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cases in which articular rheumatism was noted, besidesother 11 cases in which there was some cardiac affection of arheumatic nature. This makes a total of 64 cases, or

734 per cent. The cases labeled "endocarditis " in thefollowing table do not include more than a fractionof the instances of distinct cardiac murmur, but onlycases where a distinct murmur persisted for a longtime-in most cases as long as the patient was underobservation. Besides, in a large proportion of the casesthe murmur or its louder development coincides withthe rise of temperature and preceded the articular pains : apoint, by-the-bye, to which Dr. Hodges does not refer, thoughI have no doubt he must have frequently observed it, andwhich still further increases the resemblance between ordi-

nary and so-called scarlatinal rheumatism. One of thecases occurred as late as the eighth week, when a childaged six was running about ready for dismissal. She wasobserved to be feverish, and the temperature proved to be1006° F. A ventricular systolic murmur was found thatevening, but nothing else (a slight ventricular systolic murmurhad been present in the earlier weeks of illness, but badpassed away). The next morning there was pain with effu-sion into the right knee-joint. It was a slight case, butwhen dismissed the murmur was still present. In two casesof erythema nodosum the same course of events took place :first, the eruption, then the cardiac and lastly the jointimplication. The rheumatic condition most frequently madeits appearance towards the end of the first week in my cases,though the period of its appearance was very varied.

Comparative Frequency of the Manifestations of theRheumatic Condition.

1. Articular rheumatism ......... 53 cases 2. Endocarditis .................. 21 In 26 of these cases3. Pericarditis .................. 9 " I articular rheuma-4. Pleurisy ..................... 5 ,, ’. tismonlywasnoted,5. Chorea, peripheral neuritis, &c.... 5 "

and no other com-6. Erythema nodosum ............ 2 ., I plication or even

7. Phlebitis ..................... 1 " ) persistent murmur.

8. Urticaria ..................... 1 "

As regards the relation of rheumatism to the severity ofthe scarlet fever, 12 cases were associated with " badscarlet fever " (some of these were malignant cases, others"scarlatina anginosa ") ; but it does not appear that there isany very close connexion between them. The rheumatismin 5 cases was a direct danger to life and in the 37deaths in the whole series 2 were due to the rheumaticcondition. In one, a child aged six, in which the kidney con-dition largely shared the responsibility for the death, therewere pleurisy and pericarditis with effusion and very severearticular pain, and it was most noticeable how the kidneycondition seemed to be aggravated by the use of the salicylateof soda, though it alone seemed to relieve the pain. Theother death was due to pleurisy in a young adult after anattack of scarlet fever of a severe type. In no case did sup-purative arthritis follow rheumatism, but there were 4 cases inwhich there was a pyasmic condition with suppurative arthritis.Three of these had gangrenous conditions of the throat, andthe fourth was sent into hospital after a double osteotomy,and was in an undoubtedly septic condition. Two cases ofchorea antedated the scarlet fever, and in neither was therea history of previous rheumatism obtainable. One case ofendocarditis with pericarditis had, before his pericarditisdeveloped, a very marked phlebitis, the veins of the rightleg and left arm being beautifully mapped out. And amongstthose in whom the endothelial mischief was prominent wasa child aged six, who clinically presented all the features ofulcerative endocarditis with beautiful ague-like attacks, buthe recovered, so the diagnosis was not confirmed post mortem.Children seem to suffer more frequently, but on the wholeless severely, than adults, and in them chiefly the wrists andhands were affected. My notes do not admit of my givingthe percentage of frequency at different ages.

J nm. Sirs. vonrR faithfully.

W.A. PARKER, M.B.,Pathologist, County Asylum, Lancaster.

"CERTIFYING UNDER THE LUNACY ACTS."To the Editors of THE LANCET.

SIRS,—In THE LANCET of Nov. 14th "Lex" asks whetherthe Commissioners in Lunacy can be supposed to "interviewall patients "-all private patients, that is. From a some-what large experience of these visitors I certainly believethey do. I I Lex seems unaware that all certificates are

carefully read as they are returned to Whitehall by the Com-missioners personally, many are sent back for further in-

quiries, and a list is kept of all mild cases and of cases appa-rently due to transient causes, such as alcohol, opium, and soforth. The correspondence in all cases and letters from patientsthemselves seeming to need inquiry, are entrusted to the-respective Commissioners on their visitations, and I have con-stantly seen these papers produced and considered on the visit.I have never known a new or recent case not formally inter-viewed, and whenever, on being questioned. a patient seemsdisposed to converse a private interview is offered, and is often,of course, accepted. The visits are made leisurely, and theCommissioners seem very well able to remember all the moreintelligent inmates personally, and generally to rememberthem even by name only, in conversation with the medicalofficers. Finally, I may say that the number of patients.dismissed within a day or two of admission is considerable,though, of course, I can give no estimate of the number.In such cases there has usually been some temporary insanitywhich has as quickly passed away-rarely, I think, a falsediagnosis. I am, Sirs, yours faithfully,

--

Nov. 28th. R.V.

