- Email: [email protected]
INQUEST PRACTICE.
THE NEW
568
PHOTOGRAPHY.-INQUEST PRACTICE.
of interest. Typhoid fever of a very mild type appeared in a few instances, and in two cases-one male and one femalethe patients, when convalescent, regained their sanity. The infirmary and the female side were especially crowded, but the general health was good and the death-rate for females was very low-viz., 5’8 on the average numbers resident, and 4’9 on the total numbers under treatment. The male figures respectively were 11-9 and 9’6. On the last day of the year there were 1072 patients (486 and 586), an increase of 30 ; during the year 119 males and 115 females were admitted, and the discharges had been : Recovered, 36 and 52 ; relieved, 5 and 8 ; not improved, 9 and 3. The deaths were 57 and 34 ; total cases under treatment, 593 and 683 ; average resident cases, 478 and 578. The admissions showed little variation, although the tendency to send old people from the workhouses was mentioned ; the discharges were more numerous, and the percentage of recoveries on admissions had risen from 32’5 to 37-6; the death-rate had fallen from 10-6 to 8-8. Of the extra 30 cases, 10 came from three parishes which had been taken over by Hampshire from Wiltshire.
THE
NEW PHOTOGRAPHY.
THERE is little that is new to report this week in regard to the application of the "x" rays. Direct vision of the invisible by Professor Salvioni’s method is, as we ventured to suggest last week, likely to open up a more promising field so far as medical diagnosis is concerned. With the assistance of Mr. J. C. M. Stanton, Mr. A. A. C. Swinton has, we learn, confirmed Professor Salvioni’s experiments and has succeeded in obtaining visible shadows of coins inside a leather purse, metal instruments enclosed in a case, &c. The apparatus consisted of a tube of opaque pasteboard, with a simple aperture at one end serving as eye-piece. The other end was closed with an opaque diaphragm of double black paper, upon which on the inner side was laid a piece of blotting paper previously saturated with a solution of platino-cyanide of barium and dried. The case containing the object was held against the diaphragm with the Crookes’s tube beyond it, so that the rays proceeding through the wood &c. cast a shadow of the imprisoned objects on the fluorescent screen. The platinocyanide fluoresced brightly under the stimulus of the rays on those portions of the blotting paper where no shadow was cast and threw the dark image of the object into clear relief. Thus, the impedimenta of photography are done away with, and it may be before very long that the outlines of the bones in the flesh will be directly viewed by this means. We still need, however, a more reliable and a more
convenient
source
of these
mysterious " x"rays.
DIAGNOSIS OF GASTRIC DISEASES.
comparison with diseases of other organs the methods diagnosis of diseases of the stomach have received but comparatively little notice in our current literature. An IN
of
article by Dr. Boardman Reed in the Medical News of New York of Jan. 18th is of especial interest in that it defines minutely the methods of diagnosing certain conditions of the stomach frequently met with but seldom recognised in ordinary medical practice. The paper is entitled "The Diagnosis of Changes in the Size, Position, and Motility of the Stomach in Cases where Intra-gastric Instruments cannot be Used." It deals almost entirely with two methods of physical examination-clapotement and perDr. Reed is of opinion that it is best to cussion. examine the patient at a time when the stomach should be entirely empty-that is, the morning, fasting, or six hours at least after the last meal. If after that period the splash by clapotement can still be obtained we can infer deficient motility. Noting at
the
same time the lowest point where the splash can be distinctly heard, we may infer as a rule that the lower boundary extends to about that level. The abdomen should then be percussed in various positions to verify the result oi clapotement and to map out the boundaries. The patient then drinks from one-eighth to one-fourth of a litre of water, and another attempt is made to obtain the splash ; if it is obtained after the smaller amount it raises a question Percussion of the boundaries of the as to the motility. stomach with the viscus partially full and the patient standing is then performed. The water should be given gradually, when if the stomach is atonic the area of dulness usually extends downwards with each successive glass, but if its muscle is healthy and strong the dulness Dr. Reed differentiates extends upwards only or mainly. nine conditions which may be recognised by these methods :1. Normal stomach. If empty, no splash is heard until
