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of the brain necessarily follows a diminished supply ofblood to the organ, is not quite accurate, for the diminishedsupply may be more than counterbalanced by a still morediminished efflux ; and it is certain that symptoms ofmental depression, if by this is meant depression of

spirits, or melancholy, do not necessarily follow a diminu-tion in the blood-supply to the brain, for melancholydoes not necessarily, nor even usually, follow severe hoemor-rhage ; nor is it a usual concomitant of general ansemia."M.R.C.S." says that many cases of simple insanity appearto depend almost entirely upon active hypersemia andincreased blood pressure. I usually test by routine theblood pressure of my patients by the sphygmo-haemometer,and I find that a high blood pressure goes more often withdepression of spirits and tranquillity than with excitement ;and I would point out that a high pressure of blood in thearteries does not necessarily imply hyperasmia in the tissues,or a more rapid flow of blood through the capillaries. The

high pressure may be compensatory, and complementary tosome obstruction to the flow of the blood through the smallvessels, so that the net result may be a circulation that isnot increased, or is even diminished in velocity.

Increased blood pressure may, as "M.R C.S." asserts, bethe main cause of the delirium of persons suffering frompyrexia, and of the mental excitement produced by stimu-lants, and by the administration of ether and chloroform. Iknow of no series of measurements of blood pressurein these states to give countenance to the assertionthat increased blood pressure is present in them ; and ifit were proved to be uniformly present, proof would stillbe wanting that the high blood pressure was the cause ofthe delirium and excitement. To perform on such groundsas this a capital operation, with risk, not only of life, but ofpermanent damage to brain, even if life is not lost, would bein my opinion unwarrantable. One other statement, madeby "M.R.C.S.," as if it were established fact, seems to meopen to question. "In cases of mania," he says, " the moreacute the symptoms the greater the cerebral disturbance andinsomnia, the more favourable is the prognosis." This is not

my experience. I am accustomed to teach that the gravityof an attack of acute insanity, by which I mean the dangerto life in the first place, and of permanent alienation of mindin the second, is a product of two factors, viz :-the intensityof the attack, and its duration. If by acuteness of

symptoms I I M. R. C. S. means brevity of the acute attack, Ishould agree with him ; but if, as appears from his context,he means intensity or severity of the attack, then his

experience is the reverse of mine.I am, Sirs, yours faithfully,

Wimpole-street, W., Sept. 8th. CHAS. MERCIER.

ANESTHESIA IN DENTAL SURGERY.To the Editors of THE LANCET.

SIRS,-In THE LANCET of Sept. 8th I notice a review of thesecond edition of my little book on the above subject, andwhile thanking your reviewer for the kind things he has saidin regard to it I have pleasure in acceding to his request (oris it a challenge ?) and referring him to proof, as far aspossible, of the statement made on p. 193 that arrest of therespiration may be due, among other things, to "directretardation and arrest of the pulmonary circulation, first inthe capillaries and then in the larger vessels, due to thelocal direct action of chloroform."

If your reviewer can get hold of a copy of the Report ofthe Discussion on Anaesthetics" " of the Glasgow Medico-Chirurgical Society (1891), published by Alex. Macdougall,81, Buchanan-street, Glasgow, he will find on p. 5 that thelate Professor Coats, whose views on the physiologicalaction of chloroform were, I believe, particularly sound,draws attention to this cause of respiratory arrest, basinghis remarks on Dr. D. Newman’s work when a member of theGlasgow Committee on Anaesthetics. Whether any laterobserver has confirmed this I am unable to say, but all Iwish to contend is that I am not speaking without authorityto support me, I have avoided bibliographical references inthis book, as I am inclined to think by the average readerthey are regarded as a nuisance.

In another journal my remarks on the question of theadministration of anaesthetics by a Licentiate in Dental

Surgery were dealt with more severely than by your reviewer,the writer evidently regarding me as eminently unsoundin this respect. To many London anaesthetists it appearsnothing short of heretical to suggest that anaesthetics may

be given properly by anyone other than an anaesthetist or"fully qualified medical man." It is, however, perfectlyuseless to lay down that every man who administers nitrousoxide must be medically qualified. In certain classes of

practice it is next to impossible. I live in a country wheredentists, until quite recently at all events, even gavechloroform to patients without calling in a medical man.This is, of course, unspeakable and personally I regard thecasual administration of ethyl chloride by dentists as onlyless objectionable. At the same time I would much preferthat patients be given nitrous oxide or mixtures of it withethyl chloride or ether by a properly trained L.D.S., of whomthere are now many about, to their being elaloroformed by oneof my brother M.B.’s. To only too many such anaesthesia stillmeans oklo’l’ofo’l’m. I am, Sirs, yours faithfully,

I Edinburgh, Sept. 10th. T. D. LUKE.

