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certainly be the work of a day. Among other prospectivechanges he proposes that the grounds of Lincoln’s.inn.fields,the Foundling Hospital, St. Luke’s Asylum, the Artillery’’Ground, and various neighbouring almshouses should beutilised in this way, the dispossessed occupants of thefoundations above named being transferred to the countrynear London. To do all this of course implies no trifling«sost in effort and in money. The execution of a similarbut more limited scheme might, however, be accomplishedwithout much difficulty, and the free enjoyment of even’ene of the considerable areas mentioned would greatlyincrease existing facilities for physical recreation.

FOREIGN UNIVERSITY INTELLIGENCE.

Dorpat.-Dr. Bumm of Erlangen, who was offered the- chair of Mental Diseases, has declined to leave his present- chair.

Erlangen.-Dr. F. Hermann has been promoted to anExtraordinary Professorship of Anatomy.

Heidelberg.-Dr. T. Hoffmann has been promoted to anExtraordinary Professorship.

Leipsic.-Professor Sattler of Prague has been offered thechair of Ophthalmology, vacant by the death of ProfessorCoccius.Munich.-It is now stated that Professor Angerer is to

be appointed to the chair of Surgery recently left vacant by’Professor von Nussbaum’s death (i.e., not Trendelenberg, asin THE LANCET of Jan. 31st).

DEATHS OF EMINENT FOREIGN MEDICAL MEN.

THE deaths of the following distinguished members of ,the medical profession abroad have been announced:-’Dr. Bousouet of Marseilles, suddenly, while bending downto examine a patient.-Dr. Michaelis of Berlin, formerly inilarge practice as an ophthalmologist.

THE Parliamentary Committee of the London County’Council have recommended the adoption of the followingresolution: "That a petition be presented to Parliamentby the Council in opposition to the Metropolis Water-supply Bill ; and that the Council do oppose each of the’following B lls, against which they have presented peti-tions : The London Water Commission Bill, the Southwarkand Vauxhall Water Bill, and the Croydon Water Bill; and-that the costs and expenses incidental to the said petitionsa,nd the proceedings consequent thereon be charged to andpaid out of the county fund." It was pointed out that itwas necessary to have a majority of the Council in favourof the resolution to make it effective, and, the show of- ’hands showing only sixty supporters, a division was

"demanded, when the numbers were: For the resolution,’75 ; against, 17 ; majority, 58.

SIR G. M. HUMPHRY, F.R.S., has, we understand,- accepted the invitation of the Cambridge Medical Graduates’Club to a congratulatory dinner to be held at the

Marlborough Rooms, Regent street, on the 24th inst.:Sir George Paget, K.C.B., is to preside. Invitations to the.dinner have been accepted by Sir Joseph Lister, Bart.,F.R S. ;the Provost of King’s College, Cambridge; Sir Alfred Garrod,F.RS.; Mr. Bryant, President of the Royal College ofSurgeons; Dr. Priestley; Mr. Hutchinson, F.R.S.; andother leading members of the medical profession.

THE death is announced at Potsdam of the well-known

optician, Professor Edmund Hartnack, with whose micro-:&bgr;copes everyone is familiar. He commenced his manu-

facture of optical instruments in Berlin, but subsequentlyremoved to Paris. Political feeling there, however, drovehim out of France in 1870, and since that time he has beenliving in Potedam. The University of Bonn conferred anhonorary doctor’s degree on him in 1868, and the Ministerof Education granted him the title of professor in recogni.tion of the invaluable services he had rendered to science.

THE second lecture of the course of Ingleby lectures nowbeing delivered by Mr. Jordan Lloyd, M.B., M.S., F.R.C.S.,in the Examination Ilall of Queen’s College, Birmingham,will be given on the 26th inst. The course will be continuedon the following five Thursdays, the subject being 11 Prac.tical Observations on the Surgical Diseases of Children."

WILLIAM R. HuG GARD, M. A., M.D., M. R. C. P. Lond.Prakt. Arzt, Schweiz, has been appointed British Pro.Consul at Davos-Platz, Switzerland.

DR. DAVID W. FINLAY has been appointed ExternExaminer in Medicine to the University of Durham for thecurrent year.

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THE DEBATE ON KOCH’S REMEDY AT THEBERLIN MEDICAL SOCIETY.1

THE proceedings of the Berlin Medical Society on thellth inst.’ respecting Koch’s remedy were of considerableinterest, Professor Virchotv again intervening in a longspeech.

