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successful, and the tumour extracted by the large incision; his example was followed by Mr. Lizars, Dr. Graville, Mr. Clay, of Manchester, and Mr. Walne, all of whom performed the major operation. The credit of performing the minor operation is due to Mr. Wm. Jeafferson, of Framlingham, who first performed it in 1826.

Mr. Phillips gives a table of eighty-one cases, in which are exhibited the names of the operators, the ages of the patients, the nature of the operations, the state of the tumours, the results, and remarks on the cases. The table includes cases operated on in this country as well as on the Continent. In sixty-one cases the tumour was extracted; in fifteen cases adhesions or other circumstances prevented its removal; in five instances no tumour was found. Of the cases in which the operation was completed, the tumour being extracted, thirty-five terminated favourably, the patients recovered; in twenty-six instances the termination was unfavourable, the patients died; in the five instances in which no tumour was discovered, all recovered; of the fifteen cases in which adhesions or other circum.

ovarian dropsy which was by far the most frequent of all, and consisted in multilocular cystic degeneration of the organ, the gelatiniform or areolar cancer of some authors. All other forms of ovarian dropsy (as they were called,) were rare in comparison to this, and to it all the remarks in such a discussion as this principally or entirely applied. In most instances, (in nine cases out of ten,) this species of ovarian dropsy pursued, he believed, a regular progress onwards towards greater or less enlargement; insufferable distension; more or less repeated palliative tappings; frequently disintegration of the morbid structure; local irritation; constitutional exhaustion, and death. Generally it took a series of years to run its course, but sometimes it passed through its phases and progress more rapidly. In the practice of Dr. Frederick Bird, the ages of the patients have ranged between 18 and 22, 35 and 45; one only being above 50 years of age.

In the consideration of these cases the following points arise:

1st. Can we determine with certainty whether a tumour be ovarian or not? If not, have the failures stances prevented the extraction of the tumour, nine been so frequent as to constitute a reason why the recovered, six died.

Mr. Phillips very justly remarks, "The proper way of looking at this plan of treatment, is to observe the number of cases submitted to operation, and the number of recoveries after the removal of the tumour.

I conceive this to be the fair way, because what has happened already is, in my judgment, likely to happen again. Adhesions may be too strong and extensive to make removal prudent; the tumour may be other than ovarian; or it may be that no tumour can be found. Regarded in this light, it appears that the operation has been performed eighty-one times, and that in thirty-five instances the patient has recovered after the extirpation of the tumour. It is true that forty-nine patients survived gastrotomy, but many of them were subjected to such a painful and dangerous operation, on the one hand without necessity, and on the other without being disembarrased of the disease."

operation should not be attempted?

2nd. Supposing a tumour to exist and to be ovarian, can we ascertain the nature of its contents, as well as its connections? If not, have the failures been so many as to be an objection to the adoption of the operation at all?

3rd. Are the results of this plan of treatment sufficiently favourable to justify us in preferring extirpation to any other mode of treating ovarian tumours? and if so, what plan of operation promises most success?

The fact adduced in proof of the uncertainty of ovarian tumour is, that out of eighty-one instances in which the operation for extirpation was attempted, in five cases at least, in which the abdomen was laid open, no tumour was discovered, and in six cases the tumour was not ovarian.

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With regard to the second point for enquiry, Mr. Phillips says, we have no certain means of ascertaining the contents and connections of tumours presumed to be ovarian." In six cases the abdomen was laid open, and the tumour was found to be diseased omentum, or diseased or gravid uterus. Many times a presumed ovarian cyst has been punctured, and no Auid has escaped, for it frequently happens that the fiuid is of the consistence of a thick jelly.

Mr. Phillips has made two tables, in order to estimate the relative advantages and dangers of the major and minor operations,—one including the cases in which the tumour was removed entire, the incision having an extent of six inches and upwards; the other, including those cases in which part or the whole of the fiuid was evacuated before the extraction was attempted, the length of the incision having been under six inches. Of the former there are fifty five cases, twenty-three of which were successful; of the latter there are twenty-fifteen cases in which the operation for extraction was nine instances, of which thirteen proved successful.