HMATOGENOUS ALBUMINURIA.To the Editors of THE LANCET.

SIRS,-I have met with three cases of albuminuria inyouths of 17 to 20 years during the last few weeks. Theadministration of from 60 to 80 grains of calcium lactate hascompletely cleared this up, in one case in a few hours. Theother two cases were not examined until an interval of 24 hourshad elapsed. I find that a smaller dose than 60 grains is not sodefinite in its action. Accordingly I can vouch for the valueof the work Sir A. E. Wright has performed in solving thisoften most perplexing problem of functional albuminuriawhich must have frequently completely changed, if not ruined,the prospects of many a perfectly healthy boy.

I am, Sirs, yours faithfully,Walbrook, E.C., Sept. 7th, 1906. CHARLES B. PENNY.

WHAT IS A SPECIALIST?To the Editors of THE LANCET.

SIRS,-Your correspondents who are writing letters underthis title do not appear to be confining themselves verystrictly to supplying material for answering the question. Itis not the definition of a specialist which concerns most ofthem; rather they are concerned to speculate how farmaterial success is achieved by the practice of specialism,and how far the chances of such success are denied uhfairlyto many members of the medical profession.Has your attention been called to a contribution by Dr.

Herbert Snow in a monthly journal called the 6’M:Magazine? The paper, which I have reason to believe hasdisturbed the equanimity of some members of the medicalprofession, appears to be one of a series own "The Secretof Success," and as the seventh in succession of thisseries it deals with " Success in Medicine," and purportsto be a feast of thought furnished by several con-

tributors, voluntary or involuntary. The names ofSir Dyce Duckworth, Dr. Whipham, Dr. F. W. Andrewes(misspelt), Dr. Wethered, Dr. Herbert Snow, ProfessorClifford Allbutt, Mr. Ernest Kingscote, M.B., Miss AldrichBlake, M.D., Mr. Litton Forbes, Sir James Crichton Browne,and Mr. Brudenell Carter, all appear at the heads of suc-cessive paragraphs or pages, and these names are reinforcedby anonymity in the shape of "An Eminent London Phy-sician who has received a Baronetcy," and of " Sir X. Z., awell-known London specialist." In the case of several ofthe gentlemen mentioned it is obvious that their con-

tributions have been involuntary, inasmuch as they consistonly of extracts from their published works, but some appearto have written in reply to direct applications from themagazine. Among these, from internal evidence only,I should be inclined to place Dr. Herbert Snow, whomay at least claim the merit of having escaped from con-ventionality. He tells the public that the main elementsmaking for success in the medical profession, ranged in theorder of their importance, are unscrupulousness, selfishness,hypocrisy, industry, and ability ; that no one with themerest vestige of a conscience should attempt to becomea medical practitioner ; that everything in the nature ofbenevolent instincts, of kindly feeling for others, of sympathywith suffering and pain, should be sternly discouraged; andthat in country districts it is advisable further to varnishyour real sentiments by a cloak of religious hypocrisy. IfDr. Snow believes that these are the conditions mainly con-tributory to success he must believe also that the most suc-cessful members of the profession are men who have

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practised what he preaches. He may certainly be said tocall down upon himself the condemnation generally extendedto birds that foul their own nests.The " Eminent London Physician who has received a

Baronetcy" is delicious. Assuming that a person answeringthis description may have been asked to contribute, the

application must have been thrown into the waste-paperbasket and picked out by a manservant who has amusedhimself by giving his own version of his employer’s experi-ences and opinions. " Jeames " is writ large over thewhole of the composition. According to his story, theeminent physician is not a physician at all but a surgeon,and he became full surgeon to a

" great and famous hos- pital" within seven years of obtaining a "minor" appoint-ment there! He stepped into sudden notoriety by a