Dr. SILEX showed a case of lupus of the face, noe, andconjunctiva, which reacted well to the injections. After120 milligrammes had been given the lupus appeared to behealed ; but within ten days it reappeared, and in from twoto three weeks the nodules were as large as ever. Theeffect on the conjunctiva was less marked; indeed, thewhole of the left cornea became covered with pannus.He added that but few cases in the eye clinic had beentreated by the remedy.

Dr. A. FRAENKEL reported on the sixty-one cases oflung disease treated at the Urban Hospital for at least fourweeks ; furty-eight had been treated for more than sevenweeks, and some even for as long as eighty days. Hedivided the cases into sliglit, moderately severe, and severe.The "slight" comprised those of moderate infiltration ofone apex ; the " moderately severe" those with infiltrationof a whole lobe, or of both sides, or complicated with pleuraleffusion or slight laryngeal tubercle; and the "severe"those with indubitable signs of excavation, or complicatedwith intestinal tuberculosis or advanced laryngeal affection.Of the total eighty-three cases (including those treated forless than four weeks) there had been two deaths. One wasa woman who, together with manifest pulmonary signs, hadparalykis of the left sixth nerve ; and after the third injec-tion of 0’001 grm. she had headache and other signs oftuberculous meningitis, from which she died in a week.The other was a man aged fifty-one, with marked affectionof both lungs. He received five injections, the last being0.005 grm , which was followed by severe dyspnoea and deathin three days. But there was no evidence of acute conges-tion or pneumonia-only old caseous foci and some largecavities in the right upper lobe. In seven cases the treat-ment had to be suspended-in three on account of heamo-ptysis, in one after a week’s injections, which had reached0’1 grm., and the hæmoptysis lasted for twenty-four days.In four cases an aggravation of symptoms caused the sus-pension of injections. In one, a case of double pleurisy,with unilateral phthisis, severe dyspncea ; and in three,persistent fever with increase of local signs. One of thesewas especially remarkable-the changes in physical signsbeing very striking, and attributable to severe catarrhal

1 See THE LANCET, vol. i. 1891, pp. 215, 271, 328, and 389.2 Considerations of space compel a considerable curtailment of this

report, which occupies sixteen closely printed columns of our contem-porary, the Berliner Klinische Wochenschrift, No. 7.

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pneumonia. One case of lupus of the soft palate, pharynx,and larynx, together with renal tuberculosis, was treatedwith great cautron ; but no reaction was observed, althoughas much as 0’07 grm. was reached. Still latterly thereseemed to be some melting down of the tubercular growth onthe epiglottis and false cords. As to the pulmonary cases,he held that, whatever the value of physical signs, one couldnot speak of a relative cure so long as the sputa containedbacilli; and, indeed, he did not think the time had yetcome to speak of absolute cures. He mentioned a case inwhich bacilli had been absent for nine weeks, when bttno-ptysis supervened, possibly from a small, not recognisable,cavity. Of the sixty-one cases, there were three in whichbacilli were absent for from seven to nine weeks, and thephysical signs, always slight, had subsided. In no fewerthan fifteen of the slight cases no change as regards amountof bacilli could be noted ; and yet these were cases with thevery slightest physical signs, including some which for twomonths had been receiving 0’1 grm. twice a week. Bacillimay spontaneously disappear from the sputum for sometime. Twenty-eight cases (thirteen slight and fifteenmoderately severe) might be described as improved ;not as regards the bacilli, but subjectively, and in

aspect, in diminution of sputum, and in increase ofweight. He had often remarked a notable increase inweight of such patients before the introduction of Koch’streatment, but nevertheless the general improvement underthe influence of the injections was very striking. In twentycases (three slight, thirteen moderate, and four severe) nochange had been observed. Lastly, nine cases (six moderateand three severe) had got worse, showing that it could notalways prevent extension of the disease. He summed uphis experiences as :-1. A limited number, especially of slightcases, undergo a marked change for the better, bacilli dis-appearing from sputa and general nutrition improving, thisbeing apparently due to the melting down of caseatedinfiltration. Yet such a result cannot always be predicted,even in the mildest cases. 2. In a large number (aboutone-half) there is improved nutrition, which may be due toKoch’s method or to tonic and dietetic treatment. 3. In nosmall percentage the moderately severe cases grow worse,and sometimes from conditions attributable to the treat-ment. 4 Severe cases ought to be quite excluded from thetreatment.Dr. JULIUS WoLFF spoke of the treatment in joint disease,

detailing two cases in which marked extension of thetubercle took place. He did not think the original hope,that the presence of

