THE JOURNAL OF THE IRISH MEDICAL ASSOCIATION. THE unusual pressure on our columns from the reports of the General Medical Council, compels us, although we have increased the size of the Journal for their accommodation by one-third, to forego the publication of THE JOURNAL OF THE IRISH MEDICAL ASSOCIATION for one week. We have felt ourselves excused in doing so, because the important debates on the representation of the medical practitioner in the Medical Council embodied in the report are of such close and immediate interest to the Irish provincial practitioner that, under any circumstance, it would have been necessary to lay them before the readers of the Association Journal. We have in type an abstract of the Poor-law Commissioners' report just issued, which we hope to give in our next. COPY OF "MEDICAL PRACTITIONERS' (COLONIES) BILL." WHEREAS by the Thirty-first Section of "The Medical Act," passed in the Session holden in the Twenty-first and Twentysecond Years of Her Majesty, Chapter Ninety, it is enacted as follows:-"Every Person registered under this Act shall be entitled, according to his Qualification or Qualifications, to practise Medicine or Surgery, or Medicine and Surgery, as the Case may be, in any Part of Her Majesty's Dominions, and to demand and recover in 'any Court of Law, with full Costs of Suit, reasonable Charges for professional Aid, Advice, and Visits, and the Cost of any Medicines or other medical or surgical Appliances rendered or supplied by him to his Patients :" And whereas it is expedient to amend the said Enactment: Be it enacted by the Queen's most Excellent Majesty, by and with the Advice and Consent of the Lords Spiritual and Tem poral, and Commons, in this present Parliament assembled, and by the Authority of the same, as follows: 1. This Act may be cited as "The Medical Act Amendment Act, 1868." 2. The Term "Colony" shall in this Act include all of Her Majesty's Possessions abroad in which there shall exist a Legislature as hereinafter defined, except the Channel Islands and the Isle of Man. The Term "Colonial Legislature" shall signify the Authority, other than the Imperial Parliament or Her Majesty in Council, competent to make Laws for any Colony. 3. Every Colonial Legislature shall have full Power from Time to Time to make Laws for the Purpose of enforcing the Registration within its Jurisdiction of Persons who have been registered under "The Medical Act," anything in the said Act to the contrary notwithstanding: Provided, however, that any Person who has been duly registered under "The Medical Act" shall be entitled to be registered in any Colony, upon Payment of the Fees (if any) required for such Regis tration, and upon Proof, in such Manner as the said Colonial Legislature shall direct, of his Registration under the said Act. LIST of Entries in the Register of the Branch Medical Council, Ireland, for the month of June, 1868. Michael Joseph Keating, 4, Cumberland-place, North Circular-road, Dublin, Lic. R. Coll. Surg. Irel., 1867, Lic. K. Q. Coll. Phys. Irel., 1868; Michael Strahan, Arklow, co. Wicklow, Lic. R. Coll. Surg. Irel., 1865, Lic. R. Coll. Phys. Edin., 1866; David Bigger, Portadown, co. Armagh, Lic. R. Coll. Surg. Edin., 1868, M.B. Univ. Glasg., 1868; Philip Somerville Warren, 9, Summer Hill, South, Cork, Lic. R. Coll. Phys. Edin., 1867, Lic. R. Coll. Surg. Edin., 1867; George M. Dowidge, Chesterfield, Parsonstown, King's County, Lic. Apoth. Hall, Dublin, 1836; Thomas Ryan, Baylick, Middleton, co. Cork, M.D., 1867, and Mast.-Surg., 1867, Qu. Univ. Irel.; Charles Edward Crean, Ballenvilla, Claremorris, co. Mayo, Lic. R. Coll. Surg. Irel., 1867, Lic. 1868, and Lic. Midwifery, 1868, NOTICES TO CORRESPONDENTS. Proofs reaching authors in England on or before Friday morning are expected to be returned to the Editor, at the office, 20, King William-street, Strand, W.C., before five P.M., on Friday afternoon. Proofs reaching authors on Friday evening or Saturday morning must be returned to the office by two P.M. on Saturday, which is an early closing day. Duplicate proofs are sent to authors, in order that they may correct and return one copy, and keep the other for private use. Contributions should be LEGIBLY written, on one side of the paper only. The wonderful natural properties of the Mineral Waters of Carlsbad are too well known to require commendation; they are a fact proved by the experience of many centuries. The waters can be used in the same way at home as at the Spring. The usual dose is One Bottle of Mineral Water each morning, taken at intervals of twenty minutes, either cold or warm, and after open-air exercise if practicable, or at home and in bed if necessary. To increase the aperient qualities of the bottled Carlsbad Waters, one teaspoonful of the SPRUDEL SALT should be added. All orders for the MINERAL WATERS, SPRUDEL SALT, and SPRUDEL SOAP will be promptly executed at the Depots in all large towns, or direct by the Brunnen Nersendungs, direction of Heinrich Mattoni, Carlsbad, Bohemia. 