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an expectant heir, I should still have turned, but compleredthe labour, having used more oxytocic agents, and dealtwith post-partum haemorrhage as it required. I have justrefreshed my knowledge of this subject by reading Dr.Barnes’s clinical lecture on Placenta Pisevia in THE LANCET,

vol. i., 1861. The third case there related has many points incommon with mine. The woman at 4 was found faintand anaemic from loss of blood; placenta quite over centreof os, which was the size of half-a-crown ; no bleeding andno pains at time of examination; but delivery was urgentfrom exhaustion; so the placenta was detached from thelower zone of the uterus, a bag applied, and the cervix freelyexpanded in about five minutes, but no pains. "I was,however, enabled to pass my hand by the placenta, andreach the membranes, which 1 ruptured with a skewer......head was presenting. A foot was easily seized. I ascertainedthat neither cord nor heart was pulsating......Child ex-

tracted......premature and stillborn. Uterus made to con-tract by pressure......the placenta was speedily cast andwithdrawn. No haemorrhage followed the labour. The

patient recovered well. In this case, had I not possessedthe caoutchouc dilator, I should have been compelled tostretch open the cervix with my fingers at the risk of injury,or to encounter the alternative risk of renewed flooding anda lingering labour, with exhausted uterine power. If theuterus still remain flaccid, and if haemorrhage continue,or generally where the patient is much exhausted, so

that effective muscular contraction cannot be roused,artificial aid is called for in order to accelerate delivery."He then advises version, if the cervix can be easily expanded(as in my case), or, if undilated and rigid, to use the bags.There was no need to dilate either with bags or fingers, andversion was accomplished with the greatest facility andwith a happy result. Would Dr. Barnes have completeddelivery at once, without uterine pains, or would he havewaited? I am. Sirs. vours truly.

B. WALKER.

TERRIER’S NEPHRECTOMY.

To the oy .0/’ THE LANCET. ISiRS,-In your issue ofJune 4th you give a leadingarticle under the above he4, and in referring to a paperin the Revue de Chirurgie} by li. Terrier, speak of themethod as a new one. Two years ago I removed a largediseased kidney by an operation which seems to me essen-tially like the one you describe. After opening the abdomenover the site of the tumour, I incised the visceral peritoneumvertically over the kidney, enucleated the diseased organ,and carefully stitched the edges of the visceral peritoneumto the margin of the wound, thus completely shutting outthe peritoneal cavity from the field of operation, and espe-cially from the cut ureter, the wound being drained to thefront. This operation I have since seen performed by oneof my colleagues. At the time I did not think there wasanything new in the operation, supposing that what seemedto be such an obvious method of shutting out the peritonealcavity and draining the wound must have been followedout by others. It is my intention in my next nephrectomyto perform the operation in an exactly similar manner;but, instead of draining forward, to push a trocar throuuhthe loin, and through the opening so made to pass thedetached ureter, together with a celluloid or some firm

drainage tube, and afterwards to completely close theanterior incision. As the question has now come to thefront, I will take an early opportunity of giving a detailedreport of the case. I am, Sirs, yours truly,

A. W. MAYO ROBSON.

TRANSFUSION.To the Editors of THE LANCET.

SIRs,-In your issue of June 4th, Dr. J. Graham Brownhas pointed out that, in a paper on a case of Trans-fusion which appeared in THE LANCET of April 16th I

erroneously attribute the method there described to Mr.Annandale, whereas it was really introduced by Mr. J. M.Cotterill. I beg to be allowed to thank Dr. Graham Brownfor making the correction, and to at once acknowledge andexpress my regret for the error into which I was led by thefact that the leaflet of instructions furnished by the instru-ment maker with the apparatus described the method as

"Mr. Annandale’s." In reply to a letter of inquiry fromme, Mr. Cotterill has most courteously furnished me with asuccinct statement of the facts of the matter, which I shallesteem it a favour if you will allow me to quote :-

" 1. The fact that phosphate of soda solution preventscoagulation of the blood has been known for many years.2. Dr. Braxton Hicks is reported (Bryant’s Surgery’) tohave suggested its use in transfusion, but whether heactually used it or not I do not know. 3. I performed theoperation, as described in the leaflet, in 1883, and taught itto my class of practical surgery as the best method. 4. Twoyears subsequently Dr. John Duncan, of Edingburgb, per-formed the operation upon my very strong recommendation,and by the same method. He repeated it frequently, andmade some further suggestions, which he published in theBitis7 Medical Journal of Jan. 30th, 188G. 5. Mr. LawsonTait read a paper before the Midland Society on the snbject,

. in which he connected Mr. Annandale’s name with the

. operation. No contradiction of this was made, and it isi probable that he was led into the mistake in the same way! as yourself. 6. Mr. Annandale has authorised me to state, that he has had no connection with the introduction of the, method, though he has performed it upon several occasions."I T am. Sirs. voiir obedient servn,n.t.

WARRINGTON HAWARD.

