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(patient desirous of trying the open-air treatment. Madeirais itself a natural sanatorium and, as has been pointed outby an eminent authority, has the great advantage of enablingt patients to ascend during the warmer season to residences at’various elevations above the sea up to 2000 feet or even more,so that patients can remain in the island for the whole year.Madeira is distant from Southampton only three days and afew hours by steamer. The steamship service is perfect, theregular liners varying in size from 2000 to 10,000 tons.The beneficial effect of the climate in the other conditions

t mentioned by your correspondent-viz., rheumatism, nephritis,and neurotic states-has long been well known and one great.advantage which Madeira possesses especially affecting thosesuffering from chest affections is an absolute freedom from

,dust. Although Madeira is not in English hands, nevertheless,English visitors will find themselves amongst a large colonyof their countrymen. The splendid hotels are under English"management and nothing is left undone which might con-duce to the welfare and comfort of visitors. Apologising fortrespassing upon your valuable space,

I am. Sirs. vours faithfullv.I am, Sirs, yours faithfully,

J. GEDDES SCOTT, L.R.C.P. Lond., M.R.C.S. Eng.Funchal, Madeira, July 14th, 1899.

"PLUMBISM AND APPENDICITIS."To the Editors of THE LANCET.

SIRS,—The communications on "Plumbism and Appen-. dicitis" which have appeared in THE LANCET of May 20th andJuly 15th and 22nd have been of great interest and of some- comfort to me in regard to an error of diagnosis which I made’four or five years ago. One Saturday while I was going myrounds at the Westminster Hospital a man, 21 years of age,was admitted under my care. He walked into the ward bentalmost double with his hands pressing the abdomen. I

- . ascertained that he was a painter and I noticed a markedblue line on the gums. He said that his bowels had"not been open for a week. The abdomen was onlyslightiy distended and tender all over. I made thediagnosis of lead colic and treated him accordingly.The next day (Sunday) I was sent for to see him late atnight. I found that the pain had much increased and wasnow localised in the right iliac fossa ; he was sick and muchcollapsed. He died a few hours later. At the necropsy the

’ case was found to be one of perforative appendicitis. Afæcal calculus of the size and shape of a date-stone wasfound just outside the base of the vermiform appendix, theproximal half of which had sloughed away. It is certainly-a comfort to find that others have made a similar mistake indiagnosis, but now that attention has been directed to the,possibility of mistaking appendicitis for plumbism andvice versâ there will be less excuse in the future.

I am. Sirs. vours faithfullv.F. DE HAVILLAND HALL.

Wimpole-street, W., July 24th, 1899.

MEDICAL OFFICERS OF PARISHES INTHE HEBRIDES.

To the Editors of THE LANCET.SIRS,-I have noticed on at least one occasion inquiry

’o.;:nade in your columns as to the status and modus vivendi ofthe above, and the same inquiry has often been addressed tome personally. I have frequently visited those islands and

. adjacent parishes on the north-west mainland and have often come into contact with the local medical officers. As a

holiday resort for tired practitioners who like fishing, boat- ing, and a bit of wild-fowl shooting this wide district is most suitable. As permanent offices these appointments can-not be recommended to young or old practitioners. The

: gross incomes are rarely profitable to any extent andoften amount to no more than constitutes a somewhat

( bare existence. There is no security of tenure of office-aserious matter, seeing that about the half of the gross

’income proceeds from the advertised salary in most cases. In several parishes the club system prevails and in these theincome accruing from this source amounts on the average to at least 9d. per head of population per annum! Thist gives a fair idea of the extent of practice conducted onprivate lines. To the newly-fledged graduate such an

appointment held for a year or so offers the best opportunityfor recruiting his energies, but is uncomfortable as a perma-,nency -so long as the medical officer is at the mercy of a

body of laymen, however kindly their intentions, or at thatof any agricultural gentleman who happens to be a justiceof the peace. It is earnestly to be hoped that early legisla-tion will improve the status of the medical officers in theHebrides. I am, Sirs, yours obediently,July 24th, 1899. SENEX.

" REFORM IN THE ROYAL COLLEGE OFSURGEONS OF ENGLAND."

To the Editor8 of THE LANCET.

SIRS,-As the Council of the Royal College of Surgeons ofEngland has dismissed the memorial of Members with suchscant ceremony, it is to be hoped, as Mr. Dickinson says, thatno opportunity will be lost of compelling it to give attentionto our petition. I would suggest that the Society of Memberspetition against the granting of the proposed new Charterunless the Council first show some concession to their justdemands. It would be interesting to know the reason-ifthere was one-of the Council’s refusal to institute a

Member’s gown. LTp to the present time I had not joinedthe Society of Members, but my 2s. 6d. is now forthcoming,to be followed by another if the sinews of war are wantingon the present opportunity. At the annual meeting ofFellows I notice that not a sufficient number of Fellows werepresent to make a quorum. It is very evident that an exten-sion of the franchise is needed to throw some life into

College matters. I am, Sirs, yours faithfully,July 24th, 1899.