" dead tuberculous tissue" would moreclearly define the parts to be excised, had been fulfilled, northat the general and local reactions were at all pro-portionate to the extent of the local process. But in notone case had the general condition of the patient been un-favourably influenced by the remedy, nor in the cases

operated upon had it had any bad effect on the course ofthe wound.Dr. FLATAU referred to two laryngeal cases shown by

him a fortnight back, in which, during marked improve-ment, there suddenly arose a fresh outbreak of miliarytubercle in the larynx. In the one, where there wasnothing in the larynx at first but a small cicatrix, andwhere marked improvement took place in the pulmonarysigns, there was a further extension of disease in the larynx,and appearance of tubercle in the tonsil, which had dis-appeared ; and no further extension occurred, although theinjections were pushed as far as possible. In the otherpatient, where weakness precluded continuance of theinjections, more nodules had appeared, the older ones

becoming more opaque.Professor VIRCHOW spoke at considerable length upon the

question of the cure of tubercle, so variously interpreted ;and in the first place he inquired what was precisely meantby the term "tuberculous tissue" used by Dr. Koch. Theconception of "tubercle had undergone so many changesthat it was difficult to be sure of the meaning now con-veyed by it ; but it was clear that the tissue referred to byDr. Koch was not the circumscribed granulation, but adiffuse infiltration. It had been objected that too muchattention had been paid to anatomical facts, but only inthat way could certain information be obtained. No onedoubts that in a tubercular inflammation-e. g., arachnitistuberculosa-there are two factors : inflammation, producing ’,an exudation ; and tuberculosis, a tissue. So in the lungs,besides the true tubercle or tissue, there is in the course ofphthisis the occurrence of a quantity of inflammatory pro-

cesses which are not tubercle, such as the smooth, soft,catarrhal form, and the hard caseous form of inflamtxiatoi-ychange. The difference is as great as that between the exuda -tion and the tubercle in a tuberculous arachnitis or pleuritis. Inthe lungs there are inflammatory processes filling the alveoli,producing hepatisation &c., and another process excited*by true tubercle, which forms a tissue. A like diversity is to.be seen in the processes in tuberculous arthritis. In reference-to the action of the injections, he wished the distinction couldalways be borne in mind between (1) the tissue strictl3xtubercular, (2) the tissue which arises near to or precedesthe tubercle, and (3) the mere exudation products. One.asks-Does Koch’s remedy act on all three? Possibly, butthe ostensible action is certainly not shown to an equalextent on all three. Deferring consideration of the pointraised by Dr. Flatau as to the production of tubercle by the-injections, there is no doubt that an immediate action ofthe remedy on tubercle as such is by no means uniform andconstant. This may depend in part on the site of the-tubercle-e, g., in liver, or mucous or serous membrane, &c.,differences in physiological conditions. By the " cure" oftubercle in a mucous membrane is meant its breaking downinto an ulcer, and the ultimate cicatrisation of the latter,,all the tubercular matter having been got rid of. Ina serous membrane, such ulceration, which so rarelyoccurs there, leads to fatal issues, and cannot be re---

garded as a curative process. Laryngeal tubercle differsfrom intestinal in rarely caseating (on this groundLouis denied the existence of laryngeal tuberculosis);. ;,the ulcers it excites are more superficial and earlier-formed. As to the effect of the injections, it is ofcourse impossible to determine whether certain tubercleswere present or not before these began ; but it is clear that.the remedy does not act on all tubercle, for often no indications of degenerative change or of their resolution are visible.Tubercle tends rather to be encapsuled than removed byabsorption ; and he had not seen any more evidence iofavour of the latter process in the present than in the past.Dr. Koch had said the bacilli were unaffected by theremedy, and if it were true that the tuberculous tissuewere dissolved and rendered capable of absorption, thebacilli might be absorbed too, with considerable risk.Professor Virchow thought rather, from the clinical andanatomical facts, that tne remedy acted upon the tissue-around the tubercle, which might beneficially lead to itsextrusion, but also imperilled the patient from its extentand intensity. In his previous statements he bad only re--ferred to conditions which had occurred, and thence left.it to be inferred what were the risks involved; bubthe determination of the relative frequency of these-dangers can only be made after prolonged investiga-tion. The severe changes excited in the vicinity of the-tubercle, as seen in cases of lupus and of laryngealtuberculosis, are probably reproduced in lungs and brain,producing conditions of acute swelling, bypertemia, œdema,hæmorrhagic infiltration, leucocytal emigration, and, later"new formation of tissue. Then there is the questionwhether Koch’s method does not hasten disintegration pro-cesses. It might be affirmed positively that the remedydoes not excite any process which cannot occur apart from.it. Apart from cases showing extreme increase of a.