THE BATH WATERS AND ARSENIOUS ACID.To the Editors of THE LANCET.

SIRS,—In a letter on the above subject, which appeared inyour issue of January 8th this year, I gave expression to thebelief that in the certain discovery of arsenious acid in theBath thermal waters an explanation was obtained of theirbehaviour under certain conditions which hitherto had been

inadequately accounted for. Since then further very carefulexperiments have been made for me by my friend, Mr. Gate-house, with the result that we are in a position to state thata gallon of the waters in question contains as nearly aspossible 1/100 gr. of AS203- Can this amount be held respon-sible in any way for the "marvellous efficacy" of thesewaters in the diseases for which they are extolled? We findthat even in the case of resident patients, in whose curechange of air can have had no share, chlorosis succumbsvery readily to the waters, taken internally. May not thearsenious acid be the cause here ? The amount of ironpresent per gallon is only 1/2 gr.-therefore the ratio of theamount of water that contains an ordinary dose of iron tothe amount that contains an ordinary dose of arsenic is thatof five to four. From this it will be seen that, small as theamount of arsenious acid present may be, the share it takesin the action of the waters is probably great. The amountof arsenic eliminated from the salts of bismuth in thepurifying process is small, but there is a great differencebetween the actions of the purified and unpurified salts.From this it appears that the action of arsenic whenin a natural compound is much more marked than its actionwhen given in a prepared form. I am strongly disposed tothink that certain reagents-among which I would classarsenic-are specially efficacious when administered in theirso-called natural state, as obtains in natural spriygs, bothcold and hot.-I am. Sirs. vours trulv.

T. PAGAN LOWE, M,R.C.S., L R.C.P. Ed.

THE CONTAGIUM OF SCARLET FEVER.To the Editors of THE LANCET.

SIRS,—IN your issue of last week you noticed in an anno-tation the most recent work that has been carried on in

respect to the materies morbi of scarlatina, and, in statingthe general conclusions arrived at in that research, you in-dicated the attitude of guarded reserve in which they mustfor the present be regarded. Dr. Edington’s paper has inthe meantime been printed, and a careful survey of itscontents seems to me to fully justify the spirit in whichyour remarks were made. Attention has already beenfully directed to the observations of Dr. Klein, and theconclusion arrived at by him based on results of the mostunequivocal nature. His conclusion is directly anddiametrically opposed to that now under consideration.The issue thus raised is fortunately a direct and limitedquestion of fact; it is, moreover, satisfactory to findthat Dr. Edington’s statement is sufficiently explicit to

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render it readily susceptible of confirmation or disproof.Amongst many organisms found by him in scarlet feverblood and desquamation, the description of which isa distinct addition to our knowledge of the disease, isa small bacillus 0.4µ in breadth and 1.4µ in length, whichhe describes as the specific virus of the disease. Thisorganism is found in the blood of patients up to the thirdday, and in the desquamation on and after the twenty-firstday: in the intermediate period of eighteen days it cannotbe demonstrated in any of the tissues examined. Obtainedas a pure cultivation in nutrient media it has distinctivespecific characteristics in its mode of growth, and if inocu-lated into calves, guinea-pigs, or rabbits, it produces a diseaseclosely resembling scarlatina, and ending in a desquamativestage. Closely associated with this organism is a micro-coccus form, of frequent occurrence in the blood and desqua-mation, but without pathogenetic effects if inoculated.It is noted, however, that in cases where a vivid andgeneral rash is observed, this organism is a constantconcomitant of the so-called "bacillus scarlatinæ"; and,supposing the observations to be as careful and accurate astheir mode of presentation to the public would lead us toinfer, this point may well call for further investigation, forit must strike everyone at all acquainted with the historyof such researches that the life history ascribed to this" bacillus scarlatinas" is strange and unnatural. A solutionin the continuity of its demonstrable presence extendingover eighteen days is, to say the least of it, a very sus-picious point in its behaviour; and it will necessitate a verystrict scrutiny of the conditions associated with its reap-pearance in the desquamation, to establish its identityin its two manifestations, and to exclude the possibility ofaerial contamination under an aseptic dressing three weeksold. Although there are strong points in its technicalarrangement which commend this research to favourableconsideration, there are some grave omissions in the detailedaccount before me. The bacillus as found in the blood isnot figured, nor are we told whether it is readily demon-strable from its large numbers, or only found in isolatedscarcity, in that medium. Neither is any hint given as tothe manner of its disappearance from the blood. It doesnot appear to have been found in the urine, and althoughspore formation is mentioned, it is neither figured nordescribed. The suggested rationale of its disappearance asdue to an exhaustion of its special pabulum is obviouslybut an obiter dictum. There is also a lack of control experi-ments in regard to organisms normally present in the skin.Until these points are more fully elucidated, it is notpossible to accept this bacillus as the materies morbi ofscarlatina.

