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from diarrhoea, four from measles, four from whooping-cough, and one each from scarlet fever and diphtheria, butnot one either from "fever" or small-pox. The five deathsattributed to diarrhoea only exceeded the number in the

previous week by one, but the fatal cases both of measlesand whooping-cough showed a marked increase. The 133deaths at all ages included 23 of infants under one year ofage and 31 of persons aged upwards of 60 years ; the deathsof elderly persons showed an increase. Eight inquest Icases and five deaths from violence were registered i

during the week; and 46, or 34’6 per cent., of thedeaths occurred in public institutions. The causes of allbut one of the deaths registered in the city last week wereduly certified, showing a proportion of but 0 - 8 per cent. ;in London the causes of all the 957 deaths were duly Icertified, while in Edinburgh the proportion of uncertified ]causes of death was equal to 6 - 5 per cent. ,

THE SERVICES.

ROYAL NAVY MEDICAL SERVICE.THE following appointments are notified :-Fleet-Surgeons :

H. W. G. Doyne to the President, additional, temporary, andC. L. W. Bunton to the Carnarvon, on recommissioning.Staff-Surgeons : M. P. Jones to the Topaze ; M. C. Langfordto the Devonshire, on commissioning ; M. Cameron to theAttentive, on recommissioning; F. J. L. P. McKenna to theLeander. Surgeons : J. J. H. Rooney to the Vivid, addi-tional, for disposal; C. F. Bainbridge to the Devonshire,and A. V. J. Richardson to the Hampshire, both on recom-missioning ; F. G. H. R. Black to the Carnarvon, on recom-missioning.

ROYAL ARMY MEDICAL CORPS.The following is a list given in the order of seniority of

officers on the Indian establishment who will be tour expiredduring the trooping season of 1909-10 :-Lieutenant-Colonels:F. P. Nichols, F. J. Jackson, W. Pike, E. H. L. Lynden-Bell, J. R. Stuart, G. Wilson, W. C. Beevor, S. F. Freyer,J. R. Forrest, H. A. Haines, G. E. Hale, D.S.O., W. T.Swan, C. T. Blackwell, P. C. H. Gordon, H. D. Rowan,H. Cocks, F. W. G. Gordon-Hall, A. Kennedy, H. P. C.

Elkington, H. M. Adamson, A. R. Aldridge, D. M.

O’Callaghan, R. Holyoake, F. S. Lequesne, V.C., andA. L. F. Bate. Majors: E. A. Burnside, B. J. Inniss, R. C.Thacker, A. J. Luther, H. E. Winter, J. W. Jennings,D.S.O., C. Dalton, C. W. Duggan, T. McDermott,H. W. K. Read, J. B. Anderson, E. S. Clark, K. M.Cameron, M. Boyle, F. Kiddle, J. Grech St. J. B. Killery,G. T. K. Maurice, W. E. Hudleston, and M. McG. Rattray;Captains : C. H. Hopkins, J. G. Berne, G. B. Carter, S. 0.Hall, J. H. Brunskill, A. J. Hull, A. B. Smallman, W. F.Ellis, S. M. W. Meadows, T. E. Harty, B. G. Patch, D. P.Watson, J. E. Powell, F. M. M. Ommaney, R. H. MacNicol,S. L. Pallant, C. R. Sylvester-Bradley, J. D. Richmond,M. C. Wetherell, H. C. Hildreth, W. MacD. Macdowall,R. T. Collins, T. J. Wright, A. C. Osburn, F. J. Turner,J. Fairbairn, J. H. Douglass, R. R. Lewis, A. L. Otway,F. H. Noke, W. F. H. Vaughan, R. B. Hole, T. C. Lucas,G. E. Cathcart, W. Wiley, H. Harding, J. A. Turnbull,M. F. Grant, M. D. Ahern, F. J. Garland, A. A. Meaden,S. C. Bowle, and A. S. Arthur.

Lieutenant-Colonel Samuel F. Freyer, C.M.G., retires onretired pay (dated August 4th, 1909). Lieutenant Harry R.Edwards, from the Seconded List, is restored to the establish-ment (dated July 30th, 1909).

TERRITORIAL FORCE.

Royal Garrison Artilltry.Glamorgan: The undermentioned officers from the 2nd

Glamorganshire Royal Garrison Artillery (Volunteers) are

appointed to the unit, with rank and precedence as in theVolunteer Force (dated April lst, 1908): Surgeon-MajorJohn Lynn Thomas, C.B., Surgeon-Captain Robert JohnRichard Cobden Simons, Surgeon-Captain Charles OctaviusParsons.

