1058 DEGREES FOR MEDICAL STUDENTS.

biophors and determinants and labouring under the delusionthat the doctrine of non-transmission depends on theirimagined existence.

I am, Sirs, yours faithfully,Southsea, April 7th, 1903. G. ARCHDALL REID.

To the Editors of THE LANCET.SIRS,-Dr. H. Woods has much relieved my mind, for

apparently I am in excellent company when I confess thatI really cannot understand Dr. Grunbaum’s lectures. May Isuggest that in deference to the ignorance of those of uswhose chemistry is 30 years old, some member of your staffshould kindly supply an explanation of the rather tantalisingdiagram and formulas which old fogies such as myself wouldgladly be able to comprehend.

I am, Sirs, yours faithfully,April 3rd, 1903. B.Sc. 1868, M.B. 1872.

DEGREES FOR MEDICAL STUDENTS.To the Editors of THE LANCET.

SIRS,-There can be no doubt, from the various suggestionsmade and the endless schemes inaugurated from time totime, that the desire for a medical degree in the professionis great and widespread. But the only value of a degree tothe individual and to the public is its appreciation, dependentupon the time, trouble, and ability required to obtain it.The moment these are lessened to such an extent is the

degree depreciated. Those who legitimately obtain the

degree through the front door of the university are required :(1) to show their general knowledge in school subjects-matriculation ; ; (2) to pass a science examination-thepreliminary scientific ;(3) to pass in preliminary medicalsubjects, anatomy, and physiology-the first M.B. ; (4) thento proceed to practical subjects, medicine, surgery, andobstetrics-the second M. B. ; and (5) finally, by a furtherexamination they obtain the much coveted M. D. But thosewho are so continually striving to obtain this seal throughthe back door of the university think they should, by reasonof their excellent preliminary education through anotherchannel, be permitted to present themselves for the finalexamination alone for their degree.

Well, there is much to be said for knowledge qud know-ledge, however or wherever obtained and irrespective ofthe preceding education, training, and examination. But

suppose a university grant the prayer of these students,what happens ? Surely no university would expect anyother student-unless a candidate for honours-to besuch a fool as to present himself as a candidate forthe four previous examinations for the M.D. degreewhen he could obtain it by passing the No. 5 examina-tion alone. It would mean that the university wouldhave to cancel its four examinations for its curriculum andmerely to arrange one examination for its degree for all-comers. And when this was accomplished what would bethe value of its degree ?-less than the parchment presentedwith it. The difficulty of this degree question is a real oneand can be met by the teachers at our medical schoolspointing out to each individual student more earnestly thanthey do the importance of a degree in the eyes of the

public, and the only way legitimately to obtain it, at thethreshold of his medical life. This heart-burning grievancewould then die a natural death. Much help might also accruewere the importance of a medical degree to the medicalstudent kept before the attention of the headmasters of ourschools. I am, Sirs, yours faithfully,Rugby, March 30th, 1903. CLEMENT DUKES.

THE EFFECT OF EXERCISE ON THETEMPERATURE IN TUBERCULOSIS

AND IN HEALTH.To the -Editors of THE LANCET.

SIRS,-Dr. F. W. Burton-Fanning and Dr. S. G. Championare to be congratulated on their investigations recorded inTHE LANCET of March 28th, p. 856. Their results must

compel further observations and, in the event of confirmation,a revision of sanatorium routine. In the next issue of theJournal of Balneology and Climatology there will appear apaper which I wrote several weeks ago drawing attention tothe need for scientific clinioal observations on the effect ofexercise upon the temperature of the tuberculous and the

healthy. It is satisfactory to find the work so admirablydone. I have long held that the positive value of exercisein the treatment of tuberculosis is overlooked nowadays.The tendency in sanatoriums is to harass patientswith routine, to pursue them with thermometers, and toraise in the minds of patients and attendants a horrorof exercise and a reverence for rest. Whatever may be themysterious " scientific grounds on which exercise insanatoriums is "graduated" there can be little doubt thata definite guide is wanted and that hitherto undue importancehas been given to the thermometer. For centuries commonexperience has proved that phthisis is curable by meanswhich include active exercise far away from thermometersand other mentally disturbing influences; and in the paperreferred to I give quotations from forgotten authors to

support this contention. The paper of Dr. Burton-Fanningand Dr. Champion will, I trust, help us to cast off Teutonicinfluence and be guided by common sense and common

experience as well as by our own scientific observations.I am, Sirs, yours faithfully, - - - - --

H. LAING GORDON, M.D. Edin.Florence, March 31st, 1903.

OSLER’S PRACTICE OF MEDICINE, FIFTHEDITION: AN EXPLANATION.