partially full, and then it may still be absent or very feebly heard. Percussion will demonstrate the normal boundaries. 2. Atonic stomach. The splash may be heard from four to six hours after a full meal, but it is easily obtained after the drinking of a small quantity of water. Percussion will show delayed emptying of the organ. 3. Stomach enlarged, but motor power strong (megalogastria of Ewald). The lower border of the stomach is at the level of the umbilicus or lower. No splash is obtainable six hours after food. 4. Stomach enlarged and motility weak (dilata. tion or gastrectasia). The splash is obtainable six hours after a meal. Percussion shows enlargement of the organ nd delay in emptying itself. 5. Gastroptosis. The stomach is wholly displaced downwards, but otherwise normal. The splash is usually more easily obtainable than normal. Percussion shows descent of both upper and lower boundaries. 6. Stomach enlarged and displaced downwards as a whole, but not dilated. The same as in No.5 5 except that on percussion the upper boundary is not so much displaced. 7. Stomach wholly displaced downwards and dilated. The same as in No. 6, but the splash is obtainable too long after a meal. 8. Pyloric end of the stomach displaced downwards to the left (pyloroptosis), but without dilatation. The splash is obtained far below the level of the normal lower Percussion reveals the pyloric end low in the border. abdominal cavity. 9. Pyloroptosis with dilatation. The same as in No. 8, but the splash is more pronounced and is found too long after food or drink. Percussion shows also a widening of the pyloric end of the stomach. the viscus is
only
INQUEST PRACTICE. of considerable interest arose at an inquest points held at West recently Hartlepool. It appears that a man named Joseph Aspinall whilst travelling between Hartlepool and West Hartlepool fell down apparently in a tit and died. It so happened that Dr. Harte Gourley was travelling in the same train. When called to the case he found the man dead. At the inquest the coroner raised the question whether Dr. Gourley’s name was on the Register; the latter replied that it was, whereupon the coroner said that he must have made a mistake. If the coroner had reason to believe that Dr. Gomley Two
not a duly registered practitioner he was acting within his rights and in fact doing a service to the public and the medical profession in drawing attention to it, and inasmuch as Dr. Gourley’s name only appeared on the official list last year there was some excuse for the mistake made, and we trust Dr. Gourley is satisfied with the result that he was enabled to substantiate his professional status. Our contemporary, the -zYort7itrli, Daily Mail, in its report of the inquest mentions that one of the witnesses informed Dr. Gourley that prior to the deceased falling down in a fit the occupants of the carriage was
MEDICAL CERTIFICATES FOR THE LONDON BOARD SCHOOLS. had been playing at gymnastics."" We are of opinion that if such was the case Dr. Gourley was fully justified in saying that a medical man could not certify without making a postmortem examination, and, further, it was a fit and proper We are at a loss to case for complete investigation. understand the equity of the coroner’s observations to Dr. Gourley: "You want to open the body and get your
19-4 and 18’9 in the two
preceding quinquennia.
569 Thus,
the fatal effects of influenza, the English death-rate in the five years ending with December last was lower than in any preceding five-year period for which records exist. One of the most unsatisfactory features of recent English mortality is the absence of the due proportional decline in infant mortality, measured by the deaths two guineas fee"; and when the latter indignantly repelled under one year to registered births. During the ten years the assertion it was met by such a rejoinder as "whether 1881-90 infant mortality measured in this manner averaged you want it or not you won’t get it." The coroner had 142 per 1000; but in the five years 1891-95 the rate increased it in his power to order or refuse a necropsy, but surely it to 151 per 1000, although the death-rate at all ages continued was not necessary to embellish his decision with remarks to decline and was lower than in any previous quinquennium. This increase of infant mortality concurrently with a declining imputing dishonourable motives to a medical man. death-rate at all ages calls for careful investigation. The new English life table, based upon the mortality experience MEDICAL CERTIFICATES FOR THE LONDON of the ten years 1881-90, which will probably find place in the BOARD SCHOOLS. Decennial Supplement which should shortly be published, WE would remind our readers that a second meeting of will throw some light upon the relative increased expectation medical practitioners will be held at 20, Hanover-square at of life at birth and at subsequent ages, and will be full of£ 4 P.M. on Thursday, March 5th, to receive the report of the interest. committee which met upon Feb. 13th and to discuss the propriety of medical men giving any more certificates so long CASE OF CEREBRAL TUMOUR. as the Board persists in its unseemly attitude of revising these IN the Journal of the American Medical Association Dr. certificates at the bidding of a lay official. All medical men, of Washington relates a case of a woman