THE INVERSE RELATIONS BETWEEN PYREXIA AND GOUT.

1575

corporate’’ character;? In that case some curious results would follow. All the elements of the corporation are represented: President, Council, Fellows, and Members-even down to the mace-and the meetings are " duly summoned." A leading authority on corporations says :The power of the majority to bind the society is one of the first principles of corporation law, even in cases where the corporation has a head. It is even held that only by Act of Parliament can this rule be avoided. The binding majority is that present at a corporate meeting duly summoned. In corporations which have a head (as colleges) the head cannot veto the resolutions of the majority. It cannot be disputed (said Lord Hardwicke)that whenever a certain number of persons are incorporated a major part of them may do any commented on. corporate act; or if all be summoned and part appear a major part of In writing of the examination of the heart by percussion those that do appear may do a corporate act, though nothing be Dr. P. M. Latham remarks in his classical lectures (Collected1 mentioned in the charter of the major part. Works, New Sydenham Society, p. 10), "It is well to bes It would be further remarkable if by holding these meetaware that the erect posture is more favourable than the ings for more than 20 consecutive years the Council had rerecumbent for making this dulness or diminished resonance established ancient rightsfor the Members of the perceptible to the ear," and proceeds to give his explanation1 Corporation. Readers of " The Life and Times of Thomas of this fact. The influence of posture in this connexion has Wakleywill remember that he described the College in his no doubt been well recognised and at times investigated time as "a constitutionally rotten concern, badly behaved, since Latham’s day. For instance, the late Dr. Octaviusand of evil pedigree." No doubt it has much improved in Sturges in his excellent monograph on Heart Inflamma- many ways since Wakley’s day, but the position of the tion in Children states (p. 34) that in a boy eightt Members remains exactly what it was then. I am, Sirs, yours faithfully, years of age, who was placed "head downwards" for* five minutes, "the cardiac area (which had been carefully Nov. 20th, 1905. W. G. DICKINSON. marked out beforehand) was in no way altered." This *** We are in all sympathy with the Members of the monograph was a reprint of the Lumleian lectures of 1894. The influence of position, as Dr. Gordon remarks, is less Royal College of Surgeons of England in their desire to have noticeable in health than in disease. Like him, I was a voice in the management of their own affairs. The present unaware of any particular observations on this point when President of the College would, we feel assured, give a most I wrote on the subject in 1897,1 but at that date I dealt with sympathetic hearing to any properly organised scheme for the matter rather fully and illustrated my remarks by reform.-ED. L. diagrams. I then stated: "Whatever method be pursued in determining the dimensions of the heart by percussion it THE INVERSE RELATIONS BETWEEN is of the first importance that the posture of the patient far on so as be the successive same should, possible, exactly PYREXIA AND GOUT. occasions when this point is under examination." I proceeded 10 the Editors of THE LANCET. further to show the alterations in the dimensions of the thorax in recumbency as compared with those observed in in THE LANCET of Nov. 18th, p. 1471, an article SIRS,-In the erect position, and the data I obtained by percussion Mr. Joseph Birt describes a case in which freedom from and figures were essentially the same as those obtained by general goutiness and neuritis of eight years’ standing Dr. Gordon. I found also that in recumbency the upper rapidly followed an attack of diphtheria. He refers also to limit of hepatic dulness fell considerably as compared with a case in which three years’ freedom from acute recurrent the point it occupied in the erect position and that a minor gout followed pneumonia. Such inverse relationships difference of markings on the surface of the body could be attracted much attention and led to much speculation in accounted for by the skin altering its position by sliding past years before extreme specialisation had obscured the influence of disease upon disease. Braun pointed out that slightly downwards when the patient stood up (p. 33). It is unnecessary for me to write further in this place "gouty patients often remain for a long time free from of alterations in the pitch of cardiac sounds under con- paroxysms after a febrile malady of however foreign a ditions of rest and exercise, but this point was also dealt nature."And among recent writers Henry M. Lyman shows I have that "various acute febrile diseases and inflammations like with in the book I have mentioned (p. 193, &c.). ventured to state these facts in the interests of historical tonsillitis, bronchitis, rheumatism...... afford great relief arthritism." 2 Even accuracy, but their existence, of course, in no way lessens from the constitutional symptoms the perfect independence of Dr. Gordon’s observations nor vaccination has a like salutary influence (Heinrich Stern 3) the clinical interest of his conclusions. and many other extracts could be given having the same I am, Sirs, yours faithfully, bearing. These all go to prove that the relief attained is ALEXANDER MORISON. due to the increase in the rate of combustion associated with Upper Berkeley-street, W., Nov. 19th, 1905. pyrexia. But acute gout itself is a pyrexia and the increase in combustion and carbonic acid evolution has been demonstrated by Magnus Levy. Hence " the improvement which THE ANNUAL MEETING OF FELLOWS AND succeeds the attack is, as a rule, proportionate to the degree of febrile reaction (Braun ) and drugs which cut short the MEMBERS OF THE ROYAL COLLEGE arthritic paroxysm and so the pyrexia, tend to prevent the OF SURGEONS OF ENGLAND. amelioration in general health, and to shorten the ensuing To the Editors of THE LANCET. period of freedom from arthritic attacks which commonly attack (Sydenham, Trousseau, SIRS,-The anomalous character of these meetings, as in- follow the uninterrupted and others). Fothergill, Gardner, the was never than on this more evident Council, terpreted by It would follow that a retardation of combustion is a last occasion. A legal gentleman, apparently imported for the factor in the pathogenesis of gout and in a fundamental occasion, advised the President not only that the amendment work just issued I have attempted to show that such under discussion was out of order but that the resolution, which had been duly sanctioned by the President days a modification of metabolism is a fundamental factor but before and placed in the agenda, was also out of order ! that its action is indirect. The retardation of combustion In face of this the President took a vote on it and with leads to an unphysiological accumulation in the blood of the assistance of his colleagues on the Council defeated it. unoxidised or imperfectly oxidised carbonaceous material We wished to move the adjournment of the meeting but (hyperpyræmia). The primary carbonaceous accumulation were informed that this, too, would be out of order. So here involves a secondary progressive accumulation of uric acid from imperfect renal elimination. The uricasmia so induced we have a meeting which, if the view of the Council is finally leads to extravascular deposition of urates, which correct, cannot be adjourned and whose resolutions are of no thus becomes the proximate cause of the gouty pyrexia. effect. Truly, as the President himself said of it 20 years ago, " it is a solitary instance." But what if the view of the 1 On Gout, Gairdner, 1860, p. 28. Council is not correct ? What if these meetings turned out, 2 American Text book of Medicine, vol. ii., p. 140. Pepper’s in spite of the strenuous denials of the Council, to be of a 3 Medical Record, August, 1901. 4 On Gout, Gairdner, 1860, p. 28. 1 Cardiac 5 The Food Factor in Disease Failure, &c., London, Rebman Publishing Co. (Longmans). conclusions. Dr. Gordon offers certaiIn of the fact that the sounds and dimensions o:)f the heart vary according as a person stands or lies. As thesEe are offered tentatively it is not necessary to discuss themi. Dr. Gordon, however, remarks in his paper, as published irn the current issue of the British Medical Journal, that 11 th(S is strikingly constant, so much so that it seemss change curious that it has not been observed before " (p. 1319). In making this statement I believe him to be mistaken, for it, It is, however,, has been both observed and published. certainly curious that it has not been more frequently lead to

