- Email: [email protected]
THE THERAPEUTICS OF ACUTE RHEUMATISM.
213 latter port
distributed in various directions, many The first outbreak of rinderpest yet traced in this country occurred amongst cattle brought into immediate contact with the Revel cattle. Twenty-seven days I intervened between the landing of the latter and their appearance in the Islington Cattle Market. Rinderpest broke out, four days after the Russian animals were exposed for amongst cattle bought in the same market on the same day. The history of the Revel herd from the 23rd of May (the time i of landing at Hull) to the 19th of June (the time of I in the London market) is still very imperfect. The detailed evidence in support of these statements will, I no doubt, be made public in due time ; but their general accuracy we have seen no sufficient reason to suspect. ; The area of prevalence of rinderpest in the kingdom has largely increased during the past week.
boing
they were
sent to London.
the
exposure
Correspondence. "Audi alteram
partem."
THE THERAPEUTICS OF ACUTE RHEUMATISM.
of THE
LANCET.
SIR,-As subject of the proper treatment of acute rheumatism is one of very considerable importance, I take the liberty of making some remarks upon a leading article in your number of July 29th, in which you have noticed a paper I read before the Hunterian Society on the Blister Treatment of that affection. In the short abstract which the limits of the article allowed, you have certainly placed my views very fairly before the profession, and have cited cases which appear strongly to confirm the efficiency of the plan, and show that this method of combating the disease operates, in some instances at least, cito et t2cta, if not jucunde. You state, however, that ’4 one very obvious depreciatory feature in the cases we have referred to is that they are all hospital cases." And again: "Has Dr. Davies any cases to record of the application of ten blisters the
by a private patient ?"
With respect to the former objection, I confess that 1 cannot understand how the principle of the treatment can be in any way affected by the circumstance of the patient being in or out of an hospital, and I need scarcely add that it is in hospitals alone that new treatments can be fairly tested, as patients are there and then under complete control in every
particular. The real
appear to be simply these: Does the the inflammation, pain, and swelling of the joints quickly and effectively ?-Are relapses rare under the plan ?-and further, Is the heart in the large majority of cases shielded from endocarditis and pericarditis by the method, fully and boldly carried out ? To all these points I can answer most distinctly in the affirmative, not only as the result of my own experience in hospital and private practice, but from the testimony of several who have adopted this plan of treatment. Thus Mr. Owen of Leatherhead says : " I have been so well pleased with the blister treatment of acute rheumatism that I have been induced to try it in subacute cases as well, and I may say with very decided benefit, but the relief experienced is not so striking. I have now treated about a dozen cases, and have found relief within twenty-four hours of the application; and, as a rule, have more than eight blisters." And he concludes rarely had to use by observing : " I do not think I have had a single case of cardiac disease since using the treatment; and I may sum up by saying that if I had acute rheumatism to-morrow I would trust entirely to it." Again, Dr. Duchesne, of Woodford, reports to me the case of a middle-aged man, a gardener, who suffered from agonizing pain in all his joints, acid urine, and all the usual symptoms of acute rheumatism. "Iput on six blisters, and followed them up by linseed-meal poultices. No medicine. In ten days
questions
blister treatment
remove
Much of the
success
in this
care of Dr. C’ory, of the Comcase, mercial-road, aptly illustrates the advantages of the treat. ment :—-" I have just had a case in which your blister treat-
ment has had a most marked and beneficial effect in the,person of a foreman to a builder, exposed to various vicissitudes of
He was attacked with violent rheumatic inflammation in one hand and wrist, and the ankles also were so tender and swollen that he was unable to bear them even touched. Having passed two wretched nights, in spite of a grain of morphia at bedtime, I resolved to try your system of blistering, which was proposed to my patient, who gladly gave his consent to any plan which would promise relief, Blisters were applied around each ankle and wrist; relief was obtained in a few hours; and he slept soundly all night, awaking much refreshed. He had no more swelling or pain, no relapse or retrocession; and this morning he went to work, seven days after the application of the blisters." Mr. Adams, of Lymington, Hants, has kindly sent me the following brief notes:" W. V--, aged sixteen, had severe acute rheumatism of both knees; excessive pain and immobility; not much general fever, and no heart symptoms. Circular