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now been narrowed into a very small compass. The advo-cates of what we may term the unitarian view do not main-

tain, as far as we can learn, the identity of tracheal diph-theria with infantile laryngitis, but precisely the reverse;and, clfortiori, they entirely exclude from consideration allcases of what are called spasmodic croup.’ The onlyquestions to be now solved are, in the words of Sir WilliamJenner, * Is there a membranous inflammation of the larynxdistinct from the acute specific disease diphtheria? are

there a true croup and a diphtheritic croup?’"

THE indecent practice of holding inquests at public-houses will not, we hope, continue to be a reproach to so-ciety much longer. A movement for providing suitablepremises where the coroner and jury may pursue their in-quiries with comfort has been on foot for some time, andwe frequently learn of the establishment of a private courtin order to obviate recourse to the adjoining tavern. Acoroner’s court for Paddington, ’situated adjacent to St.Mary’s Hospital, has just been opened. It contains anelevated platform for the coroner, with ample accommoda-tion for the jury, witnesses, the press, and the public.

MAJOR BOLTON, water examiner, in his monthly reportfor December last, again says that many of the causes ofcomplaint received by the Local Government Board as to thequality of the water delivered for domestic purposes by themetropolitan Water Companies were found on inquiry to beattributable to the dirty state of the cisterns on the

premises of the complainants. All cisterns should be

frequently cleaned out, and householders are admonished toexercise great care in preventing the contamination of thewater-supply after delivery on their own premises.

MR. JoHN LIDDLE, medical officer of health for White-

chapel, called the attention of the Society of Medical Officersof Health, at their last meeting, to the importance of ob-taining direct and immediate information as to cases of

zymotic disease from all general practitioners. We referredto the subject briefly last week, and hope that the continuedand emphatic expressions of opinion on this important sub-ject will induce all concerned to aid preventive officers inthe execution of their duty.

THE many friends and admirers of the late Mr. JamesHinton may be glad to know that Messrs. Barraud andJerrard, the photographers, of Gloucester-place, Portman-square, have some excellent likenesses of a man who was an

original and subtle thinker, and possessed many exceptionalqualities of mind and character.

PROFESSOR SANDERSON ON THE PROCESSOF INFLAMMATION.

LECTURE III.

THE lecture (delivered on December 20th) began by re-capitulating the conclusions of Mr. Lister as to the natureof the vascular changes which constitute the early stages ofthe process of inflammation, according to which, in the firstplace, the dilatation of the arteries, which must be regardedas the central fact of the primary afflux of blood, is due tosuspension of the action of a 11 peripheral co-ordinating ap-paratus" capable of being acted on independently of thecerebro-spinal nervous centres ; and, secondly, the increasedresistance in the capillary svstem, of which we have evi-dence in the phenomena of congestion and stasis, is to beattributed to impaired vitality of the bloodvessels. With

reference to the latter of these doctrines, it was clearly

pointed out that it has nothing in common with that of11 capillary force." It does not imply that any part of themotion of the blood originates by liberation of energy resi-dent in the tissues or capillaries, but, in accordance with theteaching of Harvey, assigns the whole of the mechanicalwork done in the maintenance of the circulation to theheart.Mr. Lister’s paper appeared in 1858. In 1868 a new name

connected itself with the history of inflammation-a namealready as familiar to all of us as those of Paget, Virchow,Lister, or Simon. Cohnheim formulatas his conception ofinflammation in terms which, at first sight, seem to resemblethose employed by Lister-" Alteration of the physiologicalstate of the walls of the vessels is the determining cause ofthose phenomena and processes which we commonly recog-nise as acute inflammation." It would, however, be a greatmistake to suppose that the ideas of Lister had any in-fluence on his successor, for in fixing on the vessel-wall asthe seat of all that is essential in the process of inflamma-tion, Cohnheim was wholly uninfluenced by any theory,either preconceived in his own mind or derived from others.It was the direct outcome of his own great discovery as tothe mechanism of exudation-a discovery which, so to speak,took everyone by surprise, for this very reason, that it wasnot led up to, as so many discoveries are, by anything whichhad come before either in the way of theory or observation.