According to Mr. Lee,† the number of cases that have now been operated on amounts to 103, and the success is in proportion of 1 to 34. Dr. Simpsont says, the diseased condition of the ovary to which the operation of ovariotomy was peculiarly applicable, if applicable at all, was, in his opinion, that form of

• Med. Chir. Transactions, Vol. 9,

+ Jacksonian Prize Essay.

Edinburgh,

With reference to connections or adhesions, the difficulties met with are still more formidable. In

commenced, it was found necessary to discontinue it, in consequence of the extent of the adhesions. In twenty-five other instances adhesions existed. Of the fifteen cases in which they caused the abandonment of the operation, six terminated fatally. The adhesions are rarely extensive without previous symptoms of peritonitis, (in the above case they must have been very extensive, from the numerous tappings the patient underwent;) but allowing the extirpation of the diseased ovary to be a justifiable operation, it may be presumed

* Report of a debate at the Medico-Chirurgical Society, that in the absence of these symptoms it may be

ST. PANCRAS DISPENSARY.

undertaken with every prospect of being completed, • and the operator may find encouragement in the fact farnished by Mr. Phillips' tables, that of the forty cases in which adhesions were found, twenty-six survived, which is at the rate of sixty-one per cent.; whereas of the whole eighty-one operations, forty-seven recovered, or fifty-eight per cent.

The great danger of this operation arises from peri tonitis, and as far as our present experience warrants a conclusion, that danger is not increased by previous inflammation of the serous membrane and its consequent adhesions, though their existence necessarily leads to greater disturbance of the important parts exposed in the operation.

In reference to the third point, sufficient has been said in the preceding observations on paracentesis and extirpation. With regard to which operation should be selected, the calculations from the table before noticed, tell rather in favour of the minor operation; but my firm conviction is that the operation is never justifiable except when the swelling, either from pressure on the diaphragm, or from some other cause, is placing the life of the patient in extreme jeopardy.

Mr. Kirkpatrick relates a case of a patient labouring under ovarian dropsy who had been tapped 128 times. The patient died of an attack of pleuritis, the interval between the last operation and her death being eight weeks.

In addition to the usual symptoms and method of investigation in diagnosing this disease, Dr. John Hughes Bennett speaks of two other methods which seem to be capable of greatly assisting the practitioner in his efforts to form a correct opinion of the case:1st, the uterine sound recommended by Professor Simpson; 2nd, a microscopical examination of the fluid removed by paracentesis. By fixing the body of the uterus with the sound, and by elevating, depressing, or bringing forwards the handle of the instrument both the anterior and the posterior portions of the fundus may be felt, with the left hand above the pubis, through the integuments. The information is negative, but it becomes of immense importance when the question arises, whether the tumour is uterine or ovarian. By pushing the tumour from side to side, we are enabled to act upon the ovary, and to determine, by

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the impulses communicated to the hand, whether the tamour be on the right or the left side, and to form a tolerable idea, in certain cases, whether it be or attached. By this instrument, then, we are assisted in resolving the seat of the tumour. The microscopic examination of the fluid removed by paracentesis is capable of being made highly serviceable in diagnosing

the nature of the tumour.

In this fluid, flocculi exist, which are not composed of lymph as was at first supposed, but of numerous cells, varying in size from the 1-100th to the 1-40th of

millimeter in diameter. They are slightly granular, of round and oval shape, unaffected by water, and exhibit a distinct nucleus about 1-140th of a millimeter in diameter. The indented cells are imbedded in a granuler matter, which can be easily broken down.

• Dublin Hospital Gazette, Feb. 1, 1846, p. 187.

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was

They thus resemble those which constitute the epithelial surface of certain membranes. The cysts in the diseased ovary are lined by a delicate membrane, covered by nucleated epithelial cells, and there is no difficulty in identifying the corpuscles seen in the fluid with those observed lining the cysts. In one case which Dr. John Hughes Bennett examined, masses of these had evidently separated, and floated into the abdominal cavity through perforations in the external sac of the ovarian tumour. In another case none of these corpuscles could be discovered, but only shapeless flakes mixed with granules; after death the tumour found to be fibrous throughout. In another case the cells were of the character above described, combined with the débris of a fibrous structure, from which it was inferred that the external envelope of the tumour was in a state of decomposition. On examination after death, a compound encysted tumour of both ovaries was found, with sloughing of the fibrous sac on one side, and a colloid cancer of the omentum and peritoneum. There is little danger of the fluid accompanying encysted ovarian dropsy being confounded with that found in inflammatory or passive dropsy. In peritonitis we find primitive filaments mixed with plastic or pus-corpuscles, which can never be mistaken for the large epithelial cells observed in the fluid of ovarian dropsy.

