935THE CONSUMPTION OF ALCOIIOL.

been frequently recognised, but never hitherto satisfactorilyexplained, is the large proportion of cases in which theso-called presystolic murmur is absent, and the still largernumber in which it is only present during the earlier stage.The absence of the presystolic murmur when the stenosis ismost advanced, and while the auricle is still acting well, as8hown by the efficient maintenance of the circulation, is quiteinexplicable on the auricular-systolic theory of the causa-tion of the murmur. On the ventricular-systolic theory itsfrequent absence is more easily explained.In the first stage of stenosis, when the segmente of the

mitral valve are still capable of closing without allowingany regurgitation, there is no murmur, but only a prolonged,altered, first sound, due to the thickening of the segments,and possibly to a partial want of synchronism in the soundsproduced by the two sides of the heart. In the second stage,while the valve is still capable of closing, but moves slowlyand so allows of some reflux at first, the characteristic pre-systolic murmur mounting up to the first sound is produced.In the last stage, when from increased rigidity or calcifica-tion the valve is rendered incapable of closure, only a sys-tolic murmur indicative of regurgitation. and lasting duringthe whole systole, is produced; and the first sound is absent.A very good example of the latter condition has recentlybeen under my care. The mitral orifice was reduced to anarrow slit, the margins of which were calcified, and sorendered incapable of closing. There was no presystolicmurmur or first sound, but the latter was replaced by a loudeystolic murmur, quite indistinguishable from that due toregurgitation from dilatation of the mitral orifice.Before closing, may I point out that considerable hyper-

throphy, affecting the left side-though to a less degreethan the right-is much more common in mitral stenosisthan is usually taught. The duration of the disease is, Ithink, the chief element which rules the amount of hyper-trophy. It is in young subjects and in rapidly fatal casesthat there is little or no hypertrophy.

I am, Sirs, yours faithfully,Nottingham, Oct. 20th, 1887. H. HANDFORD.

*** On the above subject we have received numerousother letters, for which we regret we are unable to findspace.-ED. L.

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THE CONSUMPTION OF ALCOHOL.

To the Editors of THE LANCET.

SIRS,—When I read your notice on Sir William Roberts’sobservations on the subject of alcohol I thought that thefollowing extracts from a paper by M. Fournier de Flaixmight be considered sufficiently important to find a place inyour journal.Of France, M. de Flaix says that " the birth-rate is less

and the mortality greater in the departments where theconsumption of alcohol is small; that neither crime norsuicide are in proportion to alcoholic consumption. Thusin the Seine-Inférieure the consumption of alcohol is threetimes that in the Nord; but suicide is only twice as frequent.in the Pas-de-Calais the consumption is twice as great asthat of the Nord, whilst suicide is two and a half times less.In the Seine-et-Oise the consumption is one-half less thanthat of the Seine-Inferieure, but suicide in the former istwice that of the latter." Comparing different nations, hesays, "France consumes less alcohol than the United Kingdom;its birth-rate is less, and its mortality, criminality, andsuicide rates are greater. Italy consumes very little alcohol;its criminality is appalling (effrayante). Spain consumes threetimes less alcohol than Italy; its criminality is double. Sweden,Denmark, and Norway, with a population of about one-third, consume four times the quantity of alcohol consumedin Italy, and yet the criminality of the former is very small,whilst that of the latter is appalling (effrayante). Russia,consumes four times the alcohol of France ; its birth-rate isalmost double. Thus, all the hypotheses are upset : themost vigorous, the richest, and the most moral of the nationsare those which consume most alcohol. The prediction thatalcohol will destroy civilisation and the human race is notsupported by facts. If France, whose vitality is undergoinga crisis, were amongst the nations who consume most alcohol,she would serve as an excellent argument; but the con-sumption of alcohol by France is moderate, and it has beenestablished already that those parts of France are the most

vigorous where the consumption of alcohol is greatest.Alcohol is not, then, a scourge which threatens the Europeanrace with the fate of the Oceanic races, inasmuch as thenations who consume most alcohol are the nations whosecriminality is least and whose vitality is greatest."

I am, Sirs, your obedient servant,Eastern Hospitals, Homerton, E., Oct. 29th, 1887. ALEX. COLLIE.

SHORTHAND TEACHING IN MEDICAL SCHOOLS.To the E, ditors of THE LANCET.

SIRS,-I have reason to believe that a large number ofmedical students desire to avail themselves of the help intheir work that an acquaintance with shorthand can givethem. The desire is certainly a reasonable one on the partof those who have to learn by oral teaching, and whosepractical work involves the constant recording of observa-tions. Shorthand enables the student to secure as much ashe likes of a lecture, while the limitations of longhand arequickly reached; it enables him to keep up with thelecturer in attention, while longhand is always holding himback; and it enables him to record his observations in onequarter of the time required with longhand, and thus in agiven period he can record twice as much, and yet have50 per cent. more time in which to observe. The last is avery great help in case-taking, and in a competitive examina-tion the student who writes shorthand has a considerableadvantage over one who does not. Shorthand can be learnedfar better and far more quickly from a teacher than by self-instruction. But for students to go to a shorthand class ata distance, almost necessarily in the evening, means a lossof time that is practically prohibitory. I believe that everymedical school at the present moment contains enoughstudents desiring to learn shorthand to make it worth whileto establish a class, and I would suggest to the authoritiesof the schools the desirability of ascertaining the extent ofthe demand, and, if it is considerable, arranging for themeans of instruction. The time required for the study isnot great. Half-an-hour’s work a day will in six weeksenable the student to make use of shorthand in his dailywork, and all the time needed for proficiency will be savedat least twice over in a single year. Teachers of shorthandare readily obtained. I shall be glad to give information onthis or any other point connected with the subject.

I am. Sirs. vours trulv.Queen Anne-street, Oct. 31st, 1887. W. R. GOWERS.

"PARALYSIS OF THE ABDUCTORS OF THEVOCAL BANDS."

To the Editors of THE LANCET.SIRS,—Without entering upon numerous other points of

controversial nature in Dr. Gordon Holmes’s paper on the

above subject which has just been published in your columns,I wish to point out one important mistake, and also to statethat the list of cases given in the paper is incomplete, andnot quite correct in certain particulars.The mistake referred to concerns the motor innervation of

the larynx. The notion that the spinal accessory nervesupplies only the adductors of the vocal cord, but not theposterior crico-arytenoid muscle, is certainly erroneous.

Bischoff’s and Schech’s experiments, which showed that thespinal accessory supplied both the adductors and the ab-ductor, have again been recently confirmed by ProfessorHorsley. He succeeded, in my presence, in cutting the inner(bulbar) branch of the left spinal accessory of a dog, leaving,as subsequent post-mortem examination showed, the ex-ternal (spinal) branch of the spinal accessory and the pneu-mogastric absolutely uninjured. The immediate result ofthis experiment was complete cessation of all respiratorymovements of the left vocal cord, which at once becameabsolutely fixed in what is commonly called the "cadavericposition." This experiment proves incontrovertibly thatthe motor fibres not only for the adductors, but also for theabductors, are derived from the spinal accessory.Concerning Dr. Holmes’s tables, I have to say that I have

myself published, in greater or lesser detail, not threebut eleven cases of bilateral abductor paralysis (ClinicalSociety’s Transactions, vols. xi. and xii. ; Archives of Laryn-