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invented a clamp with parallel blades and described anddepicted its use in the operation of gastro enterostomy in1899.1 May I point out that some reference to the

writings of Doyen and others who invented clamps,especially for use in stomach and intestinal work, wouldhave saved Mr. Ward from the several errors I have hadto correct ?

Mr. Ward in his second letter gave us what he said was"the precise date" of Mr. Littlewood’s adoption of themethod of "excision of an ellipse of the mucosa from eachviscus" in gastro-enterostomy. I showed that the date he

gave was inaccurate. Mr. Ward acknowledges this and nowgives the correct date and suggests that it would have beensimpler for me to do so. I disagree. Since I have shown,and will demonstrate once again, that the method for whichMr. Ward claimed priority was not performed on either thetrue or the false date, the mere date is in itself of no con-sequence. What is vital is Mr. Ward’s credibility as a

witness ; it was only that which I was concerned toillustrate and I neither suggested nor desired that anyinference other than one relative to this should be drawnfrom any statement.When I obtained access to the record of the case quoted by

Mr. Ward in support of the claim to priority in this methodof excision of the mucosa, I found, as I have said, that itwas expressly stated that the jejunal mucosa was not excised.Mr. Ward now ass erts that this is the result of ’’ thedresser’s inaccurate statement." The defence, amazingthough it is, is worthless. In the notes of the case it ispositively said that no jejunal mucosa was removed. Thesenotes have been edited by Mr. Littlewood himself ; they bearan alteration, or rather an addition, in his own handwriting,in the brief account of the operation. The description ofthe operation is illustrated by three figures, in which thefact that no mucous membrane was removed from the bowelis clearly displayed and the legend attached to the drawingrepeats the fact. In no less than three places is thestatement made and it remains in carefully revisednotes uncorrected. It is mere trifling to suggest inaccuracynow. This record was chosen and cited by Mr. Ward himselfto establish the claim he put forward. On examining it Ifound its date incorrectly given and I am now told that therecord itself, even after its revision, is inaccurate. Therecord is true or it is false ; if true, it does not support Mr.Ward’s claim; if false, why did Mr. Ward quote it inevidence ?

Mr. Ward tells me that the operation I practise is that towhich he attaches Mr. Littlewood’s name. I will endeavourto bear this with fortitude. For I believe it to be true’that Mr. Littlewood has never yet performed this operationand I have, I think, given good reason for not acceptingMr. Ward as a sound authority upon matters of surgicalprocedure. I am, Sirs, yours faithfully,Leeds, June 25th, 1906. B. G. A. MOYNIHAN.B. G. A. MOYNIHAN.

AN OBSCURE CASE.10 the Editors of THE LANCET.

f SIRS,—The following case struck me as of interest and ofimportance in dealing with schools or families of children.A school girl, aged ten years, was found to have a rash onMay 30th. I saw her on May 31st. The child was quitewell, clean tongue, temperature and pulse normal. Therewas a papular eruption over the chest and back with two orthree spots on the face and one or two on the scalp, perhaps30 papules in all. Some on the chest and back had a tinyred punctate spot in the centre exactly like an insect bite,and of these last two or three had a hastnorrhagic ring roundthe papule. I could find no sign of a vesicle though Isearched carefully on two occasions. Nine days later thechild developed a single spot which had all the characters ofa chicken-pox vesicle. Nine days after this last occurrencean older sister developed ordinary chicken-pox. Had thefirst rash any connexion with the chicken-pox, or was itsappearance merely a coincidence ? 2

I am, Sir.., yours faithfully,ETHEL M. N. WILLIAMS, M.D. Lond., D.P.H. Camb.

Newcastle-on-Tyne, June 22nd, 1E05.ETHEL M. N. WILLIAMS, M.D. Lond., D.P.H. Camb.

1 Traité de Chirurgie, Le Dentu et Delbet. Paris, 1899, vol. vii.,p. 446, fig. 27.

LIFE INSURANCE OFFICES AND THEIRMEDICAL REFEREES.

To the Editors of THE LANCET.

SIRS,-Is there a Society of Medical Referees to InsuranceCompanies or any other society that represents their viewsto the various rich and influential offices 7 It is highlydesirable, I think, that some uniform system of paymentshould be adopted for filling up the generally most elaborateforms that are now presented to us when a person comes tobe examined as a preliminary to taking out a life policy.Generally speaking, I have noticed that the more recentlyestablished and more largely advertised the society the moreparsimonious is it in the fees it pays for medical reports, onthe accuracy and trustworthiness of which its future use-fulness and prosperity largely depend. I inclose for yourinspection a form lately submitted to me with a request thatI would examine a certain life. At the end of a string of atleast 50 questions is an intimation that if the sum assuredis under C300 the fee is 10s.6d. I wrote to the managersaying that if I made the report my fee would be 91 ls. andI received a reply that he had made other arrangements forthe examination and would not trouble me further. Thework attached to putting such a series of questions andnoting the answers alone occupies a large amount of timeand it is obvious that supplying a correct answer to many ofthem necessitates a most careful and skilled examination forwhich, in my opinion, a fee of at least 1 Is. should bepaid.