blisters of about three inches in width were applied above and below the joints. Next almost all the pain gone. The wrist and elbow were now attacked in a similar manner. Blisters were applied above the and above and below the elbow. All pains had ceased wrist on the following day. The knees were stiff and weak for a few days; but in less than a fortnight from the commencement of his illness he had returned to work. The only medicine taken was an aperient dose." I might quote other accounts given me of the success of the plan in private practice ; but a sufficient number of cases has been already laid before the profession to entitle the treatment, I believe, to its full consideration. In answer to the question as to the greatest number of blisters I have had to apply at one time in private practice, I cannot remember as many as ten being simultaneously required; but I have had several most successful cases where five, six, eight blisters have been at one time used, and by a little tact and explanation I have rarely had any difficulty in persuading my patients to allow of their application. The slightest reference on my part to the great probability of the heart being saved by this plan has almost invariably induced an eager consent to the employment of the blisters. And I may further add that neither in hospital nor in private practice have I ever heard any serious complaint of the severity of the treatment ; on the contrary, in the pamphlet which I have published on the subject will be found many instances where the patients expressed great satisfaction at the rapid and lasting relief which the blisters afforded. In some cases the "pains began to leave the inijamed joints as soon as the blisters began to draw," and in one case the patient said that "he would prefer to have forty blisters applied than undergo the agony of rheumatic fever." The same was the result in the majority of the cases treated on this plan by Dr. Jeaffreson in St. Bartholomew’s Hospital. Using the words of the editor, "Reduced temperature, slower pulse, less acid urine, sleep and appetite, are the happy train of symptoms which follow hard on extensive vesication. In most of these cases the reports would lead us to think that the patients were quickly relieved by the blisters." I can only add that the above are facts, the result of daily and most careful observation; and I would say further, that in no single instance have I seen any unusual " weakness of convalescence" or " slow healing from blistered surfaces." As to the time during which the cases reported were in the hospital, it will be observed from my pamphlet that many were discharged under three weeks, and that some remained in the wards for four, five, or six weeks. These latter cases were individuals of feeble constitution, who had been overworked and under-fed, who would have recovered their general tone but slowly after any malady, and who required rest, food, and shelter from inclement weather for some time previous to their resuming their ordinary occupations. 1 have already trespassed at some length upon your valuable columns, otherwise I should have been inclined to make some remarks upon the alkaline treatment of rheumatic fever. 1 will only quote from my paper the following statement :" That the blister and alkaline treatments are not incompatible with each other ; and I believe a 7railc course of alkali to be a useful adjunct to the directly-eliminative blister plan, but not essential, except in those cases where the rheumatic
temperature.
I
once
out and at work.
believe, from the fact that the patient was treated
an
I
at
arose, I
stage of the disease." I at Theearly under the following
sale,
To the -Edito2-
man was
case
day
214 virus attacks the heart in the first instance and appears to hesitate in fixing itself upon the joints." My object in publishing the results of the plan in fifty cases was to prove that the local treatment, fully and efficiently carried out, is allsufficient in the very large majority of cases to remove the disease rapidly and safely, and without necessitating the internal employment of such large doses of alkali which, while undoubtedly tending to counteract the acid materies morbid, considerably impair for some time the general health and tone of the constitution of the patient. The blister plan acts quickly, decisively, and to the point : at once throwing out the poison, diminishing the temperature of the body, restoring the urine to its normal reaction, and, without interfering in any way with the digestive powers of the alimentary canal, rapidly allows of the return of the appetite. Such a result is cheaply bought at the expense of a little
pain.
I sincerely wish that THE LANCET could Commission into the wards of the London Hospital to interrogate patients who have undergone, and those who have applied the remedy, as to the efficiency of a method of treatment which, if adopted in true cases of rheumatic fever, will be found, I believe, to be the most rapid and effectual mode of combating that agonizing and dangerous malady.