—*-J t

PEPSIN.

" CONSCIENTIOUS OBJECTOR "

CERTIFICATES

To the Editors of THE LANCET.

SIRS,-I shall be extremely obliged if you will giveme your opinion or kindly elicit that of a medical magistrateas to what attitude we (medical magistrates) should assumewith regard to signing the certificates of conscientiousobjectors. This is a serious matter with us (one of the mostunvaccinated boroughs in the kingdom), and I earnestly seeksound advice. Are we obliged by law to sign these certifi-cates or can we have a conscientious objection to signingthem ? We frequently find here that after applicants havesnorn that they have a so-called "conscientious objection tovaccination " they come with their children to be vaccinated.I have hitherto not signed one certificate when sitting on thebench ; but if there are only two justices present and twoare required to sign each certificate, how is one to get out ofthe difficulty I am, Sirs, yours faithfully,July 24th, 1899. F.R.C.S. ENG., J.P., &c.

" PHYSICIAN AND SURGEON."To the Editors of THE LANCET.

SIRS,—I address this letter to you that it may be readby the physicians and surgeons of Great Britain and Ireland.I have received a circular asking for aid for " The HunterFund " and bearing the names of some Licentiates of theSociety of Apothecaries in London as well as those of twograduates. Under cover of this appeal it is pointed out thatthe titles "physician and surgeon" are limited to theFellows, Members, and Licentiates of a College of Physiciansor Surgeons respectively, and it appears to be the design ofthe seven signatories to this circular to enlist the sympathiesof the profession at large on behalf of persons holding theL.S.A., and also M.B. and M.D. of the universities, so thatby a stroke of the pen it will in future be the privilege of theL.S.A. or the M.B. or M.D. to oust us legitimately qualifiedphysicians and surgeons from our position and take untothemselves our right and proper titles.

Unless the meaning of the phrase on the circular referredto, to the effect that "important principles are at stakeaffecting the well-being of a large portion of the profession,"bears this interpretation I fail to grasp its real purport.The M.B. and M.D. have already usurped our title by stylingthemselves" physicians "-which they most certainly arenot unless they are also’Fellows, Members, or Licentiatesof a College of Physicians-and now a subtle and badlydisguised flank movement is being made by some Licentiatesof the Society of Apothecaries and others with the object ofsweeping away the titles "physician and surgeon"altogether or else of perverting these titles to their ownbenefit, advantage, and use.

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Let the M.B., the M.D.,and the M.Ch. be satisfied withhis degree-unless, indeed, he is ashamed of his university.We real " physicians and surgeons " are satisfied with ourdiplomas and let the L.S.A. be satisfied with his qualification.Let him call himself what he really is-" Licentiate inMedicine and Surgery of the Society of Apothecaries." Ifhe is not satisfied with his L.S.A. let him pay his money, sitat the desk, and go through his examinations the same as we’bonâ fide and real physicians and surgeons had to do andnot try to assume a title which no more belongs to him thandoes that of M.D. or M.Ch. to us.

. I strongly commend these remarks to the real" physiciansand surgeons " of Great Britain and Ireland, especially to. those physicians and surgeons " who are highly placed inthe profession (not M.D.’s, &c.), and especially also to the

officials of the Colleges of Physicians and Surgeons in

England, Ireland, and Scotland. If any society of "phy-sicians and surgeons " is formed I would gladly subscribe toit. Of a truth, I I important principles are at stake affecting thewell-being of a large portion of the profession " and it is abouttime that the physicians and surgeons " of Great Britain and.Ireland formed line quickly to vigorously defend theirlegitimate titles against the usurpation of the title phy-sician " by university graduates-and the subtle attack onflank and rear contemplated by the L.S.A.’s. The lady whois the victim of an unfortunate blunder has my sinceresympathy, but it is a pity that her misfortune should bemade the occasion of an attack on us " physicians and

> surgeons " by the claim insinuated in the circular referred to.. I am, Sirs, yours faithfully,July 24th, 1899. A PHYSICIAN AND SURGEON.

PSILOSIS? A QUESTION OF DIAGNOSIS.To the Editors of THE LANOET.

SiRS,-With reference to Dr. I. Burney Yeo’s clinicallecture on a case of chronic diarrhoea published inTHE LANCET of July 22nd, may I be allowed to suggestthat the case was undoubtedly one of "psilosis" or4 sprue"? The history of the case, especially the previousresidence in Manila where the disease is common, the natureof the stools, and, above all, the pain, redness, and aphthousulceration of the tongue and mouth and the rapid recoveryon milk diet, all point in an emphatic manner to this

assumption. It may be urged that the length of time whichhad elapsed since the patient’s residence in Manila wouldnot favour this diagnosis, but it is now well known that thedisease may lie dormant in the system for a great manyyears before manifesting itself.