In reference to the above case, when we take into consideration the existence of numerous and firm adhesions by reason of the frequent tappings the patient underwent, as well as her advanced age, we may conclude that Mr. Cox was quite justified in refusing to propose to the patient the very doubtful chance of a cure offered by the operation of extirpation. The patient may now live for some length of time in tolerable comfort.

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CASES ILLUSTRATIVE OF THE CONDITION OF THE SYSTEM WHICH IS ACCOMPANIED BY OXALIC URINE.

By EDWARD Ballard, M.D., Lond., Physician to the St. Pancras Royal General Dispensary, and Medical Tutor in University College, London,

CASE I.-HYPOCHONDRIASIS.

J.T., aged 56 years, a native of London, where he has all his life resided, a silversmith by occupation, when in health of a very cheerful disposition, and having no hereditary predisposition to disease, applied at the Dispensary, on January 20th, 1846. When young was very irregular in his mode of living, and suffered from a chancre which was not followed by any secondary symptoms. For several years past, however, and since his marriage, he has lived very temperately; has been subject to external piles for twelve years or more; has never lost any blood by the rectum till lately. He attributes his present illness to domestic troubles and a habit of neglecting his meals for the sake of indulging a taste for reading, &c. He reads medical books when they come in his way.

He presents the very picture of a hypochondriac, ap- Auge Pil. Saponis Co. ad gr. viij.

10th. States that he feels weaker than he did; suffers more from flatulence; urine acid, of specific gravity 1020; after standing twenty-four hours it threw down a slight mucus-looking deposit, which contained a few mucus corpuscles and a tolerable sprinkling of small octohedra. Pergat. Assafoet., gr. x., ter die sumend. Capt. cum sing. pil. dosibus Inf. Cascarillæ, oz. iss.

13th. Continues to improve; bowels open without medicine; urine acid, of specific gravity 1031; deposit as before, but with fewer oxalates. Pergat.

pearing unable to concentrate his attention on anything 6th. Complains of throbbing pain in the head, especi→ but his own ailments, in the description of which he con-ally in the right temple; bowels regular, and defæcation stantly employs medical technicalities. Is an habitual is not followed by any uneasiness, Urine of this morn and close observer of the state of his tongue, pulse, ing natural in colour, slightly acid, of rather low density; and stools, the minutest variations in which fill him on standing twenty-four hours it threw down a slight with alternate hope and apprehension. His counte- cloudy deposit, containing mucus-corpuscles, epithenance expresses despondency and gloom. It appears lium scales, and a few octohedra. Auge Pil. Saponis from his own account, that his illness has lasted for Co. ad gr. x. three years, having commenced with occasional attacks of flushing of the face and head, and giddiness, with vomiting and diarrhoea, the latter however, six months ago, having been changed for obstinate costiveness, which has continued to the present time. He states that when his bowels are confined he is much more comfortable in his feelings than when they are open. A month ago he lost some blood by the rectum; the hæmorrhage lasted five or six days and has not returned; has lost strength considerably during his illness, and finds his memory failing him daily. It is with difficulty that he gets to sleep at night, and when he wakes, which is always early, he feels so excited that he is compelled to rise and engage in some occupation about the house; if he can find nothing to do he smokes. Has had some cough for the last six months. The chief part of his complaints, however, are referable to the abdomen, consisting in a "miserable sensation of pain and opression," over the lower part of that region and round the navel, especially after his stools, so that he voluntarily suppresses them as long as possible. His tongue is large, white, and irregular at the edge, and his appetite ravenous. He is an inveterate snuff-taker; and has had an inguinal, but reducible hernia for some years. Says he cannot take opium as it makes him extremely ill. Ano applic. Hirudines iv.

17th. In consequence of taking some bacon and eggs on the 15th, has suffered more from flatulence and uneasiness at the lower part of the abdomen. Sleep continues good; urine acid, of naturál colour, with a moderate rather dense deposit, consisting of lithate of ammonia and a few octohedra, more than in last specimen, of specific gravity 1031. Capt. pil. omni

nocte tantum.