66 K. Q. Coll. Phys. Irel.; Richard H. Porter, 64, Dame-street, Dublin, LIQUOR OPII SEDATIVUS HEATHFIELD'S" Lic. Apoth. Hall, Dublin, 1868; Benjamin Frederick Bradshaw, Bansha, co. Tipperary, Lic. R. Coll. Surg. Irel., 1868, Lic. 1868, and Lic. Midwifery, 1868, K. Q. Coll. Phys. Irel.; Robert Hunter. Kilrea, co. Derry, Lic. R. Coll. Surg. Edin., 1867; Richard Creed, Glasnevin, co. Dublin, Lic. R. Coll. Surg. Irel., 1868; James Berry Kenny, Killeshandra, co. Cavan, Lic. K. Q. Coll. Phys. Irel., 1863, Lic. R. Coll. Surg. Irel., 1868; Arthur Vernon Macan, 10, Gardiner's-place, Dublin, M.B., 1868, and M. Ch., 1868, Univ. Dublin; George Ivie Mackesy, 38, Lady-lane, Waterford, M.B., Univ. Dubl., 1868, Lic. 1868, and Lic. Midwifery, 1868, R. Coll. Surg. Irel.; Henry Clarke, 26, Holles-street, Dublin, Lic. 1868, and Lic. Midwifery, 1868, K. Q. Coll. Phys. Irel., Lic. R. Coll. Surg. Irel., 1866; William Sharpe, Manorhamilton, co. Leitrim, M.D., 1866, and M.Ch., 1868, Qu. Univer. Irel.; William West Fulton, Lough Brickland, co. Down, M.B. Univ. Glasg., 1868, Lic. R. Coll. Surg. Edin., 1868; John Joseph Neville, Macroom, co. Cork, L.R.C. Phys. Edin., 1867, L.R.C. Surg. Edin., 1867. AS BATTLEY'S. BEING Agents for this preparation, we beg to call the attention of the Medical Profession and of the Dispensing Chemists to its claims. It has been much prescribed by the Profession for many years, and we offer it with the greatest confidence as being prepared exactly on the same manner as Battley's. As a sedative the "Liquor Opii" has no equal, and as a favourite of forty years' standing it has maintained its position almost without a rival. We take this opportunity of urging its reputation and soliciting orders for same. BOILEAU AND BOYD, Wholesale Druggists, 92, BRIDE-STREET, DUBLIN. Original Communications. MORBID CONDITIONS OF THE THROAT IN THEIR RELATION TO PULMONARY CONSUMPTION: THEIR DIAGNOSIS AND TREATMENT. Br S. SCOTT ALISON, M.D. EDIN, FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, LONDON, AND PHYSICIAN TO THE HOSPITAL FOR CONSUMPTION AND DISEASES OF THE . CHEST, BROMPTON, AND THE SCOTTISH HOSPITAL. No. II I Now come to disease of the trachea and larynx and adjoining parts in their relation to pulmonary consumption as a simulator. This relation it is the great object of this paper to exhibit. Throat affections, when simulating pulmonary consumption, present that relation that is most interesting, inasmuch as they give rise to suspicion of dangerous disease that does not exist, constantly give way under skilful treatment, and carry away with them every fear of pulmonary mischief, or remain only for a time without impairing the value of life. These simulative diseases give scope to the exercise of that eremen eruditum which enables the physician to declare with certainty the existence of only minor and generally curable disease, and the absence of a complaint most generally fatal. How useful and comforting this skill proves to the patient and to his friends, how valuable in many aspects-as, for instance, in relation to business affairs, to arrangements in domestic life, to travel, to place of residence, to life assurance, the value of annuities and reversions, and how pleasing it is to the physician, and how creditable to that art to which many are even now so prone to affix the stigma of incompetence. That it is a common thing for purely throat affections to simulate chest disease, and more especially pulmonary consumption, I may safely say. Amongst some forty patients always under my care in the Brompton Hospital, I constantly have some who have, as far as I am able to judge, no disease whatever of the chest. During the eight years I have had the charge of in-patients, I have constantly had to record the absence of all pulmonary mischief, and the presence only of disorder of the trachea and other parts of the upper portion of the air-tube apparatus. These patients have been kept under observation in reasonable time to admit of further and repeated examination, and have not been dismissed until the most careful further scrutiny has confirmed the original diagnosis. I have constantly had occasion to recommend the early dismissal of patients under such circumstances, and in no case have I heard that the dismissal turned out to be unfortunate-that is, was followed with evidence of disease of the chest. Such cases, it should be added, have been sent to the hospital as often as consumptive ones, and with medical certificates. At present there are in the hospital under my care six patients with affections of the upper air-tube apparatus simulating more or less strongly pulmonary consumption; three are females and three are males. The chief morbid