1088 PROFESSOR VIRCHOW ON THE CASE OF THE CROWN PRINCE.

deal from the accurate study of morbid changes. Finally, lethim remind them that pathology, if as yet it had given com-paratively little aid to curative medicine, formed nearly thewhole groundwork of preventive medicine. Learning thecauses of disease in one generation, it aims to anticipate orneutralise those causes in the next, and thus to increase, asit undoubtedly has increased already, the average of humanlife. A pathologist, to attain a high position and to becapable of teaching his science, must practically devote hiswhole time to its study. For what reward ? Not for apecuniary one, for there was no prospect of emoluments tothe pathological teacher, and few of them commenced theirprofessional careerin sufficiently independent circumstancesto be able to devote themselves to a study which promisedno reward but fame. As a consequence, while a knowledgeof pathology was urgently needed by every physician, theopportunities for acquiring that knowledge were almost- completely absent. -

CHILDREN’S HOSPITAL.

Dn. MADDEN desired, he remarked, to show those who wereto be their pupils in the hospital that they were not whollyunreasonable in suggesting another addition to the for-

midable list of lectures that now confronted them as medicalstudents. Of some of these courses they might possibly bepuzzled to discover the utility when once they had passedthrough the examination portals of the profession; but mostassuredly they would then realise the fact, which was nowstrangely ignored by the licensing bodies, that in whateverpart of the world their future practice might be, its successwould be largely influenced by their competence to deal withthe protean diseases peculiar to children. This essentialpractical knowledge of disease, whether in adult or childlife, could only be acquired in one way-namely, by clinical ’,,study, the paramount importance of which was such that itwould be impossible for him to exaggerate its-value, or forthem to devote too much time to its pursuit. No portion oftheir medical training, none of the multitudinous studiesby which they must fit themselves for their profession, couldfor a moment vie with that engaging them in the hospital,to which all other branches of medical education shouldbe made subservient. In dealing with the diseases ofchildren, as they would have to do in their future practice,difficulties would present themselves, and complicationswould arise which no mere book learning could enable themto deal with fitly. In those moments of trial, when humanlife depended on the soundness of their judgment and thepromptitude of their action, they would face the emergencycalmly and act judiciously, in proportion as they wouldavail themselves of the special opportunities afforded themof acquiring such a store of sound clinical knowledge aswould, he sincerely trusted, hereafter make them successfuland justly-honoured ministers of the healing art. Medicalscience had become so widely extended within recent

years that subdivision or specialism was essential to itssuccessful cultivation; and this fact, which was wellTecognised with regard to so many other complaints,applied with special force to the diseases of childhood.In investigating these they would have to study a newsemeiology, to learn a new pathology and new therapeutics.Their old means of investigating disease would here to agreat degree fail them, and they would feel almost as if theyhad to learn their alphabet, or as if, entering a country whoseinhabitants they expected to find speaking the same

language and having the same manners as the people in theland they had lately left, they were to hear around themeverywhere the sounds of a foreign tongue, and to observemanners and customs such as they had never seen before.Dr. Madden concluded by impressing the importance ofacquiring a sound practical knowledge of the maladies ofchildren by diligent clinical study of those living pages of,disease now open to them in that hospital.

MEATH HOSPITAL.

DR. FOOT began his address by suggesting to the students,as worthy of adoption and incorporation into the essence oftheir daily life, the principles of earnestness, industry, andperseverance. He urged on their attention the paramount,claims of opportunity. Never again would such a combina-tion of advantages be at their command as they had now,