aged fifty-six Dufour especially those connected with hospitals or dispensaries, are who suffered from paralysis of the muscles supplied by the earnestly invited to attend. third, fourth, and sixth nerves of the left side, and exophthalmos and optic atrophy in the same eye. Some months ANTI-TYPHOID SERUM. before she had been operated on for empyema of the left IN view of the interest aroused in the profession by antrum, and when seen there was free drainage through the the recent reports on Dr. Chantemesse’s experiments at nostril. She was treated with iodide of potassium and the Pasteur Institute with anti-typhoid serum, and in doses of the but with small only mercury, apparently answer to several correspondents, we may inform our former drug. There was no benefit derived from the readers that Messrs. Burroughs, Wellcome, and Co. are treatment, and the upper division of the fifth nerve prepared to supply anti-typhoid serum in phials of 10 c. c. became involved and the pain in the head intense. A each. In making this announcement we do not endorse the re-opening of the antrum gave a little relief for a few statement of the results of the use of the remedy which have days only. Her condition gradually deteriorated, the right appeared in certain lay papers ; on the other hand, the optic nerve began to atrophy, word deafness became source of the therapeutic discovery is so good that, immanifest, and her mind wandered. She died about a year probable as some of the results may seem, it cannot but after she was first seen. At the necropsy there was found to receive the respectful attention of the profession. be a gumma of the dura mater in the anterior part of the middle fossa involving the left temporo-sphenoidal lobe. This growth surrounded the internal carotid artery and the RECENT ENGLISH MORTALITY. left optic nerve and exerted pressure on the cavernous sinus THE Registrar-General’s recently issued quarterly return that side. A second gumma was found in the left olfac. of for the last three months of 1895 and his fifty-seventh annual and a third lay in the angle at the right of the tory region, report dealing exhaustively with the vital statistics of 1894 commissure. The last-mentioned lesion probably optic enable us to consider the changes in the rates of mortality for the accounted late affection of the right optic nerve. in England and Wales in recent years. During the five years 1861-65 the mean annual death-rate in England and Wales was 22’6 per 1000, whereas in successive quinquennial THE LEICESTER BACTERIOLOGICAL INSTITUTE GREAT changes have come over the relations between periods the mean rate steadily fell to 19’4 in 1881-85 and 18-9 in 1886-90. The mean rate in the ten years 1881-90 medicine and microscopy during the last twenty years. Not did not exceed 19’1, against 21-4 in 1871-80 and 22-5 long ago the entire outfit of a microscopist was quite in 1861-70. Thus, measured by the recorded death-rate, portable, and for medical work the manipulations requiring the improvement in the public health, which practically most practical dexterity were staining, injecting, hardening, dates from the Public Health Acts of 1872 and 1875, was and section-cutting ; but the discovery of cultivable pathoconsiderably greater in 1881-90 than in the previous decade genic micro-organisms forthwith converted the microscope1871-80. The rates of mortality in 1890 and 1891 showed a room into a laboratory provided with sterilisers and indecided increase owing to influenza mortality, which also, cubators and plentifully furnished with tables and shelves to some extent, raised the rates in 1892 and 1893. In 1894 for glass flasks and test tubes. Previously to this the term the English death-rate fell to the unprecedentedly low figure laboratory was used chiefly to signify a building in request of 16-6 per 1000. Prior to 1894 the rate had never fallen among chemists, and incubators were a specialty of the below 18, and only three times below 19 per 1000-namely, embryologist, being required for hatching fowls’ eggs. In 18-9 in 1881, 18-1 in 1888, and 18-2 in 1889. The death-rate towns where medical schools existed the requisites for in 1895 rose again to 18-7 per 1000, showing an excess of bacteriological research were in course of time 2-1 upon the unprecedentedly low rate in 1894, but was, with introduced, but other places had no such facilities until only three exceptions, lower than the rate recorded in England Messrs. John Richardson and Co. of Leicester fitted up the and Wales in any year since civil registration commenced in Leicester Bacteriological Institute in the Stanley-road and 1837. It is, also, eminently satisfactory to note that the mean placed it under the control of the Leicester Medical Society. death-rate in the first half of the current decade-that is, in Practitioners in the Midlands have thus at hand the means of the five years 1891-95-did not exceed 18’7 per 1000, against carrying on original research work in the investigation of
notwithstanding
___
conducting
568
PHOTOGRAPHY.-INQUEST PRACTICE.