And, in conclusion,
myself in our report on hospitals haveadopted, and to refute the arguments on which he assumes these views to have been based, I prefer to regard it as a criticism on our report, and in that sense to deal with it. Dr. Anstie seems to advocate in his letter, as we have advocated in our report, the admission of fever cases into general hospitals; but he contends that they should always be treated in special wards, and never interspersed in the general wards among other patients ; and in endeavouring to establish his views, he appears to regard us as the uncompromising champions of the system which he so strongly condemns. I hope, in the first place, to show that he has misunderstood our meaning. Mr. Holmes and myself, in the course of our inquiry, could not help observing the great poverty of the medical practice in those hospitals, with scarcely an exception.
own
which in our report we have termed rural. We found that this was due in part to the system of admitting medical patients by governors’ letters, in part to the systematic exclusion of fever cases-the term "fever case" including intentionally all typhus and enteric cases, and also (as was shown in our report) unintentionally, yet almost of necessity, a very large number of those uninfectious acute medical cases which ’ I remain, Sir, yours obediently, almost more than any other cases require for their successful HERBERT DAVIES, M.D. Finsbury-square, Aug. 1865. treatment those special advantages which an hospital is designed these grounds, and on others which I need not ’* We are very happy to insert Dr. Davies’s interesting to afford. On on this subject Dr. Anstie and ourselves are in (since specify letter. We never disputed the efficiency of his method of we maintained that all hospitals professing to be accord), treatment, nor maintained that the principle of treatment was general hospitals, professing to bestow most beneficially for different in hospital cases and in private cases. Ten blisters the poor themselves the benefits of hospital treatment, ought is a question of practice rather than of principle ; Dr. Davies to be in a position to receiveand to treat, and ought to receivee himself admitting that they operate in the same way as and treat, so far as their means allow, all applicants, whether alkalies. We could wish that Dr. Davies had stated more they be suffering from fever or not. Having come to this conclusion, the question naturally explicitly his objections to the alkaline treatment, which seems arose, What arrangements should be made in regard to the to us as efficient as, and free from the faults of, his own.- reception of fever cases ?Feeling that there is, and doubtless will be for years to come, a practical difficulty in making ED. L. generally any distinction between typhus and enteric fevers, and that (excepting a few institutions where fevers are speSUPERVISION OF EXAMINATIONS. cially studied and understood) the rules made in reference to To the Editor of THE LANCET. one form of fever will be applied equally to the other form of Sir,-As the notice taken in last week’s LANCET of my fever ; feeling that in the case of almost all rural hospitals the fever to be dealt with is exclusively enteric ; feeling that the presence at the recent examinations of the University of London will, I fear, lead to misapprehension of the nature and admission of typhus cases, in small proportion and with proper precautions, into suitable general wards, is a source of purpose of my altogether unimportant visit, I am anxious, very little danger to other patients, while the accumulation of with your leave, to explain that in consequence of the absence them in special wards is a very real danger to the medical of the registrar, now on the Continent on account of his health, attendants; we advocated that in places and in years in which I and another member of the Senate, Dr. Storrar, undertook fever is not epidemic, fever cases, provided the hospital be to attend at Burlington House on the days of the vivâ-voce properly constructed and arranged, should be admitted for examinations, in case of any difficulty arising in the distribu- treatment into the general wards in some defined small protion of the candidates among the several sets of examiners. portion; but we also advocated that as far as possible no fever It is true I passed a few minutes at the oral and practical applicants should be rejected, and that if their numbers should examination on anatomy; but chiefly in order to see what sort at any time surpass that which had been fixed on as the of accommodation there was for carrying it on, and not with any maximum limit for admission into the general wards-as would view of "supervising" the examination. Nothing, indeed, most probably be the case during epidemic prevalence-then was farther from my mind, during my very brief interview with wards should be set apart specially for their reception. I wish it to be quite clearly understood that we never conthe examiners, than the notion of criticizing or amending either their written or oral questions, and that too in the presence of templated, far less advocated, the admission of typhus cases in unlimited number into general wards among other patients;’-, the candidates. Butwhile I on this occasion equally disclaim the merit of we never dreamt of recommending that typhus patients official supervision and the demerit of officious interference, I should be mixed with other patients in hospitals which, from may, without impropriety, venture to express a confident ex- their construction and arrangements, are ill-adapted for the pectation that the Branch Medical Council of England will in purpose; and among hospitals of this kind we specially included a large number of rural hospitals, and I certainly no long time be able to arrange a visitation of examinations in include the larger number of our London hospitals.** We as effectual a way as present circumstances will admit. I remain yours faithfully, judged, not from the results in all hospitals admitting typhus, but from the history of the hospitals with which we were W. SHARPEY. 14the August, 1865. severally connected, and from that of some others, that such DISTRIBUTION OF FEVER CASES IN GENERAL a limited admission of typhus as we contemplated might, with what seemed to us slight danger to patients and much general HOSPITALS. advantage, be adopted as the rule in hospitals with large, To the Editor of THE LANCET. thinly-bedded, well-ventilated wards. It is possible that these views were not so clearly defined SIR,-Dr. Anstie’s letter, relating to the Distribution of our report as they should have been. in The large amount of in in General Hospitals, which was published Fever Cases your material we had to deal with, and the very short time allowed June a of for This to calls letter, 10th, reply. judge us for digesting it and for writing our report, led unfortunately journal from its date (March 24th) and from expressions used in it, to the matter of the report being in many respects imperfectly seems to have been originally intended as an answer to one arranged, and to our opinions being in many places loosely from Mr. Holmes, which appeared in your journal of the 18th * Hospitals with small wards, or with wards conimunicating with the of March. But as Dr. Anstie’s main object is clearly to comexternal air by windows on one Bide only- seem to me, as :a rule, not adapted bat certain views which he assumes that Mr. Holmes and for the reception of typhus. send
a
_____________
W.SHARPEY.
distributed in various directions, many The first outbreak of rinderpest yet traced in this country occurred amongst cattle brought into immediate contact with the Revel cattle. Twenty-seven days I intervened between the landing of the latter and their appearance in the Islington Cattle Market. Rinderpest broke out, four days after the Russian animals were exposed for amongst cattle bought in the same market on the same day. The history of the Revel herd from the 23rd of May (the time i of landing at Hull) to the 19th of June (the time of I in the London market) is still very imperfect. The detailed evidence in support of these statements will, I no doubt, be made public in due time ; but their general accuracy we have seen no sufficient reason to suspect. ; The area of prevalence of rinderpest in the kingdom has largely increased during the past week.
boing
they were
sent to London.
the
exposure
Correspondence. "Audi alteram
partem."
THE THERAPEUTICS OF ACUTE RHEUMATISM.
of THE
LANCET.
SIR,-As subject of the proper treatment of acute rheumatism is one of very considerable importance, I take the liberty of making some remarks upon a leading article in your number of July 29th, in which you have noticed a paper I read before the Hunterian Society on the Blister Treatment of that affection. In the short abstract which the limits of the article allowed, you have certainly placed my views very fairly before the profession, and have cited cases which appear strongly to confirm the efficiency of the plan, and show that this method of combating the disease operates, in some instances at least, cito et t2cta, if not jucunde. You state, however, that ’4 one very obvious depreciatory feature in the cases we have referred to is that they are all hospital cases." And again: "Has Dr. Davies any cases to record of the application of ten blisters the
by a private patient ?"
