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indicating a well-marked or quasi-acute case of lymphatism, ]and one in which both respiratory and cardiac centres are ]

usually affected suddenly and more or less synchronously, ]

with the inevitable result, sudden death. 4. Because the i

kidneys were a little congested, to me another indication ofa quasi-acute example of the status lymphaticus. 5. Because the lungs were congested-a point that I have commented on i

before in such cases of sudden death from lymphatism.At the inquest no notes were recorded as to whether the

glands in the mesentery were dark or pale pink in colour ;whether they were uniformly large or uniformly small ;whether there was or was not any general enlargementof the smaller peripheral mesenteric glands ; and whether some groups of glands were larger and paler than others. 1

Also the condition of the miliary lymphatics in the stomach,oesophagus, ahd intestines was not recorded. All these

points might possibly have thrown further light on the case.

The cavities of the heart presumably did not contain anynoticeable quantity of blood, since no mention is made thatthey did, and I consequently surmise that it is not improbablethat its action ceased during systole, as it usually does in such cases. In THE LANCET of Dec. 26th, 1908, I drew attention to the fact that of deaths occurring while under general anaesthetics from the status lymphaticus the cata- strophes always happened during light anaesthesia, either before reaching, or on recovery from, the third stage of narcosis. In some instances where chloroform has beenadministered for an hour or more during a protracted opera- tion, although no untoward symptoms may have been presentat any time during the whole of the administration, never-theless, just as the patient is beginning to come roundand the last few skin sutures are being inserted he maysuddenly die.From this, and also in consideration of the extremely

trivial firing-off causes that may be sufficient to give rise to afulminating termination resulting in sudden death, I arguethat the effects of shock in such cases are probably of moreimportance than the effect of the narcotic. In MissDalrymple’s case, shock, caused by cognisance of the fearthat she might feel faint, subsequently reinforced by theshock of the cold lotion applied to her head, would be, at a coincidently critical period, quite a potent enough excitingcause of sudden death. In conclusion, I was sorry that bothMiss Dalrymple’s former medical attendant and the coroner’s jury should have attributed this sad and unfortunate disaster to " Death from misadventure," when surely the true verdictshould have been one of " Death from natural causes." ’

Since writing the above I have read with great interest theletter of Dr. Donald J. Munro published in THE LANCET .of Nov. 13th (p. 1468), and I would here like to take ,the opportunity of endorsing many of his views. Forpractical purposes the first point of paramount importanceis the question of diagnosis, and in this connexion may I (be allowed to suggest some modifications of Dr. Munro’s restrictions of the term " status lymphaticus"? In myopinion the five following physical signs and symptoms are .,the most important and are arranged in order of merit. 11. Signs of a persistent thymus gland as evidenced by a tlowering of the upper border of superficial cardiac dulness iin the absence of emphysema of the lungs, or old tuber-culous cavities at its bases, with or without fulness of the episternal notch, and not by a dulness to percussion behindthe manubrium. This region may even be a little hyper- fresonant, and if dulness is present it is probably due tosome new growth, and not to a simple hyperplasia of the thymus gland. 2. An uniform prominence of all the papillæ tof the tongue, especially the circumvallate papillæ, between twhich and the epiglottis posteriorly there is frequently ipresent a great multiplication, hypertrophy, and hyper- iplasia of all the lymphatic nodules, giving rise to a very tcharacteristic picture, many of these sessile nodules tmeasuring about 1-8th to 3-16ths of an inch in diameter 1at their bases ; the condition cannot be seen without tthe aid of forehead and laryngoscopic mirrors. 3. Asymmetrical enlargement of the thyroid gland. 4. Distant and muffled heart sounds, with absence of the 1sharply defined click caused by closure of the valves, asso-ciated with a soft, weak, and ill-sustained pulse, and, as Dr. Munro states, often abnormally slow and inexcitable. 5. A

rgreater or less amount of hyperplasia of any or all of the faucial, pharyngeal, and lingual tonsils, also of the uvula, iand the presence of adenoid growths in either very small or 1,

large quantities. Either or both the liver and spleen may, ormay not, be enlarged, and to such a variable extent that noreliance can be placed on the absence of physical signs ofenlargement, and very little indeed on the presence of thesame. The pupils of the eyes also may appear ratherdilated. The co-existence of 1 and 2 is pathognomonic ofthe disease.

Lastly, I cannot agree with Dr. Munro when he says,No clinical observation has ever been so hopelesslymistaken as that which stated that pregnancy conferredimmunity from the poisonous effects of chloroform." True,there are here more factors than one tending to produce anoverdose of the vapour, but the anaesthetist is prepared forthis. Despite the mechanical embarrassment to respiration,as Dr. Munro says, the heart is stronger than normal, andthe increased carrying capacity of the red blood corpuscle Iwould regard as a "virtue" " rather than a "vice." This

factor, coupled with the toxaemia from over-metabolism,probably in large measure accounts for the reason that solittle chloroform is necessary to produce and maintain anefficient and safe anæsthesia during parturition. Is it notsometimes advisable to artificially produce a toxaemia bygiving a hypodermic injection of morphine preparatory to theadministration of chloroform ’? Probably if one had tomaintain surgical anaesthesia or the third stage of narcosisduring parturition it would not be as safe as it would be

apart from the condition, but surely "light" anæsthesia ismuch safer at such a time than it is at any other.

