a which follows the closure. Dr. writes stretching Fothergill plea for the necessity of compelling householders and the me that in his opinion the systolic closure of the valves, in medical attendant to inform the sanitary authority of the a fluid in equilibrium, could not cause an audible snap. existence of infectious diseases that last year the number of I am, Sir, your obedient servant, deaths in the city from infectious diseases was 423, and BYROM BRAMWELL. Edinburgh, March 18th, 1881. assuming that for every death eight cases recovered, the large number of 3884 cases would be reached, and yet only 85 cases were removed to Monsall Fever Hospital, and 94 to PRIVATE DISPENSARIES. the Children’s Hospital daring that period. The corporation To the Editor of THE LANCET. were further of opinion that it is only by systematic inforSIR,—I have noticed various allusions of late in your mation given by medical men who are brought into contact valuable journal to what you call "private"dispensaries, with such cases that infectious diseases can be adequately dealt with. and generally of an unfavourable character. The profession A deputation of the Parliamentary Committee of the generally will sustain this representation. I was waited Medico-Ethical Association, consisting of its President, on a few weeks ago by the unqualified assistant of a well Dr. Lloyd Roberts, and its Secretary, Dr. Pierce, together known proprietor of these cheap dispensaries. His object with the President of the Society, Dr. John Roberts, Dr. was to beg a few shillinga under the following circumstances : Peatson, and the Honorary Secretaries, waited upon the He and his other unqualified colleagues had all at one fell inspector with a view of giving support to the general After swoop been discharged by his master, and, as his wages were principle contained in the by-law quoted above. only 25s. a week when in work, he was impecunious. He considerable discussion the inspector decided to recommend told me that he saw most of the patients and attended a the responsibility of reporting the cases to be laid, as the good deal of the midwifery. Such a system as you point corporation desired, on both the householder and the out in last week’s LANCET is deluding to the working classes medical attendant, but fixed the fee to the latter at the rate and discreditable to the men who carry it on. I have noticed, of two-and-sixpence per case. The forms of infections too, a tendency to make dispensaries rather with a view to disease scheduled were typhus, typhoid, variola, rubeola,