To the Editors of THE LANCET.SIRS,-May I ask the courtesy of your pages in explana-

tion of the premature appearance of a new edition ofmy text-book? To justify the confidence which the pro-fession has shown in the work I have tried to make eachedition a faithful exponent of the medicine of the day.I had hoped to be able to follow the plan of a triennialissue, but, unfortunately, the fourth edition was not

copyrighted in Great Britain, and in December, 1901,shortly after its publication by Kimpton and Company,an edition-more Americano-was published by Pentland.He was quite within his rights-quite as much so as

the American publishers who, for many years, battenedand fattened on the brains of English authors. ThatMr. Pentland should have issued the edition so promptly-insix or eight weeks, I believe-and that he should havereduced the price from 24s. to 18s. showed that he hadbettered the instruction of his teachers on this side of thewater. To obtain copyright in Great Britain a new fifthedition has had to be issued. I regret the mistake that hasdisturbed the normal process of triennial parturition, but thecircumstances justify what Rabelais calls ° the prettyperquisite of a superfoetation."

I am, Sirs, yours faithfully,Baltimore, March 21st, 1903. WM. OSLER.

GLASGOW AND WEST OF SCOTLANDCOÖPERATION OF TRAINED NURSES.

To the Editors of THE LANCET.

SIRS,-Kindly grant me space to reply to Dr. DavidNewman’s letter in THE LANCET of March 28th, p. 921. Thenew constitution, which had not previously been circulatedamongst the members, was neither read nor explained to theannual meeting, which was therefore asked to adopt it withshut eyes, and the result was that an amendment for delaywas proposed and, although strenuously opposed by the

executive, supported by the votes of their officials, was

carried. Yet Dr. Newman’s letter bears that the constitu-tion was "submitted" " and that delay was " agreed to." Some weeks later explanations of the constitution, whichwere, as above stated, refused by the executive to a publicmeeting partly composed of business men, were madeprivately to four of the 168 nurses.At the annual meeting I pointed out, in the presence of

the cooperation’s solicitor, that the effect of the new con-

stitution, according to Scots law, was to put the nurses inthe position of "servants" " and so to render them liable todismissal without any reason, without any character or

reference, and without any share in the cooperation’s funds.The truth of that statement the solicitor did not deny, yet Dr.Newman says that the rights of the nurses have in no waybeen altered. The "comma" in Rule 2, Clause (o), to whichyou refer does not affect the law on the subject of "servants,"but even if it did Rule 5, to which I direct your andDr. Newman’s attention, provides that in the event of the co-operation being wound up the funds are not to be distributed

1059RECENT ACTS AFFECTING COMPENS ATION OF WORKMEN FOR INJURY.

amongst the nurses but are to be given to some other similarinstitution. Dr. Newman omits to mention that the nurseswho at the annual meeting voted for delay in adopting theconstitution subsequently made a written apology to the- executive for doing so. Will he disclose the terms of that

apology and whether it was made voluntarily ? As the nurses had a right to vote as they chose no apology was Inecessary, and if the apology was compulsory it throws lightupon the " unanimity " with which we are told the constitu-tion was latterly adopted. It seems strange that Dr.Newman should praise so highly an executive ofwhich he is chairman and also that he shoulddo so in THE LANCET instead of in the nursing journalswhich at the time dealt fully with the questions at issuefrom the nurses’ standpoint.

In conclusion, as I do not wish to trespass further uponyour space, I would invite the executive, if my statementsare untrue, to deny them. Thanking you for your courtesyin inserting this reply.

I am, Sirs, yours faithfully,JOHN STEWART BANNATYNE.

Kelvinside N., Glasgow, April 4th, 1903.

RECENT ACTS AFFECTING THE COM-PENSATION OF WORKMEN

FOR INJURY.To the Editors of THE LANCET.

SIRS,-Like Mr. W. J. Townsend Barker, who writes inTHE LANCET of March 21st, p. 834, I also think the actionof insurance companies in regard to such working ofthe Workmen’s Compensation Act as he describes is an

attempt to exploit the members of the medical profession.Two years ago I used to have brought to me, as house

surgeon in a general hospital, similar certificates to theone Mr. Barker has transcribed but which were more

idetailed. The patients who brought them had been led by their employers to expect that I should fill them up for

nothing. From the beginning I made myself acquainted withthe text of the Act, noting particularly : ’’ Section 2 (2) :Notice in respect of an injury under this Act ...... shall statein ordinary language the cause of the injury" ; and" FirstSchedule (3): When a workmen has given notice of anaccident he shall, if so required by the employer, submithimself for examination by a duly qualified medical practi-tioner provided and paid by the employer." (The itaiics inboth quotations are mine.) Then I explained to each patientthat his employer (or the insurance company acting for theemployer) could not legally demand a medical certificatefrom him, at his own expense, in order to his getting com-pensation, and that if the employer insisted upon having amedical certificate the Act said that he must pay for ithimself. In the end some of the patients obtained com-pensation without the certificates at all, while others hadthem filled up at the employer’s charges.

I am, Sirs, yours faithfully,March 28th, 1903. D. M. MACKA.Y, M.B., C.M. Edin.