erroneous

explanations

......

’

I

of

1576 The further steps in the conservative re-action are clear. The increase in combustion involved in pyrexia disperses the carbonaceous accumulation ; this permits of free renal elimination of uric acid, the blood recovers its solvent power, the arthritic deposits are reabsorbed, and complete convalescence from ills, local and general, is assured. All the steps above referred to with the exception of the first are well known. It requires but the recognition of the blood state termed hyperpyræmia-and in support of this a large amount of independent circumstantial evidence can be adduced-to render the acute gouty paroxysm one of the simplest of the conservative reactions of the organism. Acute gout would still be a disease, but in accordance with the conception recently formulated by Sir Frederick Treves it would be a disease salutary in intent. Furthermore, it would be a disease which more often than not is salutary in effect. I am, Sirs, yours faithfully, FRANCIS HARE. London, W.C., Nov. 20th, 1905. --

ASSOCIATION OF MEDICAL DIPLOMATES OF SCOTLAND. To the Editors of THE LANCET. SIRS,-Permit me space in your valuable journal to call the attention of those holding the qualifications of the Royal Colleges of Edinburgh and the Faculty of Physicians and Surgeons of Glasgow to the good work the above association is doing. It is a comparatively young society and up to the present has achieved a great success in the following ways: the opening up of appointments to those holding the qualifications in question; the securing of a distinct academic costume ; and again this week a deputation is to attend the a petiRoyal College of Surgeons of Edinburgh to present " tion for the alteration of the title of " Licentiate to that of "Member." Is not this a good record of work done? Let me urge upon all who take an interest in these affairs to join us, so as to strengthen our hands and encourage us in our endeavours to promote the welfare of our colleagues. Our able honorary secretary, Dr. David Walsh, 18A, Hanoverstreet, London, W., will gladly forward conditions of

membership.

I am,

Sirs, yours faithfully, ----

CLAUDE ST. AUBYN-FARRER,

London, W., Nov. 20th, 1905.

President.

"RETURN" CASES OF SCARLET FEVER.

THE

ORGANISATION OF THE MEDICAL PROFESSION IN SWITZERLAND. (FBOM

OUR

SPECIAL

COMMISSIONER.)