"trivial operation" upon a well-known statesman, to whosebedside he was called in consultation. The medical"Jeames" has so far had no justice done to him in fiction,and this particular specimen ought to be induced to publishhis reminiscences for the delight of mankind. Many of uscould contribute an anecdote or two to such an autobiography.A friend of mine had occasion to go often to an " eminent

physician,"and said to Jeames, " You will be tired of openingthe door to me." "Not at all, sir," was the gracious reply ;"you are but a hunit in the hocean." Another Jeames wasaccustomed to say, during his master’s occasional absences :"you had better try hopposite. There’s a very respectableman hopposite as we often sends to when Sir William ishabsent. His name is Jenner."Mr. Ernest Kingscote begins by taking an absolutely

irrelevant story from Sir Walter Scott and spoiling itin the telling. The hero of the original story was so

far from being an Aberdeen graduate that he had notany sort of medical qualification. When Sir Walterwas sheriff-depute of Selkirkshire an illiterate farrier inthe district, who was charged with some minor offence,got away across the border, and a year or two afterwardsSir Walter met him accidentally in Carlisle and asked whathe was doing. The man said he was practising as a doctorand told the well-known "calamy and lodomy" storywith the conclusion about Flodden Field. There is noevidence that he was successful, especially as Mr. Kingscotedefines I I success," that is, as a "lucrative practice with con-genial social surroundings." Mr. Kingscote tabulates a littlecatalogue of ordinary requirements in the way of " sufficientability," "astute business instinct," &c., and provokes aquotation from Scott of quite a different character from hisown:-

So think the vulgar. Life and Time,Ring all their joys in one dull chime,Of luxury and ease."

Part of Mr. Kingscote’s advice is to avoid originality, but inquoting a precept from Assheton Smith he spells the famoussportsman’s name in quite an original manner.The passages of this extraordinary medley which appear

to be editorial cuttings from books or introductory addressesare all in what lawyers, I believe, call " common form," andcontain the usual recommendations to the practice of sundryprosaic virtues. But " Sir X. Z., a well-known London

specialist," merits comment, as be, like your correspondents,is contributing information as to what a specialist may be.It is interesting to know that when he commenced practicehe passed with distinction all the usual examinations."Most people pass some of the usual examinations before theycommence practice, and they are not informed by theexaminers whether they have passed with distinction orwithout. In spite of his "distinction" X. Z. appears tohave found himself only "one of hundreds more or lessclever men," "a hunit in the hocean," in fact ; and hedecided to become a " specialist " because as a generalphysician he would have been unable to address himself tothe public." He selected a specialty " which appealed to alarge class of persons, and in which a fair proportion of caseswere curable," and he does not on his own showing appearto have made any endeavour to equip himself with anyunusual amount of knowledge of the subjects to which hisattention was professedly directed. He seems to havecalculated that the recoveries of the many people who gotwell would be credited to his superhuman skill, and that thecondition of those who did not get well would be attributedto the neglect or the want of skill of the general practitioner.with whom he was associated in treating them, and of whomhe was manifestly ready to make scapegoats. He is oj

opinion not only that specialism is the best road to success,

but also that any specialty may easily be made subservientto the advancement of the man who professes it. All thatis necessary is to write as much as possible in lay papers andmedical periodicals, to belong to, or if necessary, start somespecial hospital, and, above all, to entertain as largely aspossible both the rank and file of the profession and thepublic. It seems impossible to believe that " Sir X. Z." is areal person, but if he be a creature of the editor’s imagina-tion the medical profession has a right to resent such apicture being presented to the public as a medical portrait." Sir X. Z.’s" self-satisfaction with his own dishonesty isamusing ; it is equal to that of Gil Blas.

This autobiography of a successful specialist would seemto me to be too preposterous for credence, even in a popularlay magazine, making not the slightest appeal to intellectualpeople, if I did not detect in the letters of some, at leastone, of your correspondents a tendency to believe that suchcharlatans were a force in our professional ranks. I canclaim a not inconsiderable acquaintance with medical practi-tioners, many of them eminently successful; some, in a sense,unsuccessful, and these by no means always the least capable,but it is common experience that the ignorant and dishonestmen, such as the " Sir X. Z." of the Grand Magazine, willalmost invariably fulfil the tradition about the porcine race,that they cut their throats in swimming. It is of highadvantage to be "clever," to make use of a much abusedword ; but it is quite possible to be "too clever by half,"and in that case detection and extinction are apt to followas cause and effect. I am, Sirs, yours faithfully,

___

F.R.C.S.