Royal Army Medical Corps.6th London Field Ambulance : Henry King Dawson to be

Lieutenant (dated July 6th, 1909).For Attachment to Units other than Medical Untts.-

Captain William Starbuck Griffith, from the Sanitary

Service, to be Captain (dated March 1st, 1909). William’

Evelyn Alston to be Lieutenant (dated July lst, 1909).The appointment to a Lieutenancy of William Henry Newtonbears date Feb. 21st, 1909.Attached to Units other than Medical Units.-Lieutenant

Alfred L. Low resigns his commission (dated March 31st,1909). Captain Alexander P. Swanson to be Major (dated’Nov. 23rd, 1908). Captain Martin A. Cooke to be Major(dated June 20th, 1908). Ivan Cochrane Keir (late Lieu-tenant, 4th Battalion, The Duke of Edinburgh’s (Wiltshire-Regiment) ), to be Lieutenant (dated July 1st, 1909).

ROYAL ARMY MEDICAL CORPS EXAMINATIONS.

The following are the successful candidates for commis-sions in the Royal Army Medical Corps at the recent exami-nation in London, for which 54 candidates entered :-

Marks,G. H. Dive, St. Bartholomew’s Hospital, M.R.C.S., L.E.C.P.... 632L. C. Hayes, Birmingham University, L.R.C.P.Lond., M.B.

Birm............................ 597-&B. G. Goodwin, Birmingham University, M.R.C.S., L.R.C.P.... 584A. S. Cane, Cambridge University and St. Bartholomew’s

Hospital, M.R.C.S., L.R.C.P................ 563T. H. Dickson, Edinburgh University, M.B., B.Ch. Edin.... 547K. Comyn, Cambridge University and King’s College Hospital,

M.R.C.S., L.R.C.P., B.C. Camb........ 542F. R. Laing, Edinburgh University, M.B., B.Ch. Edin....... 539A. G. Jones, Guy’s Hospital, M.R.C.S., L.R.C.P., M.B.,

B.S. Lond......................... 536J. M. Weddell, Cambridge University, M.R.C.S., L.R.C.P. 535P. C. Field, Bristol and Guy’s Hospital, M.R.C.S., L.R.C.P.... 528V. P. Hutchinson, Guy’s Hospital, M.R.C.S., L.E.C.P...... 518’5T. W. Stallybrass, Newcastle-on-Tyne, M.B., B.S. Durh.... 514’5H. G. Robertson, Glasgow University, M.B , B.Ch...... 513’5R. C. G. M. Kinkead, Queen’s College, Galway, M.B., B.Ch.

}R.U.I.... 511C. M. Nicol, Glasgow University, M.B., B.Ch.......... 511H. V. Stanley, Trinity College, Dublin, M.B., B.Ch.E. C. Stoney, Sir P. H. Dun’s Hospital, M.B., B.Ch....... 510-5A. P. O’Connor, Catholic University, M.B., B.Ch. R.U.I.... 507’5R. N. Davies, Durham University, M.B., B.S.......... 506R. Gale, Glasgow University, M.B., B.Ch............. 505

INDIAN MEDICAL SERVICE EXAMINATIONS.The competitive examination for commissions in the

Indian Medical Service was held on July 26th, 27th, 28th,29th, 30th, and 31st, for which 48 candidates presentedthemselves for 21 vacancies. The subjects of the examina-tion were medicine and therapeutics, surgery and eyediseases, pathology and bacteriology, surgical anatomy, phy-siology, midwifery and diseases of women and children,pharmacology, and toxicology. The following is a list of thesuccessful candidates. The aggregate of marks was 5100.

Marks.Charles Harold Smith, Liverpool University, M.D., Ch.B.,

F.R.C.S. Eng., L.R.C.P. Lond ............. ’... 3997Alan MacDonald Dick, Edinburgh University, M.B., Ch.B.,

L.R.C.P., M.R.C.S...................... 3740Thomas John Carey Evans, University College, Cardiff, and

St. Mungo’s College, Glasgow, L.R.C.P., M.R.C.S.,M.D. Brux......................... 373’5

Robert Inglis Binning, Glasgow University, M.B., Ch.B.... 3712Maurice James Holgate, St. Bartholomew’s Hospital, M.B.,

B.S. Lond., L.RC.P., M. R. C. S................ 3512,John McDougall Eckstein, St. Bartholomew’s Hospital, L.R.C.P.,

M.R.C.S............................ 3503Trevor Laurence Bomford, St. Bartholomew’s Hospital, M.B.,

B.S.Lond., L.R.C.P., M.R.C.S................ 3471William Andrew Morton Jack, St. Thomas’s Hospital, M.B.,