conditions are infected pharynx, enlarged tonsils, and congested condition of the trachea. The total number of patients is 43, and these six cases give a percentage of 16. The total number of pulmonary consumption cases is 26, and the six cases of simulated consumption with affections of the upper air-tube apparatus give the result of 23 per cent. to the cases of pulmonary consumption in the hospital under my care. One of the most common forms of disorder of the trachea and other connected parts is a state of roseolar congestion of the trachea, larynx, and glottis, conjoined with nervous irritability and spasmodic action. Sometimes there is associated a general deterioration of the health and some loss of flesh. Sometimes the general health is good and the nutrition of the body is unimpaired, but in this latter case there is less likelihood of consumption of the lungs being successfully simulated. A condition of trachea giving rise to suspicion of tubercle of the lung, involving the form and calibre of the trachea, has frequently come under my notice, and I rather think has received little or no notice from pathologists. This condition is one of constriction or narrowing of the tube immediately above the bifurcation. The reduction of the calibre begins about an inch above the bifurcation, increases for half-an-inch, and then gradually reduces in the direction of the bifurcation. The extent to which the narrowing occurs varies, but is very manifest to the eye in many cases. The narrowing affects the whole circumference of the tube, and does not proceed from projections at particular spots. The cartilages remain of the normal length, the soft parts of the posterior wall only being reduced in breadth. This narrowing of the back wall devoid of cartilage is very obvious, and depends generally upon an undue amount of muscular contraction. No morbid lesions are found, saving narrowing and signs of over-vascularity and some thickening of the mucous membrane. When the measurements of the contracted part are compared with the calibre of the joint calibre of the two bronchi at the bifurcation they are found to be greatly deficient. The calibre of the narrowed part is also found unduly less than that of the trachea in its upper part. It should be mentioned that in health the trachea is narrower below than above, and the calibre of that part is less than the joint calibres of the two bronchi. The excessive narrowing of the trachea gives rise to a certain continuous difficulty of respiration, great sense of oppression in the upper front part of the chest, including the region of the sternum. The difficulty is liable to exacerbations, an exposure of the patient to cold, and an occasion of increase of vascular congestion or of spasmodic action. This narrowing gives rise to difficulty in inspiration and also to difficulty in expiration. It is this condition of narrowing which so frequently leads to emphysema of the lungs a state occasionally associated with tubercle. The expiratory effort is opposed by the obstruction offered to the volume of air in course of expulsion, and the tender walls of the lung air-vesicles give way, dilate, coalesce, and give rise to wheezing lung inspiration, sibilant and sonorous rhonchi, imperfect oxygenation of the blood, in some cases purple countenance, and laboured and inefficient action of the heart, often accompanied with dilatation and softened flabby walls of that organ. The respiration through the trachea is highly noisy and constrictive, and this applies to the expiration as well as to the inspiration. The seat of the most intense constriction sound is immediately close to the sternum, where the stethoscope should be placed. tinct from the narrowing of the trachea, which I have desired to bring under the notice of the reader. Hypertrophy and engorgement of the mucous follicles of the posterior wall of the pharynx have been, in some cases of suspected pulmonary consumption, the only pathological conditions discernable under the most careful and repeated exploration. The posterior wall has been seen roughened and unduly injected, presenting an unusually florid colour, or an undue clarety aspect, together with enlarged and various venous twigs. The uvula, in some few examples, has been the only structure that has presented a morbid condition; generally it has been injected, often it has been hypertrophied; sometimes, on the other hand, it has been greatly reduced in size, or totally obliterated, but this part has often been found unduly long, occasionally clubbed at its extremity, but more frequently tapering to rather a fine point, membranous and almost transparent. The tonsils, in numerous examples of merely simulated pulmonary consumption, have been the only parts which, under diligent and repeated examinations, have presented a morbid condition. The morbid condition has