To the Editors of THE LANCET.SIRS,-The interesting correspondence under this heading

should have a useful issue if it not only brings to generalnotice the many difficulties of the present position but alsoenables us to see a way out. Personally, I do not think weneed trouble ourselves about smoothing the path for theman whose claim to being a specialist rests on his ownopinion of himself. Nor need we try to make it easy for himto secure the comfort and affluence which he imagines to bethe reward of specialism. It is true that in a few instancessuch a man’s estimate of himself may be well-founded andhis failure to reap his reward may be a real loss to the com-munity. But in the vast majority of cases such a man’s claimsto special capacity are as illusory as are the rewards hebelieves to be within his grasp if he could obtain the positionhe desires.What we as a profession are more concerned with is the

undoubted failure of the public to secure the advantagesthat it ought to secure from the particular knowledge andskill of those whose claims to specialism rests on

the well-founded opinion of their fellow practitioners.From want of proper organisation of the professiona very considerable number of patients, whose simple ail-ments do not require it, are under treatment by men whosecolleagues would unhesitatingly acclaim them as specialists,whilst still larger numbers are deprived of the services ofthese same specialists though their prospects of rapidrecovery would certaiuly be increased by such help. Ibelieve this to be due to the fundamental error as to the truebasis of "specialised practice." In modern medical ethicsthe chief crime of a specialist is that he wanders from hisspeciality and treats cases not strictly within his scope. Inthe opinion of some it would be better if it became thechief crime of a specialist to treat any patient indepen-dently. The special knowledge of a specialist should be

used not to attract members of the public to seek hisaid, it should be at the disposal of other members of

the profession to assist or to supplement their thera-

peutic efforts. I have satisfied myself that the fact thatnearly all specialists, including in this term the special

physician and special surgeon, as well as the eye, ear, andthroat specialist, undertake independent private practice is anundoubted bar to that free use of their services which wouldbe made by general practitioners if they restricted their workto consultations with their colleagues and to treatment carriedi out in cooperation with them. The introduction of a patientto Harpole-street often proves a very expensive experimentfor a general practitioner. The specialist to whom the

patient is sent may be scrupulous beyond reproach in hismethod of dealing with the case, but there are many otherdoor-plates in the neighbourhood, and so long as specialists

E undertake independent treatment of cases that " come on, their own," as the saying is, the danger of a patient and his

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friends and acquaintances acquiring a Harpole-street habitis a serious one.

There have always been a few specialists who have takenup the strictly consultative attitude and their numbers aresaid to be slowly increasing. If this attitude becamecommon amongst those who are attached to the greathospitals of London it would no doubt spread to all thosecentres of population capable of supporting specialists. Itcan hardly be doubted that this would be to the advantageof the specialists themselves, of the general practitioners,and of those members of the public who have real need ofthe experience that can only be acquired by specialisation.It would settle once for all that the proper answer to the

question, What is a specialist? is one who is so regarded byhis professional colleagues. It would make it clear to thepublic that the profession did not regard as a specialist onewho undertook to carry out treatment independently of ageneral practitioner. It would make it more than ever

useless for a man whose colleagues did not recognise hisclaims as a specialist to announce that he was one on hisdoor-plate. I am, Sirs, yours faithfully,

Sept. 10th, 1906. _______________

E.

PORTUGUESE QUARANTINE REGULA-TIONS.

(FROM OUR SPECIAL SANITARY COMMISSIONER.)

PART II.1THE NEW MARITIME DISINFECTING STATION AT LISBON.-

THE NEW HARBOUR WORKS.-THE BRITISH MEMBERSOF THE INTERNATIONAL MEDICAL CONGRESS AND THE" OPHIR " BLUNDER.-THE OLD LAZARET FORT ANDPRISON.-THE MODERN LAZARET.

THE port of Lisbon, if considered from the point of viewof the number of ships by which it is frequented, may beestimated as the twelfth in importance of all the ports ofEarope. This is due in a large measure to its continual

communications with the Brazils. Here, then, was established ,,

a large lazaret and its history, a somewhat sinister history,dates back for some centuries. It is situated on the leftbank of the Tagus at some distance from Lisbon, nearer tothe sea and nearly opposite the famous Balem tower. The

importance of this lazaret may be judged from the fact thatfor purposes of quarantine or of disinfection of luggagein the course of ten years from 1890 to 1900 the numberof persons detained here reached a total of 96,423. Nowthe lazaret is to a large extent abandoned and this isone among several good results which the meeting of theFifteenth International Congress of Medicine at Lisbon

helped to bring about. A maritime disinfecting stationhas been built at Lisbon itself and its completion washurried forward so that everything should be in workingorder when the members of the Congress arrived. Thestation forms a part of the great scheme of the newharbour works and was opened towards the close of theyear 1905. In most respects it is similar to the disin-

fecting station established at Leixoes and previously des-cribed. Formerly ships had to go to the lazaret on theother side of the Tagus. Here the travellers were exploitedby boatmen. The water was often rough and then theboatmen would charge high prices for landing the

passengers. There were many hardships and much loss oftime. Now these annoyances are avoided except whenquarantine detention is actually imposed and then there isno need to hurry, for there is more time than enough. This,however, only applies to infected ships. In most cases

medical inspection and disinfection alone are necessary,and then, as a result of the harbour works, the ship canmoor alongside of the new disinfection station. Even at lowtide there are eight metres of water, so that very large shipscan come alongside.