PROPOSED ASSOCIATION OF ASSISTANTSAND LOCUM TENENTES.

To the Editors of THE LANCET.

SIRS,-It has struck me that it would be very desirable toform an Association of Assistants and Locum Tenentes to-look after and uphold their mutual interests and welfare inrelation to principals, as well as to afEord mutual help andprotection in cases of sickness or want, or the unprincipledbehaviour of those on whom they have to depend for a sub-sistence, and I feel quite sure you will lend all the assistancein your power towards so laudable an object, since manygood men and true have to spend years of their lives in

doing the drudgery of the profession, and have to submit to-many grievances at the hands of bad or indifferent prin-cipals - and there are such about, unfortunately - which,were they united, they could readily rectify. I hope, there-fore, you will allow me space in your important columns to.broach the subject to assistants and locum tenentes in general,including all holding junior or assistant appointments,throughout the United Kingdom, in order that all in favourof, and both willing to join and to support, such an associa-tion, may, in the first place, send in their names to you, to-see whether the idea meets with adequate support or not; so>

that if it does, as it ought to do, preliminary steps may b&

taken towards the formation of the association, and syste-matic expressions of opinion invited both as to the formsuch association shall take and to the specific objects it isdesirable to take in hand, &c. All that is required in the first-instance, then, is that all willing to join in such an associa-tion should send in their names and addresses to you on post-cards, and if you judge from their numbers that the idea:meets with adequate support I will subsequently submitdetails and offer my services towards the organisation ofthe same ; but for the presentI I remain, Sirs, yours truly,

Nov. 16th, 1894. AN ASSISTANT.

*,* We do not underrate the possible value of such an.association to a very useful division of the profession, but w&cannot undertake to judge whether our correspondent’s idea.will meet with adequate support.-ED. L.

MANCHESTER.

(FROM OUR OWN CORRESPONDENT.)

Medical Guild.As the outcome of a paper read by Dr. Stewart of

Pendleton, in February last, at a meeting of the Medico-Ethical Association, on the Working of the Provident Dis-pensaries, in which he suggested the formation of a medical’guild, a committee was appointed, subsequently severalmeetings of the local profession were held, and the medicalguild has become an accomplished fact. As yet it is, ofcourse, in an infantile stage, but growing. Its object is toaim at the organisation of the profession in order to secureunited action and the cooperation of all for the common

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good. It was originally intended to provide also "medicalattendance for the poor and for such of the workingclasses as are not able to pay ordinary fees " ; butåt has so far been found difficult to devise a schemesatisfactory to all, and this matter is for the presentin abeyance. The provident dispensary system is extremelyunpopular with the general practitioners, especially inthe districts chiefly peopled by artieans, small shopkeepers,.and publicans. The touting for patients and advertisingcarried on by the distribution of handbills broadcast is heldto be a discreditable and unfair mode of competition. It is

only just to say that the medical staff is not often, if ever,directly responsible, and in some instances has protestedagainst it. Then, too, the private dispensaries and the six-penny doctors are not looked on as elevating the profession,.and efforts will be made to raise the status and self-respectof these practitioners. How these various and difficultproblems can be dealt with remains to be seen.

Hospital for Incurables.The annual meeting was held on the 22nd inst., and it was

stated that though the hospital, like most charities, "hadsuffered from the continued depression in trade and hadexperienced a somewhat serious loss from subscriptions, thereport, with that one exception, would be found emi-

nently satisfactory." The general administration of thehomes had been excellent and the patients had beenwell cared for ; .f:2050 had been received in legaciesAnd ;6310 10s. towards a pension fund. The total re-

ceipts had been £7045, and the payments, includingthe foregoing £310 to pension fund suspense account,£7444, leaving a balance due to the bank of .6398, being anincrease of .6310 owing to that amount. From the HospitalSunday Fund they received £727. At the end of last year108 patients were in the homes, and since then nine were.admitted to Mauldeth and three to Walmersley. Owing todeaths there were the same number (108) in the homes on0ct. 31st. One of the speakers explained that the out-

pension scheme was to assist cases with some means of theirown to find a home outside the institution. In cases not

totally helpless it would be a valuable development of thework of the hospital. Mauldeth is a few miles out ofManchester, and was once the residence of James Prince Lee,the first Bishop of Manchester, who was succeeded by the.much lamented Bishop Fraser. It is pleasantly situated andwell adapted for its present purpose. Walmersley is nearBolton, and the cases sent there are chiefly those which,though admitted as incurable, show some indications ofpossible amendment.