varied, but in most examples it has been one of considerable enlargement, undue redness and vascularity, with mucous depressions, as if scarred, or chopped, or pock-pitted. This state has usually been shared by both tonsils, but occasionally it has been confined to one. When both tonsils have been enlarged to the size of walnuts, they have, by approaching each other, greatly contracted the entrance into the pharynx, and interfered with the free pendency of the uvula. In such cases the voice has had an unduly This morbidly narrowed condition of the trachea from its nasal tone, and some little difficulty has been experienced causing shortness of breath, serves to suggest the idea of in swallowing. The respiration through the trachea in consumption, and when it is associated with streaky hæmop-most cases has been highly constrictive, and I have obtysis, which it sometimes is, with cough, general derange- served in a majority of the patients a sensible amount of ment of health, and loss of flesh, the idea of tubercle of hardness of hearing. the lung acquires strength with non-professional people, and even with medical men, who neglect the careful employment of auscultation and of other exploratory tests. The excessive shortness of breath in such cases, coupled with only moderate wasting of the body, the highly constricted respiration sounds in the throat, and the almost normal state of the respiratory voice, and percussion sounds of the chest, and of the shape and movements of that region, permits little doubt to rest in the mind of the practised physician as to the comparatively soft nature and generally local character of the disease, and as to the chance of tubercle in the lung. It may serve to guard the young practitioner, however, to say here that such a narrowing of the trachea as has been described above, is sometimes associated as a sequela of tubercle of the lung, but exploration of the chest will easily establish this coincidence where it occurs. In the healthy state, the trachea presents a difference in its volume at different parts. An inch above the bifurcation, on careful measurement of a healthy trachea, I found that a cord passed over the exterior measured three inches, while a cord passed round it immediately above the bifurcation, measured only two inches and seven-tenths. The capacity of the trachea immediately above the bifurcation is greatly less than that of the conjoined capacities of the two bronchi at their origin. The internal circumference of the trachea at this spot, I found on careful examination of a normal organ, to be two inches and twotenths, while the conjoined internal circumference of the two bronchi amounted to three inches and three-tenths. The right bronchus exceeded in its internal circumference the left by one-tenth of an inch. Stricture and constriction of the trachea have been referred to in various works on the throat, but their morbid conditions, as there described, have been more restricting and partial than the constricted condition of the trachea which I have endeavoured to describe. The partially constricted condition of the trachea, which points from tumours and foreign bodies in the tube, and from tumours outside, and from injuries by violence, are, of course, altogether dis That cases such as the above are sometimes treated as examples of pulmonary consumption, there is no doubt whatever. The cough, the occasional streak of blood, and the impediment to free perspiration, suffice to this end. Such cases of simulated pulmonary consumption are common in children, and in young persons about puberty. A girl about 12 years of age came into the Rose ward lately with such a condition of tonsils as has been described. She was rather plump. No sign of tubercle of the lung being made out, I enquired more particularly into her history. She had come to the hospital from a place in the country many miles from town, and she informed me she had seen (I believe) some eleven doctors. It was clearly a case for surgical aid, and Sir W. Fergusson, the surgeon to the hospital, being sent for, removed the hypertrophied parts, and the patient was then sent home, carrying with her no signs whatever of chest disease recognizable by myself, the house-surgeon, or my clinical assistant. CASE 3rd necessarily includes two parties-husband and wife. On January 11, 1868, Mr. D. came to get advice for what appeared to be herpes preputialis. He said he had been treated for the same affection some three years before, and that the late Dr. Halliday cured him in a very short time. He remembered the name herpes to have been used by Dr. Halliday on that occasion. The gentleman's regular habits, and unimpeached character, seemed to place him beyond suspicion of impurity of mind or body, still great caution was required in answering his pointed questions, as he seemed in greater dread of the