I am aware that some offices now make a feature of grant-ing insurances without a medical examination, as to whichwe can have no possible grievance, though we may have ourown opinion. Within my own somewhat limited experienceI have found a patient suffering from carcinoma of therectum, and yet within a week or two I have been requestedto examine him for life assurance, as a proposal for an in-surance of .B1000 had been made on his life. As this mannever showed any obvious constitutional evidence of organicdisease for some months and continued his employment con-siderably over a year afterwards I think an insurance com-pany would have found considerable difficulty in disprovingits liability had not the medical referee relieved it of allrisk in the matter.

I am not writing in any spirit of antagonism to the lifeinsurance companies, to the usefulness and liberality ofmany of which we daily testify, but simply to register amild protest against what I venture to submit is a mistakenand illiberal policy on the part of a few. One cannot helpfeeling that the accumulated millions of many offices repre-sent a very large amount of highly skilled but ill-requitedwork on the part of the medical referees.

I am, Sirs, yours faithfully,June 18th, 1906. REFEREE.

** The Star Life Assurance Society-for we see no reasonfor withholding the name of the society in question-puts alow value on medical service. The medical man first is to

write down for the candidate for insurance an elaboratestatement as to the proposer’s age, habits, and previous andfamily history. Then he is to fill up an enormous confidentialreport as to the proposer’s health. He is’ to measure him,weigh him, strip him for physical examination, examine himfor hernia, test his urine for sugar and albumin, and, infemale cases, indicate the presence or absence of symptomsof ovarian or uterine disease. And all for 10s. 6d. if the sumassured is less than 300. We strongly recommend ourreaders to follow "Referee’s" example and to refuse suchfees, even though in some instances other medical men maybe found to accept them.-ED. L.

"JACOBEAN" TREATMENT OF THE SICK.To the Editors of THE LANCET.

SIRS,—The interesting annotation in THE LANCET ofJune 23rd upon the recent correspondence in the York-shire Post, in which the Rev. Mr. Say well (auspiciousname, suggestive, Bunyan-like) described his experienceof the Jacobean treatment as applied by him, "eighteenor twenty years ago," to a Mr. N. who was "given up"

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by his doctor and was "in extremes from acute pneu-monia, reminds me of a somewhat similar case whichoccurred in my own practice, but which has hithertoremained unpublished. More than twenty years ago,in fact nearly fifty, I was in a country district inwhich there was an old woman, known to me only as

"Betty," who earned a scanty living by peddling smallwares, going errands, executing commissions in the neigh-bouring market town, and so on. She was an honestand worthy old dame, much liked and respected by herneighbours. I was one day asked to see Betty and wastold that she was dying and had been " given up by theparish doctor, Mr. A., who said that he could do no morefor her and that she must "look above." I took a

somewhat different view of her condition, and in the courseof a few days had the satisfaction of seeing her about againwith her basket. I forget the details of my treatment, butit was not "Jacobean." The old woman was duly gratefulfor her restoration, but was furious with the parish doctor,on account, I believe, of what she considered to be the

prematurity of his endeavour to turn her thoughts heaven-ward. It became a joke among the farmhouses to askwhether she had seen Mr. A. lately. " Seed he 1 " she wouldanswer, "Noa, nor doant want to. He told me to lookabuv." Now if Mr. Saywell had visited poor Betty in myplace, and if the vis medicatrix natttrae had as large ashare in her recovery as I am inclined to attribute to it, hewould have been supplied with a case not only parallel tothat of "Mr. N.," but even bearing to it, when the age ofthe patient is considered, the relation described by theCockney as subsisting between the mule and the donkey.Betty’s case would have been like Mr. N.’s, only "more so."

I am, Sirs, yours faithfully,June 25th, 1906.

________________

F. R. C. S.

THE EXHIBITION OF HYGIENE INVIENNA.

(FROM OUR VIENNA CORRESPONDENT.)

IN the middle of May there was opened in Vienna anexhibition which contains so many items of interest to themedical profession as well as to the general public that it is

worth while to describe it in a medical journal. The ex-

hibition is held in the usual place for such undertakings inVienna-namely, in the building known as the Rotunda,which was erected in 1873 on the occasion of the World’s