phlegmonous process, all the changes induced are thosepreviously known as forms of inflammation or mortification.But their progres is hastened, so that in a couple of days’as much destruction is brought about as might perhaps haveotherwise taken a month ; and under certain conditions this>is a great gain, for the more rapid removal of the noxiousmatters acts prophylactically against further infection ofneighbouring or remote parts. The "clearing up ’’ ofaffected parts of the lungs noted by some observers is ex-

plicable when the characters of catarrhal inflammation withconcomitant atelectasis and bronchial occlusion are borne"in mind. Fatty metamorphosis and the melting down orthe shrinking of the hepatised areas may conceivably ex.plain the improvement in physical signs ; not to men-tion the rarer concomitant of resolving fibrinous pneu-monia. So that the signs of "clearing up

" are>

attributable to the process of catarrhal hepatisation :Hitherto we have known nothing of a spontaneous resolution)of caseous hepatisation. When small, these foci may become-encapsuled ; when large, sofcer and excavate; but neither-of these modes of "cure" will restore the respiratorycapacity of the affected parts. No onehas affirmed that

Koch’s remedy acts favourably on indurative and encap-

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suling processes; its action consists in hastening thesoftening of caseous material. Herein lies the dangerarising trom the swallowing or aspiration of the rapidlysoftened products. So far, then, there was no evidence thatthe bacilli are killed and dissolved; no direct facts to provethat the remedy causes resolution of the true tuberculartissue or the absorption of tubercle as such. Thenthere was ample evidence that the tubercle as well as

the inflammation is rapidly destroyed, thereby warrantinga possibility of a relatively early cure. But there is no’fact showing that induration and the encapsuling ofcaseous parts are favoured; rather is it that the remedyliberates masses previously encapsuled, and in that wayconverts an apparently harmless focus into a source

of actual danger to the patient. Professor Virchow-expressed the hope that the facts he had adduced mightlead to more definite ideas as to the indications for theremedy, and the rejection of such cases as were manifestly’unsuitable. He was far from considering these experiments.as closed. He recognised with pleasure that it was highlyimportant that such researches as had been related byDr. Flatau should be pursued to determine if a trueabsorption occurs. It would be a wonderful thing if the’tubercles evoked by Koch’s remedy should also be made to’disappear by its action. It was not impossible; but yetwhen we see the thousands of miliary tubercles in thebodies of those who had been injected (tubercles whichsome thought were all present before the injections) it is- difficult to understand why tubercles arising in ordi-nary process of tuberculosis should escape, whilst thoserecently arising should disintegrate. It was important toknow whether these "new tubercles" underwent any- change spontaneously, whether, if the injections were notcontinued, they would increase in size, or what would happento them.

Dr. FLATAU explained that the ideas about the cure oftubercle of mucous membrane were not his own, and that inthe case he related the treatment bad been suspended for afortnight without any change beyond further outbreak, asrelated.

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THE MIDWIVES’ REGISTRATION BILL.

DEPUTATION TO THE LORD PRESIDENT OF THECOUNCIL.

A DEPUTATION consisting of about 100 representatives of’corporations and medical societies was introduced to LordCranbrook by the Attorney General for Ireland, for thepurpose of protesting agaiust the Midwives’ RegistrationBill now before Parliament, and down for the second

reading on March 3rd.Mr. CROLY, representing the Royal College of Surgeons

in Ireland, pointed out that the Council of that Collegewould be quite willing to accept the Bill if adequate.guarantees of education and competency were given. Thetraining of midwives in Ireland had always been conductedwith great care. The proposal to register all midwives nowin practice was altogether objectionable. They ought to bemade to show that they have been properly trained ; andthis was more important, inasmuch as the limitation to- cases of " natural labour" was quite impracticable. In’Ireland no person was recognised as a midwife without sixmonths’ training in a lying-in hospital and a subsequent.examination.The LORD PRESIDENT.-I observe that in this Bill Scotland

and Ireland, except where expressly provided for, would notbe affected by the Act.Mr. CROLY continued that it was very important that

midwives trained in Ireland should be put upon the EnglishRegister without any further tests.The LORD PRESIDENT.-Yes, and that is provided for in

Clause 8 of the Bill.Mr. CROLY submitted that it was impracticable to entrust

to separate County Councils or boards of guardians the’examination and registration of midwives.