Before Cohnheim, we thought of exudation as consistingin the sweating out from the bloodvessels of the liquid partof the blood, and particularly of its fibrin-producing con-stituent. Now we have to add to this conception that ofthe squeezing out of the corpuscular elements. From thefirst moment that the new fact was accepted as true, it wasat once seen by its discoverer that it bore upon every questionrelating to the nature of exudation, and the conditions onwhich it is dependent. He therefore devoted himself duringthe eventful years which followed the publication of thecelebrated paper °° On Inflammation and Suppuration," tothose elaborate investigations on the pathology of the cir-culation which are recorded in the essay

" On Embolism,"published in 1872, and in the Researches on Inflammation,which appeared in 1873. It is remarkable that facts whichwere of the greatest value in the elucidation of inflam-

matory exudation were brought to light by the experimentson embolism. By these experiments it was shown for thefirst time that the essential anatomical condition for theproduction of embolic infarction is, that the obstructedartery should be a terminal one-i.e., an artery of whichthe branches do not communicate directly with those of anycollateral. In accordance with the well-established prin-ciples which govern the circulation, he showed that if suchan artery is plugged, the whole vascular system of the rpgionsupplied by it becomes filled with stagnant blood deiivedfrom the veins, and that the resulting sanguineous infiltra-tion of the tissue is dependent on extravasation which takesplace through the walls of the capillaries, notwithstandingthat there is no solution of continuity of their walls. Thesefacts soon led to the inference that the reason why the cor-puscles find their way out of the vessels in this case, is tobe sought for in the alteration of property which the ca-pillaries sustain in consequence of the cessation of thecirculation.

Following out this consideration, Col: Mheim was led toinquire what would be the result if an organ were deprivedof blood for a time without being the seat of bæmorrhagicinfarction. With this view, a number of experiments weremade (the most important of which were fully desciibed inthe lecture), of which the general result was as follows.Whenever, in a mammal, the circulation is completely

, arrested in an organ (as, for example, in the ear of the

I rabbit) by the simultaneous occasion of arteries and veinsfor a sufficient number of hours (the time varying accordirgto the kind of anima.1 under observation), it is. observed’ that immediately after the restoration of the circulationI there is an abundant amix of blood in the organ so acted! upon, which in consequence becomes intensely red and hot,

the arteries being dilated to more than twice their naturalsize, and the temperature of the part higher by several

degrees than that of its fellow. Within half an hour thearteries have returned to their normal state, but the part,before merely hyperæmic, has become cedematous. On

puncturing it, it is found that the infiltrated liquid is loaded

150

with colourless corpuscles-is, in fact, purulent; in a word,the condition of the tissue is that of acute corpuscular in-filtration, with this remarkable characteristic, that it affectsequally the whole of the region previously deprived of cir-culation, and does not extend beyond it. What is to belearnt from the observation is this, that the privation ofblood, when continued, say for sixteen hours, is so damagingto the tissue of the organ placed under this condition that,although it looks perfectly healthy and natural, so long asno blood is circulating, it is in reality in the state of an in-flamed part. To prove its condition, all that is wanted isthe restoration of the circulation, for no sooner is thiseffected than the ordinary phenomena of inflammationmanifest themselves. It becomes hot, red, swollen, and nodoubt painful.

In order to connect this counterfeit process-identicalwith inflammation in result, though different in origin-withthe succession of effects ordinarily produced in a tissue byinjury, it must be contrasted and compared with them asthey exhibit themselves in the same field of observation.This comparison has been made by Cohnheim with won-derful completeness and accuracy. Among the most remark-able of the experiments he has made with this view, arethose which relate to the infla.mmations produced by ex-posure to heat and cold respectively-noxæ of which theaction is probably simpler than of any others. When theear of the rabbit is surrounded for a short time by a liquida few degrees below freezing, and then removed, it becomesred and congested, but soon the arteries contract, and thetissue returns to its natural state. If the temperature ofthe liquid is as much as seven or eight degrees belowfreezing, the ear reddens in the same way on removal, butthe redness soon becomes associated with doughy swelling.If the temperature is still lower, the so-called reaction iscorrespondingly more intense. The ear not only becomeshot and swollen, but in the microscopical examination of the exuded liquid, or of the tissue after death, you haveevidence that the part is in the condition of diffuse suppu-ration-being, in short, in a condition very similar to thatwhich was induced, with even greater rapidity, after tem-porary arrest of the circulation. In the action of high tem-peratures Cohnheim has shown that we have a similar grada-tion of action, so that the same effects which follow exposurefor a short time to a temperature of 16°, are produced with- equal promptitude by immersion in warm water of so moderatea temperature as 120°, provided that during the immersionthe circulation is arrested, so as to allow the tissue to takethe temperature of the medium with which it is in contact.Three degrees only of difference-i. e., raising the tempera-ture from 120° to 124°-are sufficient to convert non-inflam-matory into inflammatory-i.e., suppurative-œdema, andif this point is exceeded, death of the part, to a greater orless extent, is the inevitable result.We have thus two parallel series of effects produced in a