B.S. Lond., L.R.C.P., M.R.C.S................ 3433Graham Rigby Lynn, St. Bartholomew’s Hospital, M.B.,

B.S. Lond......................... 3412Louis Hope Lovat Mackenzie, Cambridge University and St.Thomas’s Hospital, M.B., B.C., L.R.C.P., M.R.C.S ... 3404Alexander Charles Anderson, St. Thomas’s Hospital, L.R.C.P.,

M.R.C.S............................ 3385Duncan Gordon Cooper, Edinburgh University, M.B., Ch.B.... 3366-William Leonard Forsyth, Glasgow University, M.B., Ch.B. 3333Keshav Sadashiv Thakur, Lahore Medical College and Uni-

versity College Hospital, L.M. & S. Punjab ......... 3289Mohamed Abdur Rahman, Guy’s Hospital, L.R.C.P., M.R.C.S. 3281Framroze Jamsetjee Koleporewalla, Grant Medical College,

Bombay, and Guy’s Hospital, L.R.C.P., M. R. 0. S....... 325SHerbert Robert Burnett Gibson, Edinburgh University, M.B.,Ch.B.......................... 3257

David Arthur, Glasgow University, M.B., Ch.B.......... 3252Edward Humfrey Vere Hodge, Cambridge University and St.

George’s Hospital, L.R.C.P., M.R.C.S............. 3225Gerald Tyler Burke, St. Bartholomew’s Hospital, M.B., B.S.

Lond , L.R.C.P., M. R. C. S................ 3181Rustom Hormusji Bharucha. University College Hospital,

L.M. &S. Bombay, L.R.C.P., M.R.C.S .............1 3143.

A TRIBUTE TO SIR JAMES MCGRIGOR.As we announced in our last issue the statue of the late’

Sir James McGrigor, Bart., first Director-General of thearmy Medical Department, has been removed from theJhelsea Hospital to the new Royal Army Medical Co]4ege in’3-rosvenor-road. The August issue of the Journal of the Royal

413

Arnty Medical Corpa contains an appreciative biography ofthe late Director-General from the pen of Lieutenant-ColonelM. W. Russell, R.A.M.C., illustrated with a portrait and areproduction of an imposing obelisk, which was originallyerected to the memory of Sir James McGrigor, Bart., in thequadrangle of Marischal College, Aberdeen, but which is nowin the Duthie Park, Aberdeen. In the same issue CaptainN. E. Harding, R.A.M.C., contributes some extracts from" Miscellanies" of Sir James McGrigor, and there is a list ofthe subscribers who contributed to the memorial which nowadorns the quadrangle between the officers’ mess and thecommandant’s quarters of the Royal Army Medical College.This list is accompanied by an excellent reproduction of thestatue.

_______________

Correspondence.

THE NATURE OF ANGINA PECTORIS.

"Audi alteram partem."

To the Editor of THE LANCET.

SIR,—Reading in THE LANCET of July 31st the necessarilycondensed but interesting res2ne of Sir T. Clifford Allbutt’sremarks in opening the discussion on Angina Pectoris atBelfast causes me to regret that I was prevented at thelast moment attending the meeting to take part in the dis-cussion, when I should have had the advantage of hearingthe whole statement, which possibly dealt more fully withsome of the points I am about to mention. I do not,however, desire to occupy any of your valuable spacefor a general discussion of the subject, but in order that Imay make my own position in the matter more clear, as SirClifford Allbutt’s courteous reference to my views which youpublish scarcely represents them quite accurately. Accord-

ing to your report (p. 337) he there states my conception ofthe cause of angina pectoris to be a lesion of the intra-cardiac ganglia." "

In speaking thus Sir Clifford Allbutt doubtless had in viewmy remarks upon a case of intravascular coronary aneurysmpublished in THE LANCET (Vol. II., 1902), in the neighbour-hood of which there was an intravascular collection of nervecells in the intima of the vessel-that is to say, in a position,so far as I know, not recognised by anatomists as innervated-and I certainly believe that in this case they might reasonablybe regarded as having some relation to the pain evinced. For,while I am aware that physiologists at present regardperipheral visceral ganglia as only motor in function,I contend that our knowledge on this point is insufficientto maintain that this is invariably the case, andthe sitzcation of the ganglion in question renders itdifficult to conceive for it a merely motor or nutritive