19th. Intends trying if he cannot resume his work. Urine presents a dense flesh-coloured deposit, consisting of lithate of ammonia; when warmed and diluted, the lithates were dissolved and a mucuslooking cloud remained, which consisted of octobedra mostly very minute; specific gravity 1025, re-action acid. Discharged.

Remarks. Whatever be the relation in which

R. Camphora, gr. ij.; Pil. Saponis, Co., gr. iij. the abdominal ailments and the mental derangement Fiat pilula nocte maneque sumend.

R. Acid. Nitric. Dil., Tinct. Hyosc., utrq., m. xv.; Inf. Serpentariæ, oz. iss. Fiat haust. ter die sumend:

Jan. 23rd. Abdominal pain relieved; sleeps better at night. Auge Pil. Sap. Co., ad gr. v.; et Acid. Nitric. Dil. ad m. xxv. Confect. Sennæ pro re nata. 26th. No oxalic or phosphatic deposit in urine of yesterday. Omitt. haustus.

of senna.

27th. Continues improved; passes good nights, and is less excited in the mornings. Keeps his bowels regular either with castor oil or the confection Urine is cloudy, with a slight cloud in addition at the bottom of the glass; the latter contained an abundance of moderate-sized octohedra; re-action acid; specific gravity 1020. Pergat.

30th. Has some trouble in regulating his bowels, and still expresses great anxiety about their condition. His spirits are much improved; urine passed this morning is of a natural colour, and throws down a dense mucus-looking deposit, containing lithate of ammonia, along with minute octobedra. Pergat. Capt. Ol. Ric., dr. j. vel ij. loco Conf. Sennæ.

Feb. 3rd. All his abdominal symptoms improved; complains again of a difficulty in getting to sleep at night, and of strange visions passing rapidly before his eyes; urine contains no oxalates nor phosphates, and only a little lithate of ammonia in the deposit.

of a hypochondriac stand to each other, it is commonly found that improvement in the one is followed by amendment in the other. In this case the abdominal symptoms were urgent, and the intense attention directed to them by the patient appeared to indicate that they must be here at least the special object of treatment. How relief was to be obtained, was partly pointed out by an imperfect attempt on the part of the system to effect it by hæmorrhage, and accordingly leeches were ordered to be applied to the anus, while opium disguised and corrected by combination with camphor, was prescribed to alleviate the irritable condition of the nervous system. That this mode of treatinent along with gentle laxatives was effectual, the issue of the case proved; for although the man was necessarily discharged in far from a healthy state, his improvement was in every respect marked:

श्र

A few words on the urine. The cases of oxaluria which have come under my notice have led me to infer that when the presence of oxalate of lime is observed along with symptoms of nervous irritability, they are related rather as concomitants than as consequent, the one upon the other; both being referable to the same debilitated condition of the constitution, the former especially, being taken as an index of the deep impression which has been made upon it by the prolongation either of disease or of other weakening causes. It is

ST. PANCRAS DISPENSARY.

in this light that I am disposed to regard the present case. The patient had long suffered from diarrhoea, and had been in the habit not only of neglecting his meals, but as he also informed me, of taking merely coffee and bread and butter, or some bacon, in place of more nourishing food, day after day, in order that he might have the privilege of reading the periodicals in the coffee-room he frequented. These circumstances, Conjoined with sedentary habits, and the re-action which followed on mental annoyance and excitement, were amply sufficient to account for his state. There was considerable variation in the size and amount of oxalates in the progress of the case; on two occasions they were altogether absent. On the whole they became less abundant as it advanced.

S.E

CASE II.-MELANCHOLIA.

-, aged 23 years, a native of, and resident in, London. None of her family have presented indications of consumption or insanity. Up to three years ago, with the exception of habitual costiveness, she had had no illness worth speaking of. At that time she suffered from anasarca, the face, as well as the upper and lower extremities, being swollen, accompanied by fever. This lasted for a day or two, and left her very much weakened. She had pain across the loins, but the urine was not bloody. Has been losing flesh and strength ever since. I was requested to visit her on September 21st, 1846.