of interest. Typhoid fever of a very mild type appeared in a few instances, and in two cases-one male and one femalethe patients, when convalescent, regained their sanity. The infirmary and the female side were especially crowded, but the general health was good and the death-rate for females was very low-viz., 5’8 on the average numbers resident, and 4’9 on the total numbers under treatment. The male figures respectively were 11-9 and 9’6. On the last day of the year there were 1072 patients (486 and 586), an increase of 30 ; during the year 119 males and 115 females were admitted, and the discharges had been : Recovered, 36 and 52 ; relieved, 5 and 8 ; not improved, 9 and 3. The deaths were 57 and 34 ; total cases under treatment, 593 and 683 ; average resident cases, 478 and 578. The admissions showed little variation, although the tendency to send old people from the workhouses was mentioned ; the discharges were more numerous, and the percentage of recoveries on admissions had risen from 32’5 to 37-6; the death-rate had fallen from 10-6 to 8-8. Of the extra 30 cases, 10 came from three parishes which had been taken over by Hampshire from Wiltshire.
THE
NEW PHOTOGRAPHY.
THERE is little that is new to report this week in regard to the application of the "x" rays. Direct vision of the invisible by Professor Salvioni’s method is, as we ventured to suggest last week, likely to open up a more promising field so far as medical diagnosis is concerned. With the assistance of Mr. J. C. M. Stanton, Mr. A. A. C. Swinton has, we learn, confirmed Professor Salvioni’s experiments and has succeeded in obtaining visible shadows of coins inside a leather purse, metal instruments enclosed in a case, &c. The apparatus consisted of a tube of opaque pasteboard, with a simple aperture at one end serving as eye-piece. The other end was closed with an opaque diaphragm of double black paper, upon which on the inner side was laid a piece of blotting paper previously saturated with a solution of platino-cyanide of barium and dried. The case containing the object was held against the diaphragm with the Crookes’s tube beyond it, so that the rays proceeding through the wood &c. cast a shadow of the imprisoned objects on the fluorescent screen. The platinocyanide fluoresced brightly under the stimulus of the rays on those portions of the blotting paper where no shadow was cast and threw the dark image of the object into clear relief. Thus, the impedimenta of photography are done away with, and it may be before very long that the outlines of the bones in the flesh will be directly viewed by this means. We still need, however, a more reliable and a more
convenient
source
of these
mysterious " x"rays.
DIAGNOSIS OF GASTRIC DISEASES.
comparison with diseases of other organs the methods diagnosis of diseases of the stomach have received but comparatively little notice in our current literature. An IN
of
article by Dr. Boardman Reed in the Medical News of New York of Jan. 18th is of especial interest in that it defines minutely the methods of diagnosing certain conditions of the stomach frequently met with but seldom recognised in ordinary medical practice. The paper is entitled "The Diagnosis of Changes in the Size, Position, and Motility of the Stomach in Cases where Intra-gastric Instruments cannot be Used." It deals almost entirely with two methods of physical examination-clapotement and perDr. Reed is of opinion that it is best to cussion. examine the patient at a time when the stomach should be entirely empty-that is, the morning, fasting, or six hours at least after the last meal. If after that period the splash by clapotement can still be obtained we can infer deficient motility. Noting at
the
same time the lowest point where the splash can be distinctly heard, we may infer as a rule that the lower boundary extends to about that level. The abdomen should then be percussed in various positions to verify the result oi clapotement and to map out the boundaries. The patient then drinks from one-eighth to one-fourth of a litre of water, and another attempt is made to obtain the splash ; if it is obtained after the smaller amount it raises a question Percussion of the boundaries of the as to the motility. stomach with the viscus partially full and the patient standing is then performed. The water should be given gradually, when if the stomach is atonic the area of dulness usually extends downwards with each successive glass, but if its muscle is healthy and strong the dulness Dr. Reed differentiates extends upwards only or mainly. nine conditions which may be recognised by these methods :1. Normal stomach. If empty, no splash is heard until