disease than its condition at the time warranted, or his past experience should have admitted of. Considering that the patient should be prepared for the possibility of evil consequences, I reserved judgment, and suggested the likelihood of his having contracted the disease in a foul privy, which hint he willingly accepted, as furnishing a respectable fons et origo mali. He had been away on business in the south of Ireland, and two days before coming to me he first noticed itching of the prepuce. He was a most temperate and regular man, as already mentioned, and lived happily with his wife (who at this time was about seven months pregnant). Rest, repeated bathings, the application of dilute lead lotion, and a mild purgative, were the remedies advised. On January 14th he was quite free from the local disease, no irritation whatever remaining, but nocturnal perspirations had become a great source of discomfort to him; for this he was recommended to sponge with tepid water impregnated with sulphuric acid. He returned on February 4, suffering from marked febrile symptoms (hot dry skin, headache, constipation, and quick pulse). For two days he had observed a bright scarlet rash (roseola) to come and go on his chest and abdomen. On examination the glandulæ concatinata were found enlarged, copper-coloured stains were discovered at the flexure of his right elbow and the back of his neck, his forehead had become very rough, but not discoloured. His throat was simply erythematous. The glands of each groin remained unaffected. Corrosive sublimate in compound infusion of gentian, to be taken with cod-liver oil, as in case 2, also 15 grs. of Dover's powder each night, rest, and plain nourishing diet constituted the treatment at this stage of his illness. He was recommended strong alum water gargle for his throat. Eleven days later (February 15), on visiting Mr. D. at his own house, I was glad to see that a great improvement had taken place in his health. The cutaneous disorders were dying away; his throat was much better with the exception of a small ulcer which had attacked the left tonsil. The glands at the back of his neck were not so perceptible, and the stains mentioned before were not so distinct. He stated that he had derived considerable benefit from sponging with the acidulated water. He complained now of his eyes being rather sore, and his sight weak, but I could not detect any morbid appearances. His wife had now unfortunately become a sharer in his sorrow, and evidently a partaker of the forbidden fruit. Her chest was as red as the shell of a boiled lobster; the glandulæ concatinate greatly enlarged, and the throat very sore, but not ulcerated. She was depressed in spirits, and feverish. She readily submitted to an examination, when for the first time she became aware of a number of ragged ulcers on the mucous surfaces of the labia. To the inside of each thigh was a patch of vesicles, which were highly inflamed and intensely itchy. A thick row of pustules extended up from the fundament to the end of the coccyx. There was no tenderness in either groin, nor could any hardness be felt, the chancres, also, were free from induration. After cauterizing all the chancres with nitric acid, and the pustules and vesicles with nitrate of silver, the parts were all stuped with poppy-head water, then dilute lead lotion on lint covered with gutta-percha tissue was applied, and the patient kept in bed. The internal medicines consisted of iodide of potassium in six grain doses, with three drachms of fluid extract of sarsaparilla in water, three times daily; ten grains of Dover's powder occasionally at bed time, and full doses of liquid extract of senna, as an aperient, when required. For the throat a powerful astringent gargle was ordered, containing tannic and the mineral acids. February 18th.-Some superficial ulcers which had formed on the tonsils were burnt with lunar caustic. Calomel was dusted on the vulva and perinæum. On the 23rd inst., considerable improvement had taken place, both locally and general. The calomel seemed to have thoroughly withered up the pustules, and the condition of the chancres had so far improved, as that no annoyance was experienced. The throat was again touched with nitrate of silver, and the other remedies continued. On March 14th, Mr. D.