With respect to the former objection, I confess that 1 cannot understand how the principle of the treatment can be in any way affected by the circumstance of the patient being in or out of an hospital, and I need scarcely add that it is in hospitals alone that new treatments can be fairly tested, as patients are there and then under complete control in every
particular. The real
appear to be simply these: Does the the inflammation, pain, and swelling of the joints quickly and effectively ?-Are relapses rare under the plan ?-and further, Is the heart in the large majority of cases shielded from endocarditis and pericarditis by the method, fully and boldly carried out ? To all these points I can answer most distinctly in the affirmative, not only as the result of my own experience in hospital and private practice, but from the testimony of several who have adopted this plan of treatment. Thus Mr. Owen of Leatherhead says : " I have been so well pleased with the blister treatment of acute rheumatism that I have been induced to try it in subacute cases as well, and I may say with very decided benefit, but the relief experienced is not so striking. I have now treated about a dozen cases, and have found relief within twenty-four hours of the application; and, as a rule, have more than eight blisters." And he concludes rarely had to use by observing : " I do not think I have had a single case of cardiac disease since using the treatment; and I may sum up by saying that if I had acute rheumatism to-morrow I would trust entirely to it." Again, Dr. Duchesne, of Woodford, reports to me the case of a middle-aged man, a gardener, who suffered from agonizing pain in all his joints, acid urine, and all the usual symptoms of acute rheumatism. "Iput on six blisters, and followed them up by linseed-meal poultices. No medicine. In ten days
questions
blister treatment
remove
Much of the
success
in this
care of Dr. C’ory, of the Comcase, mercial-road, aptly illustrates the advantages of the treat. ment :—-" I have just had a case in which your blister treat-
ment has had a most marked and beneficial effect in the,person of a foreman to a builder, exposed to various vicissitudes of
He was attacked with violent rheumatic inflammation in one hand and wrist, and the ankles also were so tender and swollen that he was unable to bear them even touched. Having passed two wretched nights, in spite of a grain of morphia at bedtime, I resolved to try your system of blistering, which was proposed to my patient, who gladly gave his consent to any plan which would promise relief, Blisters were applied around each ankle and wrist; relief was obtained in a few hours; and he slept soundly all night, awaking much refreshed. He had no more swelling or pain, no relapse or retrocession; and this morning he went to work, seven days after the application of the blisters." Mr. Adams, of Lymington, Hants, has kindly sent me the following brief notes:" W. V--, aged sixteen, had severe acute rheumatism of both knees; excessive pain and immobility; not much general fever, and no heart symptoms. Circular blisters of about three inches in width were applied above and below the joints. Next almost all the pain gone. The wrist and elbow were now attacked in a similar manner. Blisters were applied above the and above and below the elbow. All pains had ceased wrist on the following day. The knees were stiff and weak for a few days; but in less than a fortnight from the commencement of his illness he had returned to work. The only medicine taken was an aperient dose." I might quote other accounts given me of the success of the plan in private practice ; but a sufficient number of cases has been already laid before the profession to entitle the treatment, I believe, to its full consideration. In answer to the question as to the greatest number of blisters I have had to apply at one time in private practice, I cannot remember as many as ten being simultaneously required; but I have had several most successful cases where five, six, eight blisters have been at one time used, and by a little tact and explanation I have rarely had any difficulty in persuading my patients to allow of their application. The slightest reference on my part to the great probability of the heart being saved by this plan has almost invariably induced an eager consent to the employment of the blisters. And I may further add that neither in hospital nor in private practice have I ever heard any serious complaint of the severity of the treatment ; on the contrary, in the pamphlet which I have published on the subject will be found many instances where the patients expressed great satisfaction at the rapid and lasting relief which the blisters afforded. In some cases the "pains began to leave the inijamed joints as soon as the blisters began to draw," and in one case the patient said that "he would prefer to have forty blisters applied than undergo the agony of rheumatic fever." The same was the result in the majority of the cases treated on this plan by Dr. Jeaffreson in St. Bartholomew’s Hospital. Using the words of the editor, "Reduced temperature, slower pulse, less acid urine, sleep and appetite, are the happy train of symptoms which follow hard on extensive vesication. In most of these cases the reports would lead us to think that the patients were quickly relieved by the blisters." I can only add that the above are facts, the result of daily and most careful observation; and I would say further, that in no single instance have I seen any unusual " weakness of convalescence" or " slow healing from blistered surfaces." As to the time during which the cases reported were in the hospital, it will be observed from my pamphlet that many were discharged under three weeks, and that some remained in the wards for four, five, or six weeks. These latter cases were individuals of feeble constitution, who had been overworked and under-fed, who would have recovered their general tone but slowly after any malady, and who required rest, food, and shelter from inclement weather for some time previous to their resuming their ordinary occupations. 1 have already trespassed at some length upon your valuable columns, otherwise I should have been inclined to make some remarks upon the alkaline treatment of rheumatic fever. 1 will only quote from my paper the following statement :" That the blister and alkaline treatments are not incompatible with each other ; and I believe a 7railc course of alkali to be a useful adjunct to the directly-eliminative blister plan, but not essential, except in those cases where the rheumatic
temperature.