She had always been of a quiet and reserved manner, and religiously but not fanatically disposed, but for the last twelve months has been observed to become more reserved than ever, neglecting her usual occupations, and appearing to be absorbed in thought. Her friends have reason to believe that this change in her demeanour has been due to the loss of a favourite mistress, on whom she had been in the habit of attending during six years. The sister of that lady she is now living with, and the girl appears to labour under the imagination that she has committed murder, and that her mis

tress is fearful to be in the house with her alone lest she should injure her also. She says that her crimes are very black, and that all the sermons she hears are

directly levelled against herself. She has lately fancied that she was going to prison, and sometimes is very much agitated about it. She has lost flesh to some amount during her illness, and complains of feeling very weak; face flushes towards evening, and she then becomes very drowsy; has occasional headache, but no throbbing of the carotids. Her manner is rather timid, but polite, answers any questions put to her, but looks out of the window the whole time, never turning her head unless requested to do so. Bowels confined; tongue flabby, rather tremulous, with a thin white fur; pulse 75, rather weak; catamenia have always been regular, The peculiar turn of her delusion may be due to her having been in the habit lately of reading law-books which have lain in her way.

377

slightly cloudy, presenting a slight additional cloud at the bottom, of specific gravity 1023, moderate acid re-action; the cloud at the bottom contains a scanty sprinkling of octohedra, and, in addition to these, some circular thin plates, marked with concentric lines. No albumen present.

24th. Her mother thinks that she has appeared better, and less melancholy. Has been copiously purged; thirst considerable.

26th. Catamenia appeared this morning; urine of this morning rather pale, but clear, with a cloud-like deposit, of specific gravity 1016, moderate acid reaction, deposit contains no oxalate.

Capt. Pil. Coloc. Co., gr. v., tantum. Contin. Pil. Bebeerinæ.

October 2nd. Has complained of headache and languor the last two days; mental condition not much improved; sometimes talkes nonsense. Pills acted three or four times.

Omitt Pilulæ Bebeerinæ. Capt. Pil. Coloc. altera quaque nocte tantum. R. Ammoniæ Sesquicarb. gr. iij.; Tinct. Lav. Co., dr. ss; Inf. Carcarillæ, oz. iss. Fiat haust. ter die sumend.

15th. Since taking the last medicine she has been free from headache, and has lost her thirst; she feels a little stronger, and appears in rather better spirits, but otherwise is not improved; bowels have not acted for seven days; this morning's urine is clear, containing a few floating very light cloud-like flocculi, which on standing separated into a light cloud-like deposit, occupying a quarter of the liquid, and consisting of single and aggregated octobedra, with scales of epithelium, of specific gravity 1029, very feebly acid, no albumen. Contin. haust. R. Olei Crotonis, gtt. iij.; Micæ panis. q. s. pro pil. xij. Capt. j., omni nocte.

more disposed to laugh and joke than formerly; is 28th. Spirits have improved very much, and she is always better in the evening; does not talk nonsense, but after going to church on the 25th insisted that her mistress had been instructing the clergyman to preach against her; is still indisposed to rise in the mornings; has a slight cough; bowels open; stools very offensive. Aspect of urine as before; the cloudish deposit only octobedra, some mucus-corpuscles and granular matoccupies 1-10th, but contains a great many minute ter; no albumen; specific gravity 1025.

To leave home for a time. Discharged.

Remarks.-The termination of this case was not seen. Cases of insanity are not commonly met with in dispensary practice, and when they do occur, the most valuable means of treating them are withheld by the circumstances of the patient. Moral influences can in no way be brought to bear upon the disease, and the body is the only channel through which the physician is permitted to act upon the mind. The subject of these observations, although removed from her situation, was thus, notwithstanding my injunctions Ordered a nourishing diet, with malt liquor. Pil. to the contrary, permitted to have occasional interviews Coloc. Co. gr. x, alt. quaque nocte sumend. R. with the fellow servants and her mistress; and after Bebeering Sulph., gr. iij.; Extr. Gent., q. s. pro pil. ter every such meeting, a distinct increase of her gloominess die sumend. was remarked. Her mother, too, took no pains to withSeptember 22nd. Morning's urine rather pale, draw her mind from the contemplation of scenes

on which it so morbidly dwelt. Accordingly, although daily out-door exercise was enjoined, and it was other