I am, Sir, yours faithfully,R. ERNEST HUMPHRY, M.R.C.S. Eng.,

L.R.C.P. Lond.Northwood, Middlesex, Nov. 15th, 1909.

R. ERNEST HUMPHRY, M.R.C.S. Eng.,L.R.C.P. Lond.

CIVILISATION AND THE CORSET.To the Editor of THE LANCET.

SIR,-May I correct an impression which Mr. HeatherBigg conveys in his communication on the above subject ? He seems to think that men in ’’ sultry and atoniccountries "-I wonder what he means by an atonic country ?-"gird the loins " with a view of supporting nature’s

"incompetent abdominal walls." Some years ago I un-

expectedly met in Calcutta a very distinguished Londonsurgeon, an old fellow-student, who was spending hissummer holiday in going to India to personally see a thingof which he heard in connexion with native customs ; ifMr. Bigg would follow that example he would see personallythat girding of the loins " has nothing whatever to do withartificial support. He need not go beyond Aden, where hewill see the Arab camel-drivers coming in from the desert,among whom he will see magnificent specimens of activity."Girding of the loins" really means girding of the loincloth, which is wrapped round the body, passed through thelegs, and tucked in at the waist, and is no more worn for thepurpose of support than our trousers are so worn ; nor, if itwere conceivably the object, could it be obtained in anybetter degree than by our trousers. It is obvious thatthe cloth is liable to work loose, being only tuckedin, and girding of the loins " means readjusting itand tucking it in again, and the object correspondsto our object in wearing braces. Natives of India,whether fighting as uniformed Sepoys or in their native

garb, Britishers, whether fighting or engaging in friendlycontests, do not wear, and do not need, any artificial

support. I do not wish to contend for or against the use ofcorsets, the women will settle that for themselves apart fromcontradictory statements and opinions of the profession, butI do wish to correct an impression which may mislead othersin supposing that in a country like India-if Mr. Bigg callsthat an atonic country, and a visit there will correct him onthat point-men have to wear artificial support for theirloins and abdomens. The impression might lead to thethought that it is necessary in this country, though notamong those accustomed to, or knowing anything about,exercise. Fancy a Marathon runner running in an abdominalbelt !

In conclusion, I may go one point further and say thatwhich is demonstrable-namely, that where the naturalmuscular support of the loins and abdomen is deficient fromwant of tone, the best way of preventing recovery of ton.is to provide artificial support, and in no cases is this so

lamentably obvious as in the indiscriminate ordering of

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supports for spinal cases, and I am constantly engaged in I rundoing the evil done in such cases, which evil admits of ( ceasv demonstration.-I am. Sir. vours faithfullv. r

H. E. DEANE, Lieut.-Col., R.A.M.C. (retired).Weymouth-street, W., Nov. 29th, 1909.

To tie Editor of THE LANCET.SIR,-I read with great interest an article in THE LANCET

of Nov. 13th, entitled, "Civilisation in Relation to theAbdominal Viscera," which opens up a subject of wide andever-increasing importance. During the last year I havemade a careful observation of a large number of cases vary-ing in age from 15 to 50 years, having regard to those condi-tions which are said to result from chronic intestinal stasis,and I am bound to confess the existence of those conditionsis confirmed by systematic examination. In hospital workwe are able more accurately to estimate the severity andchronicity of constipation, and I should like very briefly torepeat some of the points which have been recorded in yourcolumns and which have struck me most forcibly.The worn and haggard appearance, the absence of muscular

tone, the pigmentation of the skin in definite places, andthe peculiar odour of auto-intoxication are most characteristic.Pigmentation is an early symptom and this staining may bevery marked at a time when signs of degeneration are onlyjust beginning to appear. Most constant and remarkable arethe changes in the breasts, which at first feel lumpy and latershow cystic degeneration.There is a point in connexion with this which arrests

attention, and that is that this cystic degenerationdoes not take place in married women who are havinghabitual intercourse. A striking illustration of this pre.sented itself to me a short time ago. A married woman,who had one child, 15 years old, was admitted, havingreceived a slight injury to the right breast a few days before.The patient, who had for many years been subject to chronicconstipation, showed extensive cystic changes in both breasts. On inquiry it transpired that she had had nointercourse with her husband for 14 years.

Pregnancy has a beneficial effect on constipation ; the

enlargement of the uterus so alters the mechanics of theabdomen that the bowel can more easily empty itself.

Recently I had a typical instance of this. A woman, aged39 years, was the mother of 14 children. She had beensubject all her life to chronic constipation, except during herpregnancies when there was a daily evacuation and a con-sequent general improvement in health. The almost uni-versal wasting that follows a long history of stasis is a

prominent feature. Frequently these patients will saythat up to the age of 19 or 20 they were stout, but thatafterwards they gradually began to lose flesh until at the ageof 35 to 40 they become very thin and wasted.