I
once
out and at work.
believe, from the fact that the patient was treated
an
I
at
arose, I
stage of the disease." I at Theearly under the following
sale,
To the -Edito2-
man was
case
day
214 virus attacks the heart in the first instance and appears to hesitate in fixing itself upon the joints." My object in publishing the results of the plan in fifty cases was to prove that the local treatment, fully and efficiently carried out, is allsufficient in the very large majority of cases to remove the disease rapidly and safely, and without necessitating the internal employment of such large doses of alkali which, while undoubtedly tending to counteract the acid materies morbid, considerably impair for some time the general health and tone of the constitution of the patient. The blister plan acts quickly, decisively, and to the point : at once throwing out the poison, diminishing the temperature of the body, restoring the urine to its normal reaction, and, without interfering in any way with the digestive powers of the alimentary canal, rapidly allows of the return of the appetite. Such a result is cheaply bought at the expense of a little
pain.
I sincerely wish that THE LANCET could Commission into the wards of the London Hospital to interrogate patients who have undergone, and those who have applied the remedy, as to the efficiency of a method of treatment which, if adopted in true cases of rheumatic fever, will be found, I believe, to be the most rapid and effectual mode of combating that agonizing and dangerous malady.
And, in conclusion,
myself in our report on hospitals haveadopted, and to refute the arguments on which he assumes these views to have been based, I prefer to regard it as a criticism on our report, and in that sense to deal with it. Dr. Anstie seems to advocate in his letter, as we have advocated in our report, the admission of fever cases into general hospitals; but he contends that they should always be treated in special wards, and never interspersed in the general wards among other patients ; and in endeavouring to establish his views, he appears to regard us as the uncompromising champions of the system which he so strongly condemns. I hope, in the first place, to show that he has misunderstood our meaning. Mr. Holmes and myself, in the course of our inquiry, could not help observing the great poverty of the medical practice in those hospitals, with scarcely an exception.
own
which in our report we have termed rural. We found that this was due in part to the system of admitting medical patients by governors’ letters, in part to the systematic exclusion of fever cases-the term "fever case" including intentionally all typhus and enteric cases, and also (as was shown in our report) unintentionally, yet almost of necessity, a very large number of those uninfectious acute medical cases which ’ I remain, Sir, yours obediently, almost more than any other cases require for their successful HERBERT DAVIES, M.D. Finsbury-square, Aug. 1865. treatment those special advantages which an hospital is designed these grounds, and on others which I need not ’* We are very happy to insert Dr. Davies’s interesting to afford. On on this subject Dr. Anstie and ourselves are in (since specify letter. We never disputed the efficiency of his method of we maintained that all hospitals professing to be accord), treatment, nor maintained that the principle of treatment was general hospitals, professing to bestow most beneficially for different in hospital cases and in private cases. Ten blisters the poor themselves the benefits of hospital treatment, ought is a question of practice rather than of principle ; Dr. Davies to be in a position to receiveand to treat, and ought to receivee himself admitting that they operate in the same way as and treat, so far as their means allow, all applicants, whether alkalies. We could wish that Dr. Davies had stated more they be suffering from fever or not. Having come to this conclusion, the question naturally explicitly his objections to the alkaline treatment, which seems arose, What arrangements should be made in regard to the to us as efficient as, and free from the faults of, his own.