while their attention was sharpened by curiosity, theirpowers of observation keen, their memories tenacious, theirduties novel, and their responsibilities light. In theiryouth all possibilities lay, and nothing was for them as yetirrevocable. The necessity for and the best means of cul-tivating the faculty of observation were dwelt on, and thelives and results of the life work of Bright, Addison, andLaennec were quoted to show that the task of clinicalobservation must be begun early and perseveringly followed.As the ultimate end and reward to be looked forward to ascompensation for their toil and self-sacrifice, he suggestedthat of 11 excellence in their profession." This would in-clude and cover all they could possibly hope for or expect.This was the seventh time on which he had addressed themin the same strain, and in the sixteen years that had passedsince he had first done so he had seen, heard, or learnednothing to shake his faith in the correctness of the principleslaid down on each occasion. It was difficult to enhance withany new and memorable charm of presentment truisms nowvenerable from their antiquity, but the prizes of life and howthey were to be attained were questions which knocked foranswer at the hearts of each successive race of students.The answer was, these prizes were only to be obtained byearnestness, industry, and perseverance, dominated by aworthy aim-excellence, irrespective of pecuniary reward.

PROFESSOR VIRCHOW ON THE CASE OF THECROWN PRINCE.

AT the meeting of the Berlin Medical Society on Nov. 16th(of which a full report is given in the Berlin. Klin. Wock.,No. 47, and of which the following is an abstract), Prof.Virchow asked permission to make a statement respectinghis reports upon the microscopical examinations of the por-tions of new growth which had been removed by Sir MorellMackenzie from the larynx of His Imperial Highnessthe Crown Prince. It had been publicly stated that thesereports had influenced the line of treatment adopted, and asPresident of that Society he felt it incumbent upon him tomeet the attacks which had been made upon him on this

ground. It was far from his intention to discuss the case,for it would be unbecoming to do so at a time when theywere all filled with anxiety and dsquiet at the recent

intelligence concerning it; he only desired to explain thecircumstances under which his reports were made, andto place the position he held in the matter in a clear light.He had informed Drs. von Bergmann and Gerhardt of hisintention, and they wished him to say that in their capacityas surgeons in charge they did not desire to make any state-ment at the present time, nor that any discussion shouldensue upon what would be a purely personal explanation.Professor Vircho w then related how on May 21st Dr. Wegnerbrought him a small portion of tissue which had been excisedfor the purpose of microscopical examination. The frag-ment was so small that it was entirely examined, and thereport was not published simply because it dealt with sominute a portion as to be of no value. The otherreports were published by command of the CrownPrince, and were known to all. This report of May 21ststates that the preparation consisted of a fragment ofthe surface of the mucous membrane, with, at one spot,some irregular bundles of submucous tissue. In no partwere there in the deeper layers of the mucosa any elementsforeign to that tissue, the only abnormality being an in-crease of nuclei and vascular papillae on the surface. Theepithelium was much developed, and its cells containednuclei in process of division; in some places there werenests of epithelial cells. At one spot there was markedepithelial proliferation, the cells being enlarged, cloudy,in part containing vacuoles and enclosing cells. Nothingwas found inconsistent with the characters of a simpleinflammatory process. After the report was sent in, Dr.Gerhardt examined the preparation with Professor Virchow,and was satisfied that the ‘° nests " of epithelial cells were

only found in the superficial layer. It is now generallyadmitted that these nests-which thirty years ago wereheld to be distinctive of cancroid-occur in the most variousand benign epithelial formations. Professor Virchow thenread the next report (June 9th), which has already been

1089MEDICAL ATTENDANCE ORGANISATION COMMITTEE.

published,! and with respect to it he pointed out that hehad expressly stated that an opinion on the nature of thewhole disease could not be given from an examination limitedto the excised portions. He could only frame his judg-ment upon what he himself examined, and he could notjustly have expressed the opinion that it was still pos-sible that a cancer existed. Such a possibility was