Legislative Struggle at Gurioh.-The Benefit Society of Basle.-Solidarity between the Senior and Junior Practi-

The

tioners.-Establishment of a Minimum Medical Pee.

IN Switzerland during the last few years considerable progress has been accomplished in the work of organising the medical profession. Every canton and nearly all the subdistricts have local medical societies. In the rural parts of the country these societies can barely contrive to meet oftener than twice during the course of the year. In the large towns it of course, easier to meet more frequently. Formerly, and as was the case with the various local medical societies in England, these occasional meetings were held solely for convivial purposes and for the reading and discussion of scientific papers. Of late years, however, a great change has taken place. The medical profession is none the less

is,

devoted to the study of science because it now realises that it is first of all necessary to secure the means of existence. Therefore these various medical organisa. tions commenced to discuss economic questions and during the last three years these have more and more encroached on the time and attention that were formerly devoted to scientific topics; indeed, this is so much the case that in some parts of Switzerland it was thought necessary to duplicate the societies. Thus, the Medical Society of Geneva has created the Association of the Practitioners of the Canton of Geneva and the mission of the latter body is to deal exclusively with economical and ethical questions. So also there is at Ziirich an offshoot from the parent medical organisation called the Young Practitioners’ Society. Scientific papers are occasionally read before this body but the greater part of its time is devoted to the study and discussion of the phases of the great current economic problems that affect the medical profession. At Basle, on the contrary, it was decided that it would not be wise to separate. Some medical men are more anxious to meet for the purpose of discussing economic problems. To many, unfortunately, this is a matter of necessity, as they are the victims of the modern evolution of economic forces. Others, on the contrary,

- Zo the Editors of THE LANCET. to the leading article on the above whose position is not so directly menaced, are more anxious to draw attention to pp. 612-13 of to discuss purely scientific topics. But it is most essential these sections of the medical profession should Nothnagel’s "Practice of Medicine" where, in the article that botheach other and move forward hand in hand. To on scarlatina, it is said that at the New York Hospital for support Scarlatina and Diphtheria there has been no history of con- ’ separate them is to make the one l8se influence over the tagion from a discharged patient (p. 613). Is the routine other, and this tendency has been successfully resisted at disinfection in London similar to that described for New Basle. As an example of the work done there is at Zurich a sect York ? I am, Sirs, yours faithfully, called the Nature Cure Party. It has acquired a certain VOLENS. Nov. 20th, 1905. popularity which, in any case, was sufficient to enable it to introduce in the local legislature a motion in favour of FENWICK v. THE " ACCRINGTON GAZETTE "-On sanctioning the free practice of medicine. A few years ago Nov. 18th and 20th at Manchester, before Mr. Justice Bray there was no organisation capable of fighting such a proposal. and a special jury, the case of Fenwick v. the Acc’l’ington Now, however, the Zurich medical societies launched out on Gazette Co., Limited, was heard. The libel in question the warpath and took so active a part in the political alleged incapacity on the part of the plaintiff. Early in propaganda that when the proposal was submitted from the March he was called to attend upon two children, one of cantonal legislature to the popular vote it was defeated. whom was in bed with a normal temperature but with a rash. The general opinion is that but for the recent organisation This rash was diagnosed by plaintiff as chicken-pox. The of the medical profession as a militant body attending to boy was treated accordingly and recovered. The second its economic interests, this proposition would have been boy was treated for influenza but on March 29th symptoms carried, with the result that anyone, whether qualified or of small-pox arose. Then the medical officer of health not, would have the legal right to practise medicine. At Basle there is a similar odd sect. It is known was communicated with and the two boys, the father, and two other children were removed to the small-pox hospital. as the Adventists of the Seventh Day and originates froro The health committee then decided to prosecute Mr. Fenwick the United States of America. Of the 120 practitioners for not having notified the cases. He thereupon wrote to the at Basle all except four joined the medical organisation. health committee vindicating his diagnosis. The Accrington One of these four served the Adventists and complications Gazette then published an article in which Mr. Fenwick’s of no ordinary character were anticipated when by some letter was spoken of as " a blatant attempt to bluff the lucky inspiration the spirit moved the entire sect to leave health committee." Further, Mr. Fenwick was accused of the canton of Basle. It went to Gland in the canton de trying to hush the matter up and of being so incapable that Vaud. Here there are few inhabitants, fewer medical he did not know the difference between small-pox and practitioners, but there are very good vineyards and some chicken-pox. Mr. Fenwick admitted that he had made a excellent wine. All the members of the Basle Medical mistake and the health committee did not prosecute him. Society have signed a contract by which they pledge themThe defendants withdrew the plea of justification and the selves not to accept less than the minimum fee. This is jury gave a verdict of £1000 for the plaintiff. Judgment fixed at 1 franc, or 1(M., for a consultation at the practitioner’s surgery and 2 francs for a visit at the patient’s home. was given

SIRS,-In reference subject I would like

accordingly.