- reception of fever cases ?Feeling that there is, and doubtless will be for years to come, a practical difficulty in making ED. L. generally any distinction between typhus and enteric fevers, and that (excepting a few institutions where fevers are speSUPERVISION OF EXAMINATIONS. cially studied and understood) the rules made in reference to To the Editor of THE LANCET. one form of fever will be applied equally to the other form of Sir,-As the notice taken in last week’s LANCET of my fever ; feeling that in the case of almost all rural hospitals the fever to be dealt with is exclusively enteric ; feeling that the presence at the recent examinations of the University of London will, I fear, lead to misapprehension of the nature and admission of typhus cases, in small proportion and with proper precautions, into suitable general wards, is a source of purpose of my altogether unimportant visit, I am anxious, very little danger to other patients, while the accumulation of with your leave, to explain that in consequence of the absence them in special wards is a very real danger to the medical of the registrar, now on the Continent on account of his health, attendants; we advocated that in places and in years in which I and another member of the Senate, Dr. Storrar, undertook fever is not epidemic, fever cases, provided the hospital be to attend at Burlington House on the days of the vivâ-voce properly constructed and arranged, should be admitted for examinations, in case of any difficulty arising in the distribu- treatment into the general wards in some defined small protion of the candidates among the several sets of examiners. portion; but we also advocated that as far as possible no fever It is true I passed a few minutes at the oral and practical applicants should be rejected, and that if their numbers should examination on anatomy; but chiefly in order to see what sort at any time surpass that which had been fixed on as the of accommodation there was for carrying it on, and not with any maximum limit for admission into the general wards-as would view of "supervising" the examination. Nothing, indeed, most probably be the case during epidemic prevalence-then was farther from my mind, during my very brief interview with wards should be set apart specially for their reception. I wish it to be quite clearly understood that we never conthe examiners, than the notion of criticizing or amending either their written or oral questions, and that too in the presence of templated, far less advocated, the admission of typhus cases in unlimited number into general wards among other patients;’-, the candidates. Butwhile I on this occasion equally disclaim the merit of we never dreamt of recommending that typhus patients official supervision and the demerit of officious interference, I should be mixed with other patients in hospitals which, from may, without impropriety, venture to express a confident ex- their construction and arrangements, are ill-adapted for the pectation that the Branch Medical Council of England will in purpose; and among hospitals of this kind we specially included a large number of rural hospitals, and I certainly no long time be able to arrange a visitation of examinations in include the larger number of our London hospitals.** We as effectual a way as present circumstances will admit. I remain yours faithfully, judged, not from the results in all hospitals admitting typhus, but from the history of the hospitals with which we were W. SHARPEY. 14the August, 1865. severally connected, and from that of some others, that such DISTRIBUTION OF FEVER CASES IN GENERAL a limited admission of typhus as we contemplated might, with what seemed to us slight danger to patients and much general HOSPITALS. advantage, be adopted as the rule in hospitals with large, To the Editor of THE LANCET. thinly-bedded, well-ventilated wards. It is possible that these views were not so clearly defined SIR,-Dr. Anstie’s letter, relating to the Distribution of our report as they should have been. in The large amount of in in General Hospitals, which was published Fever Cases your material we had to deal with, and the very short time allowed June a of for This to calls letter, 10th, reply. judge us for digesting it and for writing our report, led unfortunately journal from its date (March 24th) and from expressions used in it, to the matter of the report being in many respects imperfectly seems to have been originally intended as an answer to one arranged, and to our opinions being in many places loosely from Mr. Holmes, which appeared in your journal of the 18th * Hospitals with small wards, or with wards conimunicating with the of March. But as Dr. Anstie’s main object is clearly to comexternal air by windows on one Bide only- seem to me, as :a rule, not adapted bat certain views which he assumes that Mr. Holmes and for the reception of typhus. send
a
_____________
W.SHARPEY.