ounces, every hour, as long as tolerated by the rectum, were ordered, and the "general hot air bath" was employed twice daily. Sweating was profuse and during the first twenty-four hours after labor sixty-two ounces of urine were passed. The bath was employed for one week when the oedema had entirely disappeared. Three weeks later repeated examination revealed no albumen or casts in the urine.

Case 7. Mr. F. P. Age 30. Diagnosis, gonorrhoeal rheumatism of the left wrist joint developing in the fifth weekof an acute gonorrhoea. As a result of pain experienced on the slightest movement of the wrist the patient had been confined to his bed, and when I first saw him in consultation four weeks later he was taking from a grain to a grain and a half of morphine daily for relief of pain, all the usual internal and local remedies having failed. The joint was exceedingly tender and painful and the wrist partially flexed owing to distention from fluid at the back of the joint. The effusion extended down the sheaths of the extensor tendons as far as the fingers. The swelling was boggy and pitted on pressure. There was a very slight urethral discharge in the morning. Return flow irrigation was advised, but as he was a married man and for reasons of secrecy this could not be employed, injections of zinc sulphate were used. The "local hot air bath" was employed daily. Methyl salicylate was applied to the joint, and the arm placed on a splint. Temporary relief from pain was afforded by first treatment, but it returned after two or three hours, so that gr. 1⁄2 of morph. was given during the night. The next day he was up and about owing to the support of the splint. Treatment was continued for one week and pain, tenderness and swelling entirely disappeared, the discharge having ceased on the fourth day. There is still slight stiffness of the joint which I believe better not be interfered with at present.

Case 8. Mrs. G. H. Age 70. Diagnosis, fibrous adhesions of the extensor tendons of the hand with a deformity produced by a fibrous exudate on the back of the hand, just below the wrist joint. This condition was the result of a fracture of the lower end of both bones of the forearm treated with anterior and posterior splints. Twice the adhesion had been broken up but had reformed, owing, I believe, to the fact that the necessity of continued active and passive motion had not been sufficiently impressed upon the mind of the patient. For over two months the arm had been practically useless and from this disuse fibrous adhesions had formed about the shoulder joint so that the hand neither by active or passive motion could be placed upon the head. Pain both in the arm and shoulder was almost constant, and increased upon the slightest motion. There was marked atrophy of the muscles of both arm and forearm. There was scarcely any flexion of the fingers with active motion and but slight flexion with passive motion. Patient did not approve of adhesions again being forcibly broken. The "local hot air bath" was used every day on the forearm, the shoulder being included in the bath twice a week and followed by massage and passive motion. At the end of the first week the tips of the fingers could be made to touch the palm of the hand, and there was no pain in shoulder or wrist. At the end of a month

the fibrous exudate upon the back of the hand had been absorbed. Passive notion of the hand was perfect. Active motion, though assisted by exercise, massage and electricity, returned more slowly, owing to the long disuse and atrophy of the muscles, though now after fifty baths, the fingers can be completely flexed by active motion with the exception of the distal phalanx of the index finger, and this is improving with exercise. With the exception of stiffness in the morning or after a few hours of disuse the result is all that could be desired. The hand can be placed upon the back of the head by active and passive motion, and the patient has been able to "do up her back hair" and accomplish other feats which before had been impossible. In fact the shoulder is normal, with the exception of complete elevation of the arm in position of abduction, and this I think is due to the presence of a urate deposit upon the upper and anterior part of the rim of the glenoid cavity. Lithium hippurate was the only internal medication in this case.

In conclusion I will simply add that while I consider hot air by no means a "cure all," it is certainly a valuable adjunct to other treatment in the class of cases in which it is indicated, and chief among these indications I would again emphasize its use for the absorption of serous or fibrous exudate, or breaking up of fibrous ankylosis or adhesions, and in the treatment, prophylactic alleviative and curative (?) of sub-acute and chronic articular rheumatism.

518 SECOND AVENUE

Correspondence

MEDICAL EDUCATION IN GREAT BRITAIN.

TO THE ANNALS:

MANCHESTER, ENGLAND, August, 1900.

A reader of the ANNALS who thought that an explanation of our English medical qualifications and degrees would elucidate some misconceptions asked me to write a brief communication upon this subject.

A man can become qualified to practice medicine in Great Britain in one of two ways. The first way is to reside at one of the leading universities such as Oxford, Cambridge, London, Victoria, etc. The student attends the lectures at his university and the clinics at some recognized hospital. He then goes in for the final examinations of his university anp has its degree conferred upon him. If, for instance, a man

fulfils the necessary conditions and passes the examinations at Victoria University he will receive the degree of bachelor of medicine and surgery which graphically would read "M. B., Ch. B., (Vict.)." This degree fully qualifies him to practice medicine and surgery in Great Britain. In order to obtain this degree three sets of examinations must be passed, the first in biology, chemistry and physics after a year's work on these branches.