- who had been away on business, and persevering with the prescribed treatment, returned, complaining of severe rheumatism in his right arm, which he could not bend nor raise to his head. Febrile disturbance, ulceration of the tonsils, weakness of sight, and falling out of his hair, were the accompanying symptoms. He was now recommended Donovan's solution, and stimulating applications to the hair, as in Case 2. The following liniment greatly relieved the pain in his arm :-Ꭱ Lin. aconiti. The ulcers on his tonsils were being daily brushed with a strong solution of nitrate of silver, and thereby improved rapidly. Two days later (March 17) Mrs. D.'s right arm became affected in precisely the same way as her husband's, when the same embrocation as was used in his case proved equally efficacious in the removal of pain. In the course of a week both parties were perfectly free from this latter symptom. Both patients continued to improve from this forward, save as regarded the ulcers of the throat, which in each case seemed difficult of cure. On April 14, a bald ulcer appeared on the right side of Mrs. D.'s tongue, for which she was recommended chlorate of potass in ten gr. doses, as was also her husband. 23rd. The lady was confined of a very fine healthy son, free from any mark of disease or delicacy. For it she had a plentiful supply of milk, of which it partook freely. Her mouth and throat had quite returned to a normal state. All remedies were now dispensed with, it being considered unnecessary to further continue their use. Mr. D., who had been travelling on business from the preceding Saturday, arrived home on April 25th, and, I may say, almost recovered. His hair had ceased to fall out. No cutaneous eruption whatever remained, but the throat was still slightly troublesome, and his sight still impaired. I ordered him a strengthening eye-wash, and told him to continue the chlorate of potass and the oil, which he did till the end of the month, when, being apparently cured, he left off taking anything in the shape of medicine. In this last case, or joint case as it may be termed, the first peculiarity noticed was the herpetic character of the primary disease, and the rapidity with which it was cured, contrary to the law of specific sores; secondly, the occurrence of night perspirations (generally looked on as a late symptom of constitutional syphilis) five days after the first appearance of local disease, or as soon as the latter was removed; thirdly, the development seventeen days later of secondaries (roseola, copper-coloured stains, and erythema of throat), the lymphatic ganglia of the groin remaining unaffected. Fourthly, the presence of vesicles in the lady's case on the inner surface of each thigh, precisely similar to those which were observed on the prepuce of her husband, and the absence, as with him, of glandular enlargement in either groin. Fifthly, the almost simultaneous attack of rheumatism in the two persons; and, lastly, the equally satisfactory results which attended the treatment of the one by iodine and the other by mercury; and the untainted condition of their infant when born. THREE CASES OF MITRAL DISEASE, IN WHICH THERE WERE NO MURMURS ON ACCOUNT OF THE INTENSITY OF THE VALVULAR LESION. BY LAWSON TAIT. In the summer of 1866 I placed a young Irishman under the care of my much-lamented friend, the late Dr. Scoresby Jackson. The patient was about twenty-four years of age, and suffered from rheumatic fever about five years previous to the time I first saw him. The history of his illness pointed to pericarditis as the lesion from which he had suffered; but no very definite history could be obtained. The disease was ordinary atheroma, softer, however, than in the other two cases, and extended completely round the orifice. The aortic valve had only two segments, and the pericardium was congenitally absent. That the intensity of the murmur has no general relationship to the amount of lesion, and that many very serious forms of heart affection are entirely without murmur, are facts well understood and frequently insisted on; but that the murmur in valvular affections may be in abeyance from the very intensity of the disease, is a condition not so generally recognised. SHORT NOTES ON NICE. By JAMES STANNUS HUGHES, M.D., F.R.C.S.I., PROFESSOR OF SURGERY IN THE ROYAL COLLEGE OF SURGEONS, IRELAND; The appearance presented by him was not very much that of a man suffering from heart-disease. He was breathless in going up a hill, complained of uneasiness over his heart, and great weakness. At first sight I took his case to be one of phthisis; but examination did not give any reason to support this. The action of the heart was irregular, or rather every now and then there occurred an interval of rather greater length than a beat, during which the heart seemed to be still, and then there was very markedly that vermicular motion under the skin supposed to indicate adherent pericardium. The latter, indeed, was the condition that I diagnosed; and Dr. Jackson agreed that this probably was the case. The patient was examined by several competent stethoscopists, and while several concurred with us, none, if I remember rightly, suggested mitral disease. The patient left hospital, and died in three weeks. After a very great deal of trouble I got permission to examine the condition of the heart, and found, very much to my surprise, not only that the