partially full, and then it may still be absent or very feebly heard. Percussion will demonstrate the normal boundaries. 2. Atonic stomach. The splash may be heard from four to six hours after a full meal, but it is easily obtained after the drinking of a small quantity of water. Percussion will show delayed emptying of the organ. 3. Stomach enlarged, but motor power strong (megalogastria of Ewald). The lower border of the stomach is at the level of the umbilicus or lower. No splash is obtainable six hours after food. 4. Stomach enlarged and motility weak (dilata. tion or gastrectasia). The splash is obtainable six hours after a meal. Percussion shows enlargement of the organ nd delay in emptying itself. 5. Gastroptosis. The stomach is wholly displaced downwards, but otherwise normal. The splash is usually more easily obtainable than normal. Percussion shows descent of both upper and lower boundaries. 6. Stomach enlarged and displaced downwards as a whole, but not dilated. The same as in No.5 5 except that on percussion the upper boundary is not so much displaced. 7. Stomach wholly displaced downwards and dilated. The same as in No. 6, but the splash is obtainable too long after a meal. 8. Pyloric end of the stomach displaced downwards to the left (pyloroptosis), but without dilatation. The splash is obtained far below the level of the normal lower Percussion reveals the pyloric end low in the border. abdominal cavity. 9. Pyloroptosis with dilatation. The same as in No. 8, but the splash is more pronounced and is found too long after food or drink. Percussion shows also a widening of the pyloric end of the stomach. the viscus is
only
INQUEST PRACTICE. of considerable interest arose at an inquest points held at West recently Hartlepool. It appears that a man named Joseph Aspinall whilst travelling between Hartlepool and West Hartlepool fell down apparently in a tit and died. It so happened that Dr. Harte Gourley was travelling in the same train. When called to the case he found the man dead. At the inquest the coroner raised the question whether Dr. Gourley’s name was on the Register; the latter replied that it was, whereupon the coroner said that he must have made a mistake. If the coroner had reason to believe that Dr. Gomley Two
not a duly registered practitioner he was acting within his rights and in fact doing a service to the public and the medical profession in drawing attention to it, and inasmuch as Dr. Gourley’s name only appeared on the official list last year there was some excuse for the mistake made, and we trust Dr. Gourley is satisfied with the result that he was enabled to substantiate his professional status. Our contemporary, the -zYort7itrli, Daily Mail, in its report of the inquest mentions that one of the witnesses informed Dr. Gourley that prior to the deceased falling down in a fit the occupants of the carriage was
MEDICAL CERTIFICATES FOR THE LONDON BOARD SCHOOLS. had been playing at gymnastics."" We are of opinion that if such was the case Dr. Gourley was fully justified in saying that a medical man could not certify without making a postmortem examination, and, further, it was a fit and proper We are at a loss to case for complete investigation. understand the equity of the coroner’s observations to Dr. Gourley: "You want to open the body and get your
19-4 and 18’9 in the two
preceding quinquennia.
569 Thus,
the fatal effects of influenza, the English death-rate in the five years ending with December last was lower than in any preceding five-year period for which records exist. One of the most unsatisfactory features of recent English mortality is the absence of the due proportional decline in infant mortality, measured by the deaths two guineas fee"; and when the latter indignantly repelled under one year to registered births. During the ten years the assertion it was met by such a rejoinder as "whether 1881-90 infant mortality measured in this manner averaged you want it or not you won’t get it." The coroner had 142 per 1000; but in the five years 1891-95 the rate increased it in his power to order or refuse a necropsy, but surely it to 151 per 1000, although the death-rate at all ages continued was not necessary to embellish his decision with remarks to decline and was lower than in any previous quinquennium. This increase of infant mortality concurrently with a declining imputing dishonourable motives to a medical man. death-rate at all ages calls for careful investigation. The new English life table, based upon the mortality experience MEDICAL CERTIFICATES FOR THE LONDON of the ten years 1881-90, which will probably find place in the BOARD SCHOOLS. Decennial Supplement which should shortly be published, WE would remind our readers that a second meeting of will throw some light upon the relative increased expectation medical practitioners will be held at 20, Hanover-square at of life at birth and at subsequent ages, and will be full of£ 4 P.M. on Thursday, March 5th, to receive the report of the interest. committee which met upon Feb. 13th and to discuss the propriety of medical men giving any more certificates so long CASE OF CEREBRAL TUMOUR. as the Board persists in its unseemly attitude of revising these IN the Journal of the American Medical Association Dr. certificates at the bidding of a lay official. All medical men, of Washington relates a case of a woman aged