The next year or eighteen months is devoted to anatomy, physiology and materia medica and these form the subjects for the second examination. College and hospital work are carried on concurrently during the next three years. Six months are spent as surgical dresser, the first three months in the out-patient department and the next three in the wards. The students apply all the dressings and bandages and gain much practical experience. Six months are also spent on the medical wards as clinical clerk. The clinical clerk keeps the records, notes and charts and receives a great deal of bedside instruction. The subjects covered in the final examination are medicine, surgery, pathology, gynaecology, obstetrics, public health, medical jurisprudence and therapeutics. This makes a total of over five years, including three years at a hospital, before a man can receive his degree.

An "M. B." cannot sign himself "doctor"-just plain commonplace "Mr." If an "M. B." decides to devote himself to the study of medicine he sets about to get the higher degree of "M. D." This is awarded only after a really good thesis or some original work is submitted to the university. This requires usually from six to twelve months of work and study. Holders of the "M. D." degree are entitled to be addressed as "doctor" and to use that much abused title. For the men with surgical proclivities some universities award the degree "M.S." (Master of Surgery) to men previously qualified who have done some acceptable original work.

The English surgeons cling to the term "Mr.' and feel insulted if addressed as "doctor."

The second method is to pass the examinations of one of the recognized medical colleges who have the power of granting a license to practice. By far the most important of these is the Royal College of Physicians and Surgeons who

give a joint diploma represented by the letters "M. R.C.S., L.R.C.P." (Member of the Royal College of Surgeons, Licentiate of the Royal College of Physicians). Another diploma is the "L.S.A." (Licentiate of the Society of Apothecaries). These are the only two in England but there are others in Scotland and Ireland. They are not degrees, only licenses, and are of distinctly lower standing than the university degrees because they used to be much easier and cheaper to obtain and did not require such a long college course. Latterly the length of study required and the difficulty of the examinations have been increased and are much the same as university requirements, though not quite. They still however do not give a man the same standing. To obtain these licenses one must attend the lectures and hospital course at one of the recognized schools of medicine as connected with most of the leading London hospitals.

In addition to these there are certain other titles which may be obtained by examination or in some cases simply by election. The Royal College of Physicians, which I have before mentioned, has a very stiff examination, which, when passed, confers the Membership of the Society—' M. R.C. P." It is open only to qualified men and therefore is not in itself a qualification. The College also confers by election the title of Fellow, "F. R. C. P.," upon distinguished physicians and this is one of the highest honors to which an English physician can aspire. Similarly the Royal College of Surgeons has a very rigid examination in surgery which is only open to qualified men. This confers Fellowship of the College upon successful candidates ("F. R. C.S."). This is about the highest surgical distinction. There are a few other diplomas which college or universities give to men previously qualified, such as "D.P.H." (Diploma of Public Health), but they are more or less subsidiary.

A surgeon might sign after his name "M. B., Ch. B. (Vict.) M.S.., F.R.C.S." These letters should now be intelligible. In this case however the surgeon would simply put "M.S., F.R.C.S.," as the fact of having the degree of "M.S." would show that he must previously have obtained the degree of "M. B., Ch. B." at the same university. For the same reason a man with "F. R.C.S." would not add the lower title of

"M. R.C.S., L.R.C.S.," since although the fellowship of the college is not a qualification to practice yet he must already be qualified in order to hold it. He would therefore simply sign himself "John Smith, F R.C.S."

I have, etc.,

W. J. S. BYThell.

The

of Tropical Dysentery

Editorial

There are few subjects in medicine that have Bacteriology attracted more attention than dysentery. Its history dates from the earliest written records and its ravages have continued practically unaltered to the present day. That this is so is certainly not due to any want of research activity into the nature of dysentery. Indeed, the literature contains some of the most distinguished names in medicine, by whose efforts much in its clinical history, epidemiology, and pathological anatomy has been elucidated. Despite all this energy it must be confessed that the attempts to establish a common etiological factor for all cases of dysentery have thus far failed. Professor Simon Flexner, of the University of Pennsylvania, in the MiddletonGoldsmith Lecture delivered before the New York Pathological Society, April 12, 1900 (Philadelphia Medical Journal, September 1, 1900), has contributed some of the results of his own work in this direction, when in the Philippine Islands in the summer of 1899. Passing over the early investigations of Klebs, Prior and Ziegler, Hlava, Chantemesse and Widal and Grigariew upon the bacterial origin of dysentery to the studies of Maggiori, Laveran, Celli and Fiocca, and Escherich, who attributed the disease to the bacillus coli communis, the author then successively takes up the various organisms which have been identified by various observers with epidemics of dysentery investigated by them in various parts of the world. In Japan a fine bacillus liquefying gelatin was isolated from dysenteric cases by Ogata. The same organism was again isolated from twenty-three cases occurring in Padua by Vivaldi. The pyogenic cocci have been regarded as the chief pathogenic agents by Zancarol, Silvestri of Turin, Bertrand