pericardium was not adherent, but that, with the exception of a few milk-visit Nice, viz. :spots, it was perfectly healthy. The heart was considerably hypertrophied. The mitral valve admitted only the forefinger, and was perfectly rigid, being, in fact, only a ring of calcareous matter, from which the endocardium on the upper side had been denuded by ulceration. Many of the chorde tendinea were ruptured, or had been ulcerated through. No. III. SOME of the best published observations I have read on the climate of Nice are the following, which are contained in that excellent little work of Dr. Edwin Lee's, which he has published under the heading of "Nice and its Climate," a book I can strongly recommend to those about to "The frequentation of Nice and its environs on the score of health dates from the period of the occupation of the country by the Romans, when patients were frequently sent from Rome to Cimiez; and the reputation of this climate has ever since been maintained; many professional and non-professional writers having spoken highly in its favour. About 100 years ago, Smollett observed in his J. G., æt. 37, had never suffered from any form of rheu-Letters from Nice,' 'There is no place where rain and matism, but for the last five years had suffered from symp-wind prevail less (in winter) than here. To give you an toms which led his medical attendant to believe that he had some form of disease of the heart. He presented an extremely anæmic appearance, had some general symptoms, such as slight cough, occasional bloody sputism, breathlessness on exertion; but there was no murmur, only the same irregular and tumultuous action of the heart. I had no means of registering the heart's action, but it might be roughly represented thus, taking the period from the beginning of one beat to the beginning of another as 55:5:12:5:3:3:5:5:12: He From the above conditions I suggested mitral disease as the cause of his symptoms, and ventured to diagnose a condition similar to the case first mentioned. died in a few months, and I found my diagnosis most singularly well established; the mitral orifice would not admit the fore-finger, and it only wanted an extension of the deposit for an eighth of an inch at one spot to make it a complete circle of cretaceous material. The endocardium seemed to be still intact over the foreign substance. The heart was considerably hypertrophied. As both the above examinations had to be conducted hurriedly in private houses, with friends of the deceased looking on, weights and measurements could not be more accurately taken. A. P., æt. 29, presented an extremely anæmic condition. A year before I saw her, she had her right breast removed for malignant disease, in St. Mary's Hospital, Manchester. For some months after her recovery she acted as a barmaid, and enjoyed fair health. About seven months after the operation she found that on any unusual exertion she became breathless, and this increased so rapidly, that in two months more she had to give up work. Her condition, when I saw her, indicated serious disease; and from the physical signs being identical with those of the second case, I diagnosed mitral constriction with inelasticity of the valvular appendages. The question came up-Might it be malignant disease? and I was inclined to believe that it was. The fatal issue occurred three weeks after she came under my care, and post-mortem examination showed that I was right as to the condition of the valve, but wrong as to the disease. The valve admitted the middle-finger, and both flaps were much ulcerated on the upper surface. idea of the serenity of the air, I can assure you that during "A German physician, Dr. Sulzer, likewise wrote at a later period (1792): I cannot quit this country without panegyrising its climate, which is excellent among the most privileged. The English who are accustomed to leave their cloudy island in autumn to pass the winter in the southern zones of Europe, have greatly contributed to bring into repute the remedial and comforting influence of the environs of Nice, and assuredly this reputation is well merited in more respects than one. Persons who do not look for the noisy pleasures of large capitals are sure of finding here a benignant and constantly warm atmosphere in which the body feels its infirmities disperse, and its youth regained. Here, one is sheltered from cold, snow, and fog, and one enjoys in the depth of winter the delights of a perpetual spring. "The air of Nice seems to me to be much more pure and serene than anywhere else. A tolerable judgment may be formed of its character in this respect from the brightness and sparkling of the constellations, and the number of shooting stars, which are only visible in Germany on the finest winter nights. There is, perhaps, no town in Europe which is so well adapted for the establishment of an |