In view of the interest at present attaching to the questionof the zymotic origin of the disease, it may not be out ofplace to refer to some of the best known recent publicationswhich have appeared upon the subject. I need not refer tothe statement of Dr. Klein’s results, already detailed inTHE LANCET of May 28th, nor repeat the facts observed byMr. Power, but refer to some prior investigations of whichDr. Klein’s paper affords confirmation, and to which it addsthe conclusiveness they themselves lacked. Coze and Feltz("Maladies Infectieuses," 1872) described a diplococcusin connexion with the disease which they looked on asa causal agent in its production. Pohl-Pincus (Cen-tralblatt f. d. lVled. Wisse2?sc7iaft, 1883) described a similarorganism in the desquamation, on the skin surfaces, and onthose of the palate and pharynx. Crooke (THE LANCET, 1883)described a large bacillus in the last of these situations; butin a subspquent paper from Eberth’s laboratory (Fortschritteder Medicin, 1885), be recounts the results of a long series ofexperiments in which micrococci were found, chiefly in thetissues of the neck, and more rarely in distant internalorgans. He does not appear to have examined theblood in these cases. In a few very severe cases bacillimade their appearance at the end of the second or

the beginning of the third week, but they were not seen inordinary cases, and he does not ascribe any patbogeneticsignificance to their presence. Bokaiof Buda-Pesth ("OrvosiHetilap," 1885) found micrococci single and in chainsin the post-scarlatinal joint affections. A negative resultis recorded by Cornil and Babes (" Les Bacteries," 1885), whoexamined the desquamation for the presence of organisms.The organisms normally present on the human skin are noless important in their relation to the present question ;they are described by Bizzozero (Yircbow’s Archiv Bd. 98iii., 1884), and by Bordoni-Uffreduzzi (Fortschritte der

lledicin, 1886). The latter describes five varieties of micro-cocci and two of bacilli as normally present. His descrip-tion of one of the latter, B. epidermis, so closely resemblesthat given by Edington of his B. scarlatinæ, as to sugoesr,their identity. I remain, Sirs, yours obediently,June 15th. M.D.

THE PRACTICAL ELEMENT IN MEDICALEDUCATION.

To the Editors of THE LANCET.SIRS,—Requiring an assistant lately to help in my surgery,

I engaged a gentleman who said he had been taught prac-tical pharmacy at a large London Hospital. Finding himvery slow in dispensing, I made inquiries. He tells me he

was never allowed to make up a prescription for a patient,or even to compound a stock mixture. He had never madea pill, and did not know how to spread a blister. He was

simply shown the drugs and told to learn their compositionand uses, and for this he had to pay four guineas. He then

goes to the College of Physicians and passes his examinationin materia medica, the chief questions being the actionof the alkaloids on the system, and all this before beingtaught to compound medicine. Sir W. Gull may deprecatedrugs, but the large majority of medical men, as well astheir patients, believe in their efficacy, and what is wantedis to teach the student the real practice of the medical art,such as he will need in his after professional life. I do hopethat the appointment of Dr. Glover’s committee will lead tosome form of the old apprenticeship being made compul-sory. It would be more useful than attending routinelectures, which most students hate and would gladly dis-pense with. I am, Sirs, yours truly,June, 1887. A GENERAL PRACTITIONER.

NORTHERN COUNTIES NOTES.

(From our own Correspondent.)

THE NEWCASTLE EXHIBITION.

LAST week must be considered a most successful one forour Exhibition, as nearly 120,000 visitors went up to theMoor. The weather was very dull on Saturday, buttowards evening it underwent a favourable change, whichhas still continued. An accidental circumstance has givena variety to the throng of excursionists in our city. A fewdays ago the Chinese steamer Toonan came into the Tyne,with nearly 700 "Celestial" sailors on board. They havecome to take charge of some Chinese war ships now fittingup at Sir W. Armstrong’s. These sailors crowd the streets,and create no little curiosity as they go about in theirpicturesque groups.

SUNDERLAND.

Mr. A. E. Harris, medical officer of health for Sunderland,is to be congratulated on the present sanitary condition ofhis borough. During tha past week the death-rate wasonly 15-7, being the lowest point indicated in the list ofthe twenty-eight great towns. The epidemic of measles,which for some time had assumed so alarming an aspect,appears now to be practically suppressed. A few years agoMr. Harris, on his appointment to the borough, found a veryserious state of matters, and the way he had to grapplewith many sanitary abuses before he could effect theirremoval would have tried the patience of many lessdetermined officers. He is now rewarded, however, for hisup-hill work in the present sanitary state of Sunderland.

GATESHEAD.

A letter has been received by the Gateshead Town Councilfrom the Lord Chancellor’s secretary, recommending theappointment of new magistrates. Many of your readerswill be glad to hear that Dr. George Douglass of Gatesheadis included in the list.

HEXHAM.

Lieut.-Colonel Nicholson, who died at his seat, HalliwellDene, Hexham, on Friday night last, in his sixty-eighthyear, was formerly a member of our profession, havingserved his time to the late Dr. Jefferson of Hexham,and on becoming qualified practised for a few yearswith much success in this ancient abbey town, but about