Hospital Saturday and Sunday Fund.The twenty-fifth annual meeting was held in the Town Hall

last week. The honorary secretary said that up to June 30ththe amount received was £7882. Last year it was .67887, butof,24 13s. had been received since, so this year’s receipts were£19 8s. more than those of 1893. For the last few years the’amount collected at the churches and chapels has gradually,though almost imperceptibly, diminished, while the Saturdayliund has steadily increased. It would be interesting toknow if this has arisen from the trade depression tellingmore on the middle than on the working classes. Sinceits establishment in 1870 the fund has yielded .f:187.676to the medical charities of Manchester and Salford.A resolution was unanimously passed expressing regret atthe retirement of the honorary secretary, the Rev. JohnHenn, and testifying to the great value of his services tothe community in starting the Hospital Sunday movementtwenty-five years ago, &0. Mr. Henn made an interestingTeply, sketching the history of the fund. He "invited to a

meeting the leading representatives of all the denominations.of religious bodies, gave them his views of the necessities’then pressing on the community, and how he thought theycnight be met. This was in January, 1870, and the result-was the establishment of Hospital Sunday and the firstcollections made the following month resulted in the noble,contribution of .65540. This mode of raising funds forinstitutions which were necessary to the community wasspeedily copied, not only in this country but in almost everylpart of the English-speaking world." Mr. Henn remains amember of the committee. It seems fitting that his name,,should be remembered by the medical profession, and still,more by those who have been directly benefited by the actionhe took a quarter of a century ago.

Manchester Royal Infirmary.The removing of patients to the meetings of the medical

societies for purposes of demonstration has of late been

strongly opposed by one member, but has no w been sanctionedby the lay board, subject to proper regulations. An eightweeks’ course of post-graduate lectures is to be given in theinfirmary wards in the afternoons during the months ofJune and July. There will be two lectures a week, onemedical and one surgical.Nov. 27th.

_______________

NORTHERN COUNTIES NOTES.(FROM OUR OWN CORRESPONDENT.)

The University of Durham.DR. KITCHEN, the new Dean of Durham. issued the usual

notices calling Convocation together on Nov. llth forthe purpose of, amongst other business. affixing the seal ofthe University "to a petition to Her Majesty the Queen fora supplementary charter to enabie the University to conferdegrees upon women and to hold convocations elsewherethan in Darham." The latter clause will enable medicalstudents who pass their examinations in Newcastle to receivedegrees there, instead of being, as hitherto, compelled tocome to Durham for that purpose.

Tynemouth Infirmary.At the annual meeting of the Tynemouth Infirmary it was

stated that the income had been well within the expenditureand that one-half of the voluntary contributions had beengiven by the working men of the borough.

Death of Mr. MacCalloch of Abbey Town, Cumberland.Much regret is felt in Holme-Cultram at the unexpected

death of Mr. MacCulloch of Abbey Town. He was for anumber of years medical officer of health of the urban sani-tary district of Holme-Cultram and medical officer of theBowness district in the Wigton Union.

The lees Floating Hospital.Much interest was shown in a paper read by Mr. Stain-

thorpe last week at Middlesbrough, before a meeting of thecounty engineers, describing the floating hospital now at theTees mouth, and which is unique of its kind. The hospitalwas floated on ten huge cylinders, each 86 ft. long by 6 ft. indiameter, and provided the usual wards, and the adminis-trative department was fully and well arranged separately. A

300-gallon cistern provided the fresh water-supply, and hotand cold water had been freely laid into the wards. Greatcare had been taken to secure thorough ventilation by doublesashes and Kites’ fresh inlet ventilators. About 60,000seamen entered the Tees every year from all parts of theglobe, so that this hospital was a necessity. It was floating inan artificial bay with a strong breakwater to protect it fromthe north-east winds. Its cost was £10,000.

Death of Dr. Walker of Redear.I regret to note the death of Dr. Walker of Redcar, which

took place last Friday at his residence, Coatham. He hasleft a widow, but no family.Newcastle-on-Tyne, Nov. 28th.

SCOTLAND.(FROM OUR OWN CORRESPONDENTS.)

Edinburgh Royal Infirmary.IN the financial statement submitted by the treasurer to

the managers of the Royal Infirmary the total income wasshown to be .629,686 Os. 5d., being a decrease of f:1083 4s.10d.as compared with the previous year. There was a decreaseof f:937 in subscriptions and of £428 in students’ fees. The

extraordinary receipts amounted to E22,376, compared with£14,618 for the preceding year. The weak point in thefinances of the infirmary is the comparatively small contribu-tions made from some of the counties. The infirmary is opento all sick persons, and patients attend and are admittedfrom all parts of Scotland and the north of England. Duringthe past year, for instance, fifty-four patients from Inverness-shire were treated, and the contributions from that countyonly amounted to £6 14s. 6d. or 2s. 6d. a head.

The Oetober Examinations at Edinburgh University.The statistics of these examinations have now been pub-

lished, and the results show that the total number of first