Dr. MACNAUGHTON JONES, representing the Royal Uni-versity of Ireland, large numbers of the graduates of whichwere practising in England, said they opposed the Bill onthe ground that it contained so many elements of dangerthat it was incapable of being satisfactorily amended incommittee. It was an effort to legislate for an unknown

quantity, and it did not attempt at any definition savingin one clause, where it refers to the midwife restrictingherself to cases of "natural labour" only. Scientificobstetricians could not agree on this point. The Bill gavethe women permission to attend that form of labourin which more than any other unskilled and uncalled-for in.terference imperilled the life of the offspring, and converteda perfectly safe case into one of considerable dangerand difficulty. Legislation should take the form ratherof’securing for the public a high type of obstetric nurse,than in stereotyping and perpetuating an old and inferiorgrade of midwife. Not the least dangerous part of the Billwas that which qualified every existing " Gamp" who choosesto call herself a midwife to be registered without conformingwith educational regulations and examination tests. Ifthey could not do so, they ought to remain monthly nurses.The Bill did not define the duties of a midwife, or herresponsibility in regard to puerperal septicaemia or the con.vexing of infection, and attached no penalty for neglect onthe part of a midwife to call in skilled assistance at theproper time. The Bill contained inherent evidence of itsbaving been drafted for a class without due regard to theinterests or safety of the public.

Dr. JACOB, secretary to the Council of the Royal Collegeof Surgeons in Ireland, pointed out that it would be per.missible for incompetent women who were placed on theRegister to come to Ireland, where a high standard ofeducation had always been maintained, and practise mid.wifery. They dreaded that a similar thing would happenwhich occurred on the passing of the Dentists RegistrationAct, in consequence of which 4700 persons were admittedto the Register, the large majority of whom were notdentists in any sense of the word, and there they remainedtill the present day. They felt apprehensive that a similarcourse would be followed in the case of midwives, and thepublic for the next twenty-five or thirty years would bepreyed upon by a large number of incompetent persons whohad been annexed under this Bill simply by signing a paperstating that they were bonâ-fide practitioners of midwifery.He was authorised by the Apothecaries’ Society of Irelandto state that in their opinion no amending would make thepresent Bill tolerable."

Dr. GILBART SMITH, President of the Irish Schools andGraduates’ Association, pointed out that, from the point ofview of an ordinary physician, labour often became com-plicated from obscure organic disease, such as Bright’sdisease, and it would hardly be fair to leave the decision ofsuch questions in the hands of a woman qualified by only afew months’ training. The question had been discussed ata meeting of the Fellows of the Royal College of Physicians,and a committee had been appointed to inquire into theBill, and there was no reason to believe that they wouldreport in any direction but that of opposition to the Bill.He firmly believed that the best interests of the public andof the profession would be served by setting aside the presentBill.

Dr. RENTOUL said that the Medical Act of 1886 requiredthose who practised midwifery to possess a qualification inmedicine and surgery as well. This Bill was an endeavourto break through the spirit of that Act. The GeneralMedical Council had laid it down that a student must studyfor at least five years, and fixes the minimum of knowledgewhich it was necessary for him to possess. This Bill wanted toeducate the midwife in a few weeks or months, and enableher to claim fees in a court of law for all "natural labours"-that is, 990 out of every 1000 cases. The Bill could notmake it penal if midwives attended abnormal cases, and itfollowed that the midwife ought to be competent toundertake cases in which delay threatened the life of themother or infant. Under these circumstances she wouldrequire a full and complete training. In 1888 the report ofthe Registrar-General stated that 4160 died from "theaccidents of childbed," most of whom lost their lives fromcomplications arising from diseases of the heart, kidneys,or lungs. The midwife was not able to recognise thesediseased conditions. Further, 30 per cent. of totalblindness which affects persons in this country is dueto infantile ophthalmia. There were not at presentsufficient cases to supply both the medical student andthe pupil midwife in midwifery. At the last session ofthe Council Dr. Glover moved that the minimum number ofcases for each student should be thirty. To supply thisnumber of cases to that number of students would require51,990 cases. The voluntary medical charities gave relief