not excluded by the terms of his report, for he had expresslyaffirmed that he only reported upon what was sent to him.At no time was he in a position from personal observationto gain any knowledge of the condition. He had notseen His Imperial Highness since the end of the winter,and at that time he was suffering from considerablehoarseness. His third report was dated July Ist,2 and thisconfirmed the previous examination-viz., that it was a simplehard wart. But the portion excised was so superficial thatno further opinion could be formed as to the condition ofthe deeper parts. He had expressed a wish for a detailedaccount and drawing of the precise relative position ofthe four fragments, and learnt that the first portionhad been removed from the left vocal cord, and thelast from the posterior third of the upper surface ofthe same cord. As to the other two portions, the nature of thesubjacent tissue made it probable that they occupied theposterior third, probably to the right of the arytenoidcartilage; so that all the growths had probably been removedfrom the same region. At this time they learnt from Englishand German journals that Sir Morell Mackenzie had placedthe responsibility of the diagnosis upon himself (ProfessorVirchow). He had kept silent, although he could indeedsay that he was often very impatient, for he well knew theactual value which the English laryngologist would placeon such a diagnosis.3 During all this time he had (notspoken to Sir M. Mackenzie, nor communicated with himby letter. Then came the authoritative reports that themorbid growths had been entirely removed, and that asmall swelling which occurred had receded. It was re-peatedly stated that no new outgrowths appeared atthe seat of operation, and that is probably so. For, asDr. Schmidt personally assured him (Professor Virchow), theleft vocal cord is now not affected by the disease, which isdescribed in the official report as in the hypoglottic region-how far or near to the cord Professor Virchow could not say.It seems, then, there has been no recurrence in loco, and thatthe clinical course of the case also rendered it impossiblethat the portions he examined were portions of cancer, ifsuch had been present. He could not enter on the generalquestion as to the conclusions upon the nature of the diseaseto be drawn from the examination of excised fragments, butcould only say that he has since examined many specimensof laryngeal cancer in museums, and has not found one inwhich there were neighbouring warty growths quite inde-pendent of the cancer. He had never expressed the opinionthat no other part of the larynx would become affected, butif, after the lapse of months, there had been no appearanceof disease elsewhere the prognosis would have been muchmore favourable than is now unhappily the case.

MEDICAL ATTENDANCE ORGANISATIONCOMMITTEE.

A CONFERENCE was convened by the above committee atthe Society of Arts on Nov. 22nd, at 4 P.M., to discuss ascheme which they had prepared to secure co-operationbetween the general metropolitan hospitals and providentdispensaries, and to establish more institutions of the latterclass, to be supported by small periodical payments. Therewere present a large number of ladies and gentlemenwho were representatives of metropolitan hospitals, or hadpublicly interested themselves in the question of supplyingmedical aid to the poor.

1 See THE LANCET, vol. i. 1887, p. 1302. 2 Ibid., vol. ii. 1887, p. 133.3 Vide Morell Mackenzie: Growths in the Larynx, p. 36. (London,

1871):—"Malignant growths: It is not always easy to distinguish be-tween benign and malignant laryngeal growths; the latter, however,are diagnosed by being thoroughly blended with the surrounding tissue,by being very frequently ulcerated, and by the constitutional historyand symptoms of the patient. In these eases, should particles be expec-torated or removed during life, with the aid of the laryngoscope, themicroscope cannot be relied on for differential diagnosis. Several cases havecome under my notice where the histological features were decidedlychose of cancer, whilst the clinical history was of a totally oppositecharacter, and vice versâ."

Sir SPENCER WELLS, who presided, in the course of hisremarks referred to the desirability of forming some kindof union between the various hospitals and dispensaries ofthe metropolis. The result of the labours of the committeeduring the past year had been embodied in a series ofresolutions which ran as follows :-That the governing bodies of the metropolitan hospitals be requested

to co-operate with provident dispensaries, recognised by the MetropolitanProvident Medical Association, on the following conditions :-Thatapplicants for co-operation are bo2tdfide provident dispensaries for supply-ing medical aid to the industrial classes, and managed by a responsiblecommittee. That such dispensaries shall in the main be conducted inconformity with the scheme of the Medical Attendance OrganisationCommittee. That no pecuniary liability, apart from their own normalexpenditure, be incurred by the hospitals in consequence of this con-nexion, and that either party be at liberty to terminate the arrangementat any time, with such notice as may be agreed upon. That the objectsof such co-operation shall be as follows :-

1. Suitable Members of Provident Dispensaries to be referred to Hospitals.-That the medical officers of these provident dispensaries be entitled tosend cases to hospitals for consultative advice or treatment; and thatpriority be given to patients who bring a form approved by thehospitals, and issued by the Metropolitan Provident Medical Association.That the physicians or surgeons of the hospital shall be at liberty, withthe patient’s consent, to retain for hospital treatment any case ofclinical interest thus sent to the hospital.