It was against this wall and close to the disinfectingstation that arrangements had been made to moor the OrientLine steamer Ophir which was chartered to convey the

greater part of the British members of the Fifteenth Inter-national Medical Congress to Lisbon. The water here is

deep and pure-that is to say, there are no sewer outfallsanywhere in the neighbourhood. On the contrary, from a

1 Part I. was published in THE LANCET of Sept. 8th, p. 684.

point near to the arsenal right away some distance on theroad to the Balem tower, a main collecting sewer has beenbuilt within the new embankment. Here on this embank-ment an electric tram would have taken the passengersresiding on the Ophir to the centre of the town in a fewminutes, while under the embankment a main sewer conveysall sewage far away towards the sea. The appended mapshows well the details I am describing (see Fig. 2). On theother side of the Commercial, or the so-called " Black HorseSquare," where the Ophir eventually rode at anchor, areseveral of the worst sewer outfalls of Lisbon-indeed,the whole question of the Ophir is so utterly to thediscredit of British management that it should not be

forgotten but should be constantly recalled as a lesson and awarning for the future. It will be remembered that a scarewas raised about sewer outfalls and therefore the British

contingent, through their representatives, declared that theydid not wish their ship to come alongside of the quay. Themooring place secured for them was consequently given up,and of course the Germans, being as usual very muchbetter informed, eagerly availed themselves of the oppor-tunity to secure this excellent berth for their ship the Oceana(see Fig. 3). Surely, before thus rashly giving up a favouredposition a map of the sewers could have been procured.There was no difficulty in obtaining such a map. This mapshows that where the Ophir should have been moored, andwhere Dr. Henry de Rothschild moored his yacht theNemesis and the Germans their ship Oceana, there are nosewer outfalls whatsoever. The Ophir, however, and toavoid sewer outfalls where they did not exist, went to amost inconvenient position and this facing a district wherethey did exist-in fact, they cast anchor just opposite noless than five large sewer outfalls. Fortunately, there is somuch water and the Op7tir was so far from the shore thatthese five sewer-mouths were not likely to do any harm, buteach time members of the British contingent went to shorein rowing boats or in a tender they had to navigate throughthe sewage. To land at " Black Horse Square " they had topass close to the mouth of one of the most obnoxious andodoriferous of these sewer outfalls. If in spite of theenormous volume of salt water in the Tagus those seweroutfalls that still remain occasion any risk to persons on

board ships then the Ophir anchored where the risk was

greater than if she had gone alongside as originally in-tended. ("Black Horse Square" is marked in the mapjust to the N. and W. of the fifth s marking sewer outfallscounting from the right or eastern side of the map )The new harbour works at Lisbon have involved an

expenditure of E2,880,000, and an embankment some fivemiles long has been built together with basins, gravingdocks, and vertical quays accessible to the largest ships atwhatever state of the tide. There is a vertical quay 10,240feet in length with 26 feet 3 inches of water at low tide.These great works will undoubtedly have some effect uponthe health of the town. Not only is a large portion of thesewage conveyed away by the main ewer laid in theembankment, but this building, by drying up the landand preventing the exposure of mud at low tide, has

put an end to the excessive prevalence of low feveramong those who lived close to the water’s edge. Themortality from typhoid fever, taking the average for periodsof four years each, was equal to 0’ 38 per 1000 inhabitantsannually from 1881 to 1885. During the next four years it was0’ 35 per 1000. The new harbour works were commenced in1892 and concluded in 1898. For the period 1891 to 1895 themaximum deaths from typhoid fever was reached, the pro-portion being 0’39 per 1000. Then as the works approachedcompletion the figures fell to 0’29 per 1000 from 1898 to1900 and to only 0 - 21 per 1000 from 1901 to 1905. It doesnot follow that the harbour works have brought about thisreduction in typhoid fever, but the digging and the disturb-ance of the earth while the works were going on do seemto have increased the number of cases. On the other hand,the better sanitation resulting from the completion of theworks was doubtless one of the contributory causes ofthe present falling off in the number of deaths from thatdisease.The new maritime disinfecting station has been built on a

portion of the vertical quay to the west of Lisbon, and at thebase of the hill where the Royal palace of Necessidados issituated. The railway lines are laid here so that goods can beloaded on the trucks as soon as they have been disinfected.From the disinfecting station luggage can be sent direct toany part of Europe. It is not necessary after landing