living tissue by agents differing entirely from each other,one a purely negative one, the privation of arterial blood,the other a noxa of the simplest kind : cold or heat, as thecase may be. In both series we have the effects followingeach other in the order of their intensity, in the former ac-cording to the time during which the part has remainedwithout circulation, in the latter according to the tempera-ture. In both cases the relation between cause and effect isso well ascertained, that if, for example, it is known howlong the arrest of circulation has lasted, it can be predictedwith certainty whether determination of blood, congestionwith cedema, diffuse suppurative infiltration, or gangrene,will be the result; and in like manner, by regulating thetemperature to the required point by the thermometer, wecan as well determine beforehand the supervention of eitherof these several degrees of inflammation.

Clearly the same close relation between cause and effect,between noxa and lesion, holds good throughout thepathology of inflammation ; and if this is so, it appearsthat no view can be taken of the process of inflammationmore simple, and at the same time more satisfactory, thanthat which was enunciated in the first lecture-namely,that inflammation is nothing more than the aggregate ofthose results which manifest themselves in an injured partas the immediate consequence of the injurious action towhich it has been exposed.[Erratum,-In the report of Lecture II., the word "moxa" should have

been noxa.] ]

Correspondence.

THE UNIVERSITIES AND MEDICAL DEGREES.

"Audi alteram partem."

To the Editor of THE LANCET.

SIR,-In your leading article of to-day on this subject,one important point seems rather to have escaped your con-sideration-viz., that the value of a title or degree, like thatof most other things, is not a little estimated by the diffi-culty experienced in obtaining it. The title of Doctor of

Medicine, there seems some reason to fear, is likely to be soeasily assumed that it will be scarcely worth the assuming ;and a large number of medical men will probably, ere long,prefer, as some now do, to be without it. The degree ofDoctor of Medicine at a University, however, will retain itsvalue so long as it is felt to represent a higher mentalculture, and, in the case of the Oxford and Cambridgedegree, that social culture and the other advantages whichare regarded as connected with a residence at those Univer-sities. Now this higher mental and social culture necessi-tates the expenditure of time in its acquisition, and thatinvolves the expenditure of money. This is the real difficultyin the way of obtaining a degree at the old Universities,and I think it will puzzle you to suggest a plan by whichthis can be lessened much more than has already beendone without lowering the value of the degree in a man-ner which I am sure you would be the last to wish.Some years since, it is true, there were other diffi-culties, such as those arising from religious views&c., which had the effect of dissociating the professionfrom the Universities. These have been entirely removed;but it takes some time to awaken the country and the pro-fession to the fact that there is no barrier whatever againsta degree at the old Universities, except the time and theknowledge required. Even the former has of late beenpractically much reduced: first, owing to the arrangementsby which the examinations in the subjects of general edu-cation may now be passed at the very commencement of theUniversity career, or even, through the 11 Oxford and Cam-

bridge Schools Examination Board," before the studentcomes into residence, so that the whole, or nearly the whole,of his time at the University may now be spent in the studyof Natural Science and Medicine; and, secondly, there isnow so much instruction and opportunity for work in thesesubjects, both at Oxford and Cambridge, that the old Uni-versities offer at the present time (in my opinion) to theindustrious and intelligent student the very best entranceinto the profession. I do not mean to say that we shouldbe content. Contentedness in such a matter savours ofthat dulness which is akin to deadness. Not to go on im-proving our educational system is certainly to go back;and if we go on, there is, I feel sure, a great future beforethe Universities in relation to the medical as well as thegeneral education of the country. The improvement mustnot be looked for much in the direction of lessening thetime, or the expense, or the standard of knowledge re-

quired. To lower the last, high though it undoubtedly is,would be fatal; and I question whether its maintenance iscompatible with any material further reduction of either ofthe other two.The number of degrees in Medicine conferred is, unques-

tionably, far too small. This, however, must now increase,as the number of students entering is increasing, and per-sons are beginning to be aware that the Universities are notonly freely open, but are good avenues to the profession;and the expense attendant on university education is notdisproportionate to the standard of knowledge required.It must, however, not be forgotten that many of our stu-dents do not proceed to the degree of Doctor. Some arecontent with the degree in Arts, some with the degree ofBachelor of Medicine, and some with the licence to practise

obtained elsewhere, finding that they are not equal to obtainthe degree here; so that the influence of Cambridge uponthe medical profession must not be estimated solely by thenumber of degrees conferred. The spirit of this University,and the same, I believe, may be said of Oxford, is essen-tially liberal, as much as that of any body with which I am