fifty-six Dufour especially those connected with hospitals or dispensaries, are who suffered from paralysis of the muscles supplied by the earnestly invited to attend. third, fourth, and sixth nerves of the left side, and exophthalmos and optic atrophy in the same eye. Some months ANTI-TYPHOID SERUM. before she had been operated on for empyema of the left IN view of the interest aroused in the profession by antrum, and when seen there was free drainage through the the recent reports on Dr. Chantemesse’s experiments at nostril. She was treated with iodide of potassium and the Pasteur Institute with anti-typhoid serum, and in doses of the but with small only mercury, apparently answer to several correspondents, we may inform our former drug. There was no benefit derived from the readers that Messrs. Burroughs, Wellcome, and Co. are treatment, and the upper division of the fifth nerve prepared to supply anti-typhoid serum in phials of 10 c. c. became involved and the pain in the head intense. A each. In making this announcement we do not endorse the re-opening of the antrum gave a little relief for a few statement of the results of the use of the remedy which have days only. Her condition gradually deteriorated, the right appeared in certain lay papers ; on the other hand, the optic nerve began to atrophy, word deafness became source of the therapeutic discovery is so good that, immanifest, and her mind wandered. She died about a year probable as some of the results may seem, it cannot but after she was first seen. At the necropsy there was found to receive the respectful attention of the profession. be a gumma of the dura mater in the anterior part of the middle fossa involving the left temporo-sphenoidal lobe. This growth surrounded the internal carotid artery and the RECENT ENGLISH MORTALITY. left optic nerve and exerted pressure on the cavernous sinus THE Registrar-General’s recently issued quarterly return that side. A second gumma was found in the left olfac. of for the last three months of 1895 and his fifty-seventh annual and a third lay in the angle at the right of the tory region, report dealing exhaustively with the vital statistics of 1894 commissure. The last-mentioned lesion probably optic enable us to consider the changes in the rates of mortality for the accounted late affection of the right optic nerve. in England and Wales in recent years. During the five years 1861-65 the mean annual death-rate in England and Wales was 22’6 per 1000, whereas in successive quinquennial THE LEICESTER BACTERIOLOGICAL INSTITUTE GREAT changes have come over the relations between periods the mean rate steadily fell to 19’4 in 1881-85 and 18-9 in 1886-90. The mean rate in the ten years 1881-90 medicine and microscopy during the last twenty years. Not did not exceed 19’1, against 21-4 in 1871-80 and 22-5 long ago the entire outfit of a microscopist was quite in 1861-70. Thus, measured by the recorded death-rate, portable, and for medical work the manipulations requiring the improvement in the public health, which practically most practical dexterity were staining, injecting, hardening, dates from the Public Health Acts of 1872 and 1875, was and section-cutting ; but the discovery of cultivable pathoconsiderably greater in 1881-90 than in the previous decade genic micro-organisms forthwith converted the microscope1871-80. The rates of mortality in 1890 and 1891 showed a room into a laboratory provided with sterilisers and indecided increase owing to influenza mortality, which also, cubators and plentifully furnished with tables and shelves to some extent, raised the rates in 1892 and 1893. In 1894 for glass flasks and test tubes. Previously to this the term the English death-rate fell to the unprecedentedly low figure laboratory was used chiefly to signify a building in request of 16-6 per 1000. Prior to 1894 the rate had never fallen among chemists, and incubators were a specialty of the below 18, and only three times below 19 per 1000-namely, embryologist, being required for hatching fowls’ eggs. In 18-9 in 1881, 18-1 in 1888, and 18-2 in 1889. The death-rate towns where medical schools existed the requisites for in 1895 rose again to 18-7 per 1000, showing an excess of bacteriological research were in course of time 2-1 upon the unprecedentedly low rate in 1894, but was, with introduced, but other places had no such facilities until only three exceptions, lower than the rate recorded in England Messrs. John Richardson and Co. of Leicester fitted up the and Wales in any year since civil registration commenced in Leicester Bacteriological Institute in the Stanley-road and 1837. It is, also, eminently satisfactory to note that the mean placed it under the control of the Leicester Medical Society. death-rate in the first half of the current decade-that is, in Practitioners in the Midlands have thus at hand the means of the five years 1891-95-did not exceed 18’7 per 1000, against carrying on original research work in the investigation of
notwithstanding
___
conducting