PROVINCIAL

wise endeavoured to restore the tone of the system, Medical & Surgical Journal.

the success was by no means what (under more favourable circumstances,) might fairly have been looked for. As in the former case, the oxalic urine was connected, not only with marked derangement in the functions of the nervous system, but also with a depraved condition of the general health. Indeed, had it not been for the debility which for two years had preceded the death of her mistress, it is probable that this event, deplored as it would still have been, by so affectionate a disposition, would have lost its freshness with the progress of time, and that her mind would not have given way under the shock. I do not know whether much stress is to be laid upon the disappearance of the oxalates at the catainenial period. I have noticed the same thing in another instance. Two other points relative to the oxalates in this case deserve notice; one of these is the form of the deposit on the 15th of October, and the mode in which it fell.

WEDNESDAY, JULY 14, 1847.

The arduous nature of the duties which devolve upon medical practitioners,—the long and comprehensive course of study which is required to fully qualify them for the discharge of these duties, the continual application necessary to keep up with the advance of knowledge, the closeness of observation, the hours' of thought and watching in the closet and by the bed-side, indispensible to successful practice, the responsibilities which attach to them,— finally, the devotion and self-sacrifices required of them, cannot fail to be apparent to the reflectform a well-instructed and skilful physician or ing mind. The qualifications necessary to surgeon are not those of the million. They require for their attainment a combination of mental acquirements, energy, and perseverance, with which comparatively few are endowed; and yet, though this is a truth which will probably not be questioned, and though it is admitted that the labourer is worthy of his hire, it is in a literal sense the hire of the mere labourer which is apportioned to the reward of such services as men thus qualified are called upon to bestow.

I have reason to believe, from the result of 139 observations on this species of urine, that this is the form which oxalate of lime most commonly presents when falling at a distinct precipitate. Lime, either alone, or mixed with crystals of uric acid, or some epithelium scales, occurred in ninety-two instances. The other point to which I desire to allude is the occurrence of what I imagine to be a form of oxalate of lime, hitherto undescribed, although I know that others have noticed it in circular thin plates about the 1-700th of an inch in diameter, some larger, and some much smaller, generally having somewhat of a bluish tinge, and being more or less distinctly marked with connective lines. I have met with these plates ten times, and with three exceptions, always in condition to obtain them for themselves. The state junction with octohedral crystals.

Perhaps a few words may not be out of place upon one of the remedies employed in this case, the sulphate of bebeerina. To such as have used it little need be said in its praise; to those who have not, I may state that for the last twelve months I have employed it with the most beneficial effect in the dispensary practice, as a substitute for quina, and almost to the exclusion of that alkaloid. It is about half the price, and its medicinal value so far as I can judge, is equal to it. It was introduced into practice in this country by Dr. Maclagan. It may be administered either in a pill with extract of gentian, or after dissolving in boiling water, along with a few drops of sulphuric or hydrochloric acid, in a draught. As in the present instance, it is apt to produce thirst, and sometimes it acts upon the bowels.

Since writing the above, I have accidentally heard that this patient's mental condition is scarcely at all improved to the present time. She spends a considerable portion of the day in bed, refusing to get up, and will allow no medical man to see her.

(To be continued.)

No one questions'either the value of these services, or the necessity which exists for securing them to all classes of the population not in a con

provision made for efficient medical attendance in the army and navy, and in Poor-Law unions, and the numerous charitable medical institutions throughout the country, hospitals, dispensaries, &c., are sufficient evidences of the estimation in which the advice and assistance of medical practitioners are held. Yet, notwithstanding, we will venture to assert, that with the education and station of gentlemen, and intellectual qualifications, not inferior to those of any class of the community, the entire revenues of the profession derived from the emoluments of practice are not sufficient for the support of one fourth of their number.

We have been led to these reflections at the present moment by a consideration of the memorial lately presented to the Lord Lieutenant of Ireland, signed by upwards of one thousand physicians and surgeons of that country. This memorial was published in our last number, and is worthy of deep attention, as shewing what sacrifices are required from the medical profession, and in what consideration such sacrifices are virtually held by the Government. Five shillings per diem is, it appears, considered a fitting remuneration.

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