2. Limztation of the Number of Out-patients.—That the number of out-patients received each day and the hours for seeing them be limited, sothat not more patients be received than can be deliberately attended bythe stated officers of the hospital (and used for clinical instruction inhospitals having schools attached), and also that the present abuse ofkeeping patients waiting for a great part of the day be reformed. Thatthe " casualty department " be strictly limited to accidents and streetemergencies, and that only accident cases attend more than once. Thatin the interests of hospitals, provident dispensaries, and of the poorthemselves, it is desirable that an agent, well trained, and thoroughlyconversant with the locality, rates of wages, &c., be employed at

general hospitals and free dispensaries to fulfil the following duties :-(a) To ascertain whether the patients should receive advice and treat-ment gratuitously; (b) to make inquiries and investigation on the plannow in force at the "London" Hospital.

3. Ineligible tippliccznts for Medical Belief at Hospitals to be referred to,Provident Dispensaries.-That the committees of hospitals, in co-opera-tion with provident dispensaries, be asked to recommend to applicantsfor out-patients’ treatment, who are priind facie able to make thenecessary provident payments, that they should become membersof the dispensaries, with the assurance that if they should needspecial or hospital treatment, they would be recommended by themedical officers of the dispensaries to the hospitals for that pur-pose, and be received by them. That notices, giving particulars ofthe provident dispensaries in co-operation with the hospitals, be placedin their out-patients’ waiting rooms. That this proposal be adopted, onthe understanding that all patients, whose cases are prinzd facie urgent,are eligible for first treatment, and also that those cases which arevouched for by the physicians or surgeons as of special interest beretained for hospital treatment.

4. Students to be permitted to make use of Provident Dispensaries for theStudy of Common Disease.-That students of hospitals be permitted, undersuitable regulations, to attend the practice of provident dispensaries inco-operation with their hospitals, when the medical officers see or visittheir patients.He invited those present to join in the discussion on theplan, and for the convenience of the meeting resolutionswould be proposed, which could be discussed in detail.

Mr. W. BousFIELD moved: " That the scheme of theMedical Attendance Organisation Committee for co-opera-tion between hospitals and provident dispensaries be

accepted as a basis of negotiation." He said that at thehospitals many were treated who could afford to pay, andthe out-patient departments were for the most part over-crowded and needed reforming. The Metropolitan ProvidentAssociation, which was formed in 1881, had been appreciatedby the poor, but its progress had been slow from two causes:general practitioners had not supported it on the groundthat people who could afford to pay were admitted aspatients, and because no check had been put on the numberof out-patients admitted to hospitals. Under the newscheme minor ailments would be treated at dispensaries, and,should need for consultative opinion arise, they could betransferred to the hospital.

Dr. GILBART SMITH, in seconding the motion, thoughtthat the scheme would neither harm the hospitals nor

deprive the really necessitous and deserving poor of themeans of relief which were now open to them.The Rev. Dr. WACE (King’s College) proposed as a modifi-

cation of the resolution, " That the scheme of the MedicalAttendance Organisation Committee for co-operation betweenhospitals and provident dispensaries be referred to a com-mittee composed of hospital representatives and of membersof the Medical Attendance Organisation Committee fortheir consideration, and that the committee be requestedto bring the scheme, when settled by them, before thegoverning bodies of their respective hospitals." This wasseconded by Mr. Holmes.

After further discussion, in which Dr. Alfred Carpenter,Colonel Francis Haygarth, Mr. Jabez Hogg, the Hon. Conrad