THE MEANING OF URIC ACID ANDTHE URATES.

To t7te Editors of THE LANCET.

SIRS,-As the publication in THE LANCET of Jan. 31st,p. 288, of Professor Woods- Hutchinson’s paper on the Mean-ing of Uric Acid and the Urates appears to me to be anevent of importance in relation to clinical medicine, I ask

your permission to refer to that subject before it passes fromthe notice of your readers, and much as one naturally shrinksfrom referring to one’s own personal experiences I think that,in the circumstances, such a feeling should not be allowedto prevail.Some 20 years ago I had been declining in health for

five years with symptoms, slowly but steadily increasing infrequency and severity, of painful enlargement of the arhi-cular ends of bones, more especially of those of the handsand feet, with periosteal inflammation of parts subjectedto any kind of violence, such, for example, as the phalangesof the left hand struck in the act of percussion, migraines,decline of appetite and of digestive power, together withexcretion of uric acid steadily increasing in frequency tillit became a matter of daily occurrence. During the latterthree years of that period I sought the advice of the most

distinguished of my friends in the profession and strictlyfollowing their injunctions I steadily diminished the amountof nitrogenous food, and more especially of meat, until

during the last 12 months of the period referred to not ashred of butcher’s meat passed my lips and but little ofeither chicken or fish. In the meantime I plied myself withrecognised remedies such as moderate daily potions ofFriedrichshalle and Hunyadi waters, alkaline medicines, andoccasional doses of calomel or blue pill. My condition, how-ever, went from bad to worse until, after a period of

exceptional mental and physical fatigue, I suffered withinsix weeks two accesses of what I presume would now becalled appendicitis. During the progress of convalescencefrom the second attack I resolved to exercise the courage of

opinions which had long been maturing and to do the exactopposite in the way of régime of what I had been taught andtold to do. As soon as possible I placed myself upon adietary which might be called of the strictest diabetic typeand in two or three weeks I found myself in the enjoymentof a state of health and vigour that I had not known for

years and which, I am thankful to say, has been maintainedunder similar conditions of diet to the present day, withconspicuous absence of all the painful symptoms from whichI previously suffered. In the light of my experience I com-pletely revolutionised the treatment of patients sufferingfrom similar and allied ailments who came under my careand for their use formulated a dietary of the kind which hadbeen of service to myself. That dietary and the methods ofpharmaceutic treatment which I then adopted for myself andothers have now been followed for about 20 years with whatI may perhaps be allowed to characterise as conspicuoussuccess. My experience, which has thus borne the brunt ofa prolonged test in a variety of circumstances, is, there-fore, entirely in harmony with the views of Professor Woods-Hutchinson and has brought me on purely clinical groundsto conclusions identical with those to which he givesexpression. ,

it may, nowever, be interesting to inquire wnetner, inaddition to the commonly recognised symptoms of a so-

called lithæmic state, there is to be found any conditioncommon to its numerous developments which would give aclue to the source of the powerful toxic agents to whichit may be traced. I have now closely observed manyhundreds of such cases and believe myself to be in a

position to say that a pathognomonic indication is the

frequent, and sometimes prolonged or even permanent,deficiency of biliary colouring matter in the evacuations,together with a more or less acid reaction and otherevidences of fermentative putrefaction. It is furtherto be noted that in proportion to the accentuation ofthat condition will, in the main, be the severity ofthe incidence of toxic effects whether on the skin, joints,bones, mucous membranes, or other tissues. The decline ofthe biliary pigmentation of the evacuations referred to andthe accompanying changes would appear to be due to inter-ference in various degrees with the patency of the commonbile-duct. That condition, where not attributable to organicstricture or obstruction by a calculus, is caused by theextension of a gastric or gastro-intestinal catarrh and entailsthe following results : provision of abnormal and inefficientgastric juices, the admixture with the food of mucus

depraved in quality and excessive in quantity, deficientadmixture of the hepatic and pancreatic juices with thechyme in its passage through the duodenum, and, finally,decomposition of the contents of the stomach and bowel andmore especially of those which are capable of undergoing theprocess of fermentation-namely, carbohydrates, fruits, andwines.The worst cases are those in which absorption of toxins

from the rectum is encouraged by the fluid state of theevacuations maintained either by the catarrhal state of theintestinal tract or by the habitual iegestion of aperients.If the facts themselves and their relation to each other besuch as I have suggested, it follows that catarrh of thedigestive tract, limited or extensive, as the case may be, isthe main, if not exclusive, pathological basis of the numerousfamily of ailments which owe their origin to the state whichis commonly regarded as uric acid toxæmia. Of that familyperhaps the most important group is that which comprises alarge proportion of the affections of the circulatory organs.

In THE LANCET of March 21st, 1896, p 755, there

appeared in your columns a paper of mine entitled "Self-poiscning and Heart Disease." in whi, h I expressed the

opinion that at least 90 per cent. of cardio-vascular affections