Exposition in honour of the silver wedding of the EmperorFrancis Joseph and the Empress Elizabeth. The managingcommittee has arranged the masses of the various

objects in a very convenient way, enabling the visitorto see at a glance in which of the eight divisions

they are to be found. Of the committee about one-

third are medical men occupying official positions as

directors of hospitals, chairmen of sanitary boards, chiefofficers of health, &c., and the remainder are representativesof the commercial, manufacturing, and wealthy classes.The objects on view in the Rotunda have been classified ineight divisions, three of which are of essentially medicalinterest. The attention of the visitor is at once attractedby a group of objects sent by the city of Vienna. Thisexhibit offers a good opportunity of studying the progressof medical work during the last century. Large modelsof the first general hospital founded by the reigningEmperor in 1792 are here placed in contrast with its

successors-namely, (1) the general hospital as it exists

to-day and (2) the one in course of construction as itwill appear in 1909, when it will be finished. Whilst thefirst contained 300 beds and covered an area of about 8000square yards, the last-mentioned one will contain 2400 bedsand will cover an area exceeding 200,000 square yards. Thenew hospital has been planned on the pavilion system,providing for each clinic all necessary accommodation forscientific research, so that each pavilion may be regarded asa special hospital in itself. The models of a new institutionfor mental diseases and of the lunatic asylum, also built onthe principles of isolation and free access of air, completethis group. Methods of disinfection en masse are alsoshown. For this purpose two systems are in use, one employ-ing steam alone and another based on the production ofdisinfectant gases or vapours, chiefly formaldehyde. For the

disinfection of clothing and hospital beds the first system -is adopted, whilst the municipal authorities employ theformaldehyde method for disinfection of houses or rooms bymeans of an apparatus which contains a large lamp and whenin use emits a jet of mixed steam and formalin. An extra-

ordinarily fine exhibit is that of the Vienna hospitals. In it asurgical ward and an operating theatre fitted with the latestaseptic appliances are shown, and the children’s hospitals havesent representations of their cots and playrooms ; the twonurseries-" how they should be" and" how they shouldnot be "-form an interesting group. The first is fittedwith white enamelled furniture and has no carpet, whilstthe latter, with its dusty carpet, long-haired dolls,and non-washable walls, provides abundant shelter formicrobes. The clinics show many kinds of apparatus andvery instructive tables of statistics, from which it may belearned that the number of out-patients at the hospitals hasexceeded 700,000 in one year, whilst more than 25,000 in-patients occupied the beds of the general hospitals duringthe same period. Quite a novel feature is the use ofcasts (moulages) in teaching. The word 1’,nioulage" isapplied to the lifelike reproduction of visible patho-logical conditions of the body in a material resemblingwax. These casts are made by Dr. Henning, at once

an artist and a medical man, who has brought the

preparation of these absolutely lifelike copies of diseased

parts to a high degree of perfection. The methodcomes from France but it has been developed here and asfar as the aspect of the diseased part is concerned it fullycompensates for the absence of clinical material. Dermatolo-

gists, surgeons, and ophthalmologists already make use of itas a means of instruction and some casts of syphilitic roseolaand of the eruptions of small-pox and scarlet fever conveyeven a better idea of the disease than the actual cases them-selves. The reproduction can be made from any part of theliving body, except, of course, the inside of organs, whilstpost mortem everything short of microscopic changes can bereproduced. The collection of Dr. Henning comprises notonly clinical specimens but also moulages for the use of theAnti-alcohol Society which has its exhibits next to the

hospital group. An instructive collection is to be seen there,comprising moulages of normal organs and of organs diseasedby the action of alcohol, and the changes are quite per-ceptible even to non-medical eyes. Numerous tables, con-taining such particulars as the money spent in drink indifferent countries, the relation between crime and drunken-ness, the prevalence of bodily and mental disease indrunkards, and the comparative mortality of abstainers andnon-abstainers, complete the admirable and very prettilyarranged group.The group which deals with the rendering of first aid in

accidents and in war has a very complete appearance. As

regards the latter, there are three different exhibitors whohave contributed separate groups. First of all the Ministryof War has placed on view a fully equipped hospital train ;the train consists of carriages for the medical attendants andnurses, for kitchen purposes, and for dressing materials;there are also ten carriages, each providing accommodationfor 15 or 20 wounded men. Similar facilities for the con-veyance of wounded men are exhibited by the Red CrossSociety and by the Order of the Knights of Malta; the latterof these two has also erected a field hospital in the form of atent which is capable of being quickly removed in case ofneed. Turning to the first-aid institutions, the exhibit of theVienna Rettungsgesellschaft, or street ambulance corps, thefirst of its kind in every respect, shows that no efforts arespared in maintaining its high position. This institution,which has served as a model to many similar ones, showsambulance vehicles of the latest type, fitted with allappliances for rendering help in cases of accident or

poisoning, as well as vehicles padded inside for the con-

veyance of lunatics. For infectious cases there are carriageswhich can be disinfected by steam. For the relief of thesufferers from a disaster on a great scale, such as an earth-quake, an inundation, or a fire, there is a carriage fitted upas a kitchen, capable of preparing food for nearly 1000 personsin less than three hours. A respiration apparatus supplied withcompressed air for workers in a foul atmosphere is the latestaddition to the stock of life-saving appliances belonging tothe corps. The most attractive feature of the exhibitionis undoubtedly the rescue chamber of a coal-mine whichhas been erected by the Ministry of the Interior. TheAustrian mining laws require such precautionary measures.A narrow passage, closely imitating its prototype in an