I am, Sirs, yours faithfully,July 23rd, ]899. l’LEET BUHGEON, It.l’II.

NOTES FROM INDIA.(FROM OUR SPECIAL CORRESPONDENT.)

The Plague in India.-The Report of the German PZag7eCommission.-Dr. Galeotti and the English Plague Com-mission.FOR some weeks past I have been able to record a

diminution in the number of deaths from plague innearly every part of India which has been infectedand the total number of such deaths had reacheda minimum since the epidemic first started in 1896.There were indications, however, in one or two districtsof renewed outbreaks and the plague returns for theweek ending July lst show a considerable increasein mortality, having risen from 470 in the previous sevendays to 733 this week, the advance being due to more deathsin the Bombay Presidency and outside Bombay city. Poonaseems doomed to experience another recrudescence andalarm has been created, causing many people to leave thecity. Karachi has now nearly got rid of plague as well ascholera, but there are fresh troubles with the Khoja com-munity and the headmen will be required under penalty tomaintain the peace. Calcutta records nine deaths only andthe weekly returns of the general mortality seem to indicatethat just at the present time it is exceptionally healthy.The outbreak in Calcutta may be considered to be practi-cally over for the time being, but there is every probability

that after a temporary period of apparent absence it willbreak out again. In Bombay, on the other hand, there hasnot been a clear interval from the time the epidemic firststarted and the city returns for the past week show 45-deaths. Notwithstanding the continuance of the disease inthe Punjab it seems to lack virulence and only a fewvillages are affected. In fact, it can hardly be said that the.Punjab has been seriously invaded at all. The SouthernMahratta country, which has borne the brunt of theepidemic, is again showing signs of distress, and as therehas now been a comparatively free interval for some time it,would not be surprising if a recrudescence of the epidemicoccurred in this district.One item in the complete report of the German Plague

Commission oalls for comment. That report attributes the-exemption of the white population to the greater protectionafforded by their clothing and it states that the evidenceseems to show that it is usually abrasions or perforations of’the skin even of the most insignificant character that.afford the plague bacillus an entry into the body,whereas the poison is much less readily absorbed

through the lungs or the digestive organs. In answer-

to this it may be stated that abrasions of the skinhave been most carefully looked for and investigatedand only in a very small proportion of cases has it been,

thought possible that the plague bacillus could have foundentry by these means. Moreover, the glands of the groin are as.often affected among the white population who clothe their-feet and legs as among the native population. There is.

hardly a single instance to indicate that the poison wasabsorbed through the digestive organs and the smallnumber of nurses, attendants, ward boys, and relatives andfriends of patients who have been attacked shows that it can.seldom be taken in through the lungs. The local inoculationtheory would be an easy explanation for the spread of the-disease if it could be shown that it was generally true. At the-present time only a few cases can be explained on this hypo-thesis. It must be admitted that the means of spread for-the majority of cases are unknown. Why some villageshave been decimated, why the large cities have been attackedat the rate roughly of 1 in 40 of the population, and whyother places have escaped lightly are problems which remainto be discovered and are not disposed of by the theory of localinoculation.

Dr. Galeotti, who has been working in Bombay with.Professor Lustig’s serum, complains in a letter published’in THE LANCET of June 17th that I have incorrectlydescribed his opinion about the value of the serum. 1assert, as I have reported before, that the statistics pub--lished concerning the serum are not only valueless butmisleading. The cases were picked and from these picked’cases certain statistics were compared with the total3returns of the plague hospitals. The system is unscientific.Dr. Galeotti once more asserts the low mortality of his-treated cases as compared with the non-treated patients,.but he does not say that he selected his cases. Ithas been found that about 33 per cent. of admissionsto the large plague hospitals die within 24 hours andthat about 50 per cent. die within 48 hours. Moribund as"well as other cases were not treated by Lustig’s serum, so.that there is no wonder his mortality is only 53 per cent.The mortality of the plague hospitals is about 79 per cent.,so that if the moribund cases are excluded and those that,die within the 24 hours the percentage of mortality would be-actually lower than that recorded for the serum treatedcases. I repeat that a fair comparison has not beetvinstituted with treatment on other lines.Julv 6th.

AUGUST BANK HOLIDAY ON THE CONTINENT.-Cheap tickets will be issued to Brussels, available for eight.days, vid Harwich and Antwerp. Passengers leaving Londonin the evening reach Brussels next morning after a night’s.rest on board the steamer. For visiting The Hague, Amster-dam, and other parts of Holland, the Rhine, North andSouth Germany, and Basle for Switzerland, special facilitiesare offered viti the Great Eastern Railway Company’s Royal’Mail Harwich-Hook of Holland route, through carriagesbeing run to Amsterdam, Berlin, Cologne and Basle, also’restaurant cars on the North and South German expresstrains to and from the Hook of Holland. The General Steam

Navigation Company’s fast passenger steamers will leaveHarwich on August 2nd and 5th for Hamburg, returningon August 6th and 9th.