Enfeebled circulation with cold hands and cold feet is asource of great discomfort to the habitually constipated.Pain is always present, though it varies in position andseverity and there are periodical remissions. These peopleare admitted into a hospital for various reasons. Loss offlesh, loss of appetite, indigestion, abdominal pain, vomiting,displacements of the uterus from loss of fat, sleeplessness,nervous depression are some of the numerous symptomscomplained of. With painful monotony it is found that a

long history of chronic constipation is given. They showsome temporary improvement from treatment in bed, due ina slight measure to a daily purging, but chiefly to the

assumption of the recumbent posture. It is surely notdifficult to believe that a system whose resisting power is solowered by auto-intoxication becomes an easy prey to thetubercle bacillus and other organisms.

These are some of the effects briefly enumerated whichcannot fail to be noticed on methodical examination.

I am, Sir, yours faithfully,Lewisham, Nov. 18th, 1909. H. M. M. WOODWARD.H. M. M. WOODWARD.

THE JUBILEE OF THE DENTAL CHARTERTo the Editor of THE LANCET.

SIR,-The dental surgeons have shown themselves desirousof commemorating the Jubilee of their Charter, and the RoyalCollege of Surgeons of England, as the first examining bodyto grant degrees in dental surgery, has endeavoured toshow its interest in this branch of the profession, first, byaccepting the trust of the Odontological Museum, which is

now accommodated in a room adjacent to the Hunteriancollection; and, secondly, by entertaining the leadingmembers of the profession at a dinner within the precinctsof the College. I would venture to suggest that this move-ment might well be directed towards a more permanentmemorial of the Jubilee of the Dental Charter by establish-ing a research scholarship and demonstratorship in connexionwith the Dental Museum. There are already two smallendowed prizes, the Tomes and Cartwright prizes, admini-stered by the College, the one awarded every third and theother every fifth year ; but the dental profession is deservingof something of a much wider scope than these for the stimu-lation of research and for the higher teaching of its scientificbranches. My own view favours a far more ambitious schemethan anything in the form of a mere prize, whether awardedafter examination or conferred in recognition of original workcompleted. I would ask for the modest sum of £10,000 toendow a research and teaching demonstratorship in con.

nection with the Dental Museum. In this way not onlywould a scientific worker be secured, but he would by hisdemonstrations attract the students from the various dental

hospitals to study in the Dental Museum. Such a sum could,I am sure, be easily collected from among the dentalsurgeons alone ; but if they were to impress upon theirpatients the necessity of endowing dental research thereneed be no hesitation in raising the sum I have suggested to50,000, whereby not only research and teaching demon-stratorships might be established, but travelling scholarshipsmight be founded which would be of great advantage inkeeping English dentistry in touch with that of foreigncountries.

It is some 25 years ago since I first began to advocate thebringing of the dental surgeons back within the pale of theprofession and giving them the same opportunities as

ophthalmic, aural, and other specialists. One could scarcelyhave anticipated so encouraging a development as hasoccurred within so short a period. The dental surgeons havenot been slow of late to seize the occasions for better

recognition, and by placing the Odontological Society underthe Eegis of the Royal Society of Medicine, and by handingover their superb museum to the care of the Royal Collegeof Surgeons they have shown their desire to be associatedwith the general body of the medical profession. Now Ithink the time has come for the further development of thescientific side of the branch, in which direction severalmembers have already gained great eminence.

Should my suggestion find favour with the dental sectionof our profession, I should be pleased to cooperate with anyinterested in this project ; but it must be distinctly under-stood that I write quite unofficially, though I have littledoubt that the Council of the Royal College of Surgeonswould give its consent to the administration of such aresearch demonstratorship as that proposed if the moneywere forthcoming for its endowment.

I am, Sir, yours faithfully,London, W., Nov. 27th, 1909. R. CLEMENT LUCAS.R. CLEMENT LUCAS.

THE TREATMENT OF MORPHINISM.10 the Editor of THE LANCET.

SIR,-I have been much interested in the letters of Dr,C. J. Douglas and Dr. Oscar Jennings which have appeared inyour columns under the above heading. The subject is inreality much larger than the heading might lead one toinfer, for the treatment of morphinism is but a chapter inthe volume on the treatment of habit, and accordingly thequestion raised in respect of one drug-the proper methodof treatment of its abuse-is of fundamental importanceand applicable in the main to all forms of drug abuse, if notto every form of acquired evil custom.

Dr. Douglas suppresses the habit, breaks its custom, by thehelp of hypnotic remedies ; for him ’’ I sleep solves the problemof the painless withdrawal of morphine ...... when thepatient awakes the painful period is passed and all desirefor morphine is gone." 1

Dr. Oscar Jennings also suppresses the habit, breaks itscustom, but by the help of the patient’s own good will, inarduous operation ; his method stepping in to reinforce andencourage the operation of the will during the withdrawal ofthe drug, and, at the same time, to lessen the arduousness of

1 THE LANCET, Oct. 2nd, 1909.