purpose. But intravisceial or intravascular ganglia, if a sourceof pain in some cases, are only one source of angina, and Ican conceive no reason why a certain degree of stimulationof the cardio-vascular nerves in any portion of their coursefrom Sir Clifford Allbutt’s " suprasigmoid" " area downwards,should not likewise be capable of originating the pain withor without an actual breach of surface. The chief factors inthe production of such stimulation may therefore, I wouldsuggest, be the plus or minus action of the cardiac muscleaccording as it is hypertrophied or degenerated, the impac-tion of a foreign body in the coronary vessels, whichan ante-mortem clot essentially is, or disturbance or lesionof the aorto-cardiac nervous system. The constant characterof the process or syndrome is to be attributed to theconstant anatomical and physiological nature of thestimulable cardiac nerves.Apart from the question of the source of the pain in

angina, I am glad to find myself in accord with SiiClifford Allbutt in regarding the cause of death in suclJcases to be an inhibition of the cardiac action by thaishock to the nervous system which either induces rapicdeath in diastole, as proved by necropsy, or such 2

depression of the contractility of the organ (to USE

a term descriptive of a phenomenon rather thaidenotative of a vital action) as kills after a longe:interval, during which, while death is approachingcertainly, pain is usually absent owing to the fall of bloo(pressure attending a failing heart. In his experience ocomplete and permanent recovery from what used to b

called angina vera and which it is sometimes convenient, ifillogical, to use clinically still, Sir Clifford Allbutt has beenmore fortunate than myself. While I have known the affec-tion to be apparently in abeyance for long periods, my ownexperience is that angina once established, so as to leave itsdiagnosis indubitable, death from cardiac failure dueto local conditions and with or without pain is therule-a fact which argues a local source of the affec.tion. But the experience of angina by individual observersdiffers, and the holding of this discussion in Belfastreminds me that that prince of cardiologists in his day,William Stokes of Dublin, in his memorable work, pub-lished in the ripeness of his experience in 1854, states thathe had never personally met with a case 1 It is, moreover,an interesting fact that the Registrar-General’s reports showthat in Ireland there has always been a disproportionatelysmall, as there is in Scotland a disproportionately large,death-rate from angina pectoris as compared with that

occurring from the same cause in England.I am, Sir, yours faithfully,

ALEXANDER MORISON.Upper Berkeley-street, W., August 1st, 1909.

** In our report of Sir Clifford Allbutt’s remarks atBelfast we referred to his theory as having been first pub-lished in part in 1894. This statement was not quite correct.Sir Clifford Allbutt then advanced the same hypothesis in itsentirety as he continues to uphold.-ED. L.

A CERTIFICATE OF THE CAUSE OFDEATH FOLLOWED BY AN

INQUEST.10 the Editor of THE LANCET.

SiR,—Your correspondent, Dr. Edwin J. Toye, is scarcelyIstified in his statements in THE LANCET of last week. Hehere remarks, "As a matter of fact, the medical man has.0 such discretionary power. It is obligatory upon him toertify the cause of death even if violent." He then giveslart of the 20th section, leaving out these words:-And such person shall, upon giving information of the death, deliverhat certificate to the registrar, and the cause of death shall be enteredn. the register, together with the name of the certifying medicalpractitioner.

a is quite clear that the medical attendant of the deceased)erson is not required to give a certificate unless the death be’rom natural causes, and such as the registrar may acceptvithout hesitation and enter upon the register. To give the;ause of death as due to violence would be waste of time andirouble. In the 39th section of this same Act the refusal tolive a certificate is only enforced when this is done "withoutreasonable excuse." When there is one the medical attendantaas a discretionary power and it is his duty to refuse toertify and to refer the case to the coroner. Moreover, the3rd subsection of Section 20 runs thus :-Where an inquest is held on the body of any deceased person a

medical certificate of the cause of death need not be given to theregistrar, but the certificate of the finding of the jury forwarded by thecoroner shall be sufficient.

When this Act was passed in 1874, coroners acted uponthe ancient statute of 1 Edward III., stat. 1, c. 8. This

required the coroner to go to the place where any beslain or suddenly dead or wounded, to summon a jury, andto inquire as to the cause of death. Acting upon thiscoroners claimed the right to hold an inquest in any andevery case of sudden death, even though its cause was wellknown to the relatives and to the medical attendant. The3rd section of the Coroners Act, 1887, passed just 13 yearslater than the Act quoted by Dr. Toye, requires the coronerto hold an inquest in every case of violent or unnaturaldeath, or sudden death the cause of which is unknown.There is thus no difficulty in determining when to giveand when to refuse a certificate. Should the medicalattendant have any doubt, it is clearly his duty to refer thecase to the coroner, with whom rests the responsibility ofdeciding whether there is reasonable cause to suspectthat the death is one of those I have named. Whatis required is to avoid useless inquests involving theattendance of twelve jurors at great inconvenience to them-selves. Writing from an experience of 44 years as a